Possible association between Guillain‑Barré syndrome and SARS‑CoV‑2 infection in children: A case report and literature review
Affiliations: Department of Pediatrics, Chivasso Hospital, I‑10034 Turin, Italy, Department of Child Neuropsychiatry, ASL TO 4, Chivasso Hospital, I‑10034 Turin, Italy, Department of Neurology, Chivasso Hospital, I‑10034 Turin, Italy, Department of Neuroradiology, Chivasso Hospital, I‑10034 Turin, Italy
- Published online on: May 23, 2022 https://doi.org/10.3892/etm.2022.11389
- Article Number: 462
Copyright: © Mussinatto et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
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The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide since December 2019; overall, >280 million cases have been reported globally and the number of deaths exceeds 5 million (1).
Neurological manifestations of SARS-CoV-2 infection are common, varying from mild cases (including dysgeusia, anorexia, olfactory dysfunction and nausea) to more debilitant symptoms, including fatigue, headache and dizziness. Severe diseases such as encephalitis and meningitis have also been reported as complications of novel coronavirus disease 2019 (COVID-19) (1). A series of studies (2-7) have also shown a possible association between Guillain-Barré syndrome (GBS), the most common cause of acute flaccid paralysis in all ages (8), and SARS-CoV-2 infection.
The incidence of GBS increases with age, peaking at 70-80 years old (4-5 cases/100,000 individuals). By contrast, it is a rare pathology at pediatric age, with an incidence of 0.62 cases/100,000 children aged 0-9 years, and 0.75/100,000 children aged 10-19(9). GBS is usually triggered by common infections such as minor respiratory illnesses, gastrointestinal illnesses and immunizations. The pathogenesis of SARS-CoV-2-associated GBS remains under debate; several reports suggested a para-infectious etiology, while others suggest a classical immune-mediated post-infectious mechanism.
GBS may present in a number of clinical variants, ranging from the acute demyelinating inflammatory polyneuropathy (AIDP) to the acute motor axonal neuropathy (AMAN). Both are characterised by rapidly-progressing, ascending symmetrical weakness, with attenuation or loss of muscle proprioceptive reflexes.
Campylobacter plays a significant role among the infectious triggers, in particular for Miller Fisher Syndrome (MFS), the localized form of GBS characterized by ophthalmoplegia, ataxia, and areflexia. In the differential diagnosis of GBS, Borreliosis, Citomegalovirus infection and rare cases of paraneoplastic isolated myelopathy must be excluded (10).
Among pediatric patients, 75% can no longer walk unaided in the acute phase, 30% are tetraparetic, 35-50% show cranial nerve involvement, and 15-20% have respiratory failure and/or autonomic dysfunction (9). Localised forms of GBS such as MFS and Chronic inflammatory demyelinating polyneuropathy (CIDP) are extremely rare in childhood (11).
Case reports of COVID-19-associated GBS mainly include adult patients, while only a few pediatric cases have been reported (12-25).
Here we describe the case of a GBS in an Italian 9-year-old girl with previous SARS-CoV-2 infection as a possible trigger and we conduct a literature review on pediatric COVID-19-associated GBS cases.
Materials and methods
Infectious and immunological research kits
We used the following kits for the infectious and immunological tests carried out in our patient: PCR analysis on cerebrospinal fluid (CSF): BioFire® FilmArray® meningitis/encephalitis (ME) panel (BioFire Diagnostics, LLC); CMV PCR search on CSF: CMV ELITe MGB® Kit(ELITe InGenius® ELITechGroup); Campylobacter search on stools: culture on Biomerieux plates and identification with VITEK MS Maldi-Toff Biomerieux; Autoantibodies search on CSF: GanglioCombiTM ELISA (Buhlmann Laboratories AG); Paraneoplastic antibodies search on CSF: EUROLINE paraneoplastic neurological syndromes 12 Ag (igG) (EUROIMMUN Medizinische Labordiagnostija AG); Viral serologies (SARS-CoV-2, CMV and EBV) on plasma: LIAISON SARS-CoV-2 S1/S2 IgG; CMV IgG and IgM; EBV IgG and IgM; DiaSorin
Magnetic resonance imaging (MRI) parameters
Philips Ingenia 1,5T; Spin-echo, Turbo Spin-Echo, Inversion Recovery, Gradient Echo, Echo Planar with T1, T2, DP weighted sequences, pre and post-contrast.
Literature review criteria
We systematically reviewed literature available on PubMed until November 2021 in order to find all pediatric cases of GBS associated with SARS-CoV-2 infection (3-17 years) reported as case report, meta-analysis, randomized controlled trial, review and systematic review. We only considered papers written in English.
The PubMed search string was: (‘Coronavirus’ OR ‘Coronavirus disease’ OR ‘novel coronavirus’ OR ‘Severe acute respiratory syndrome coronavirus 2’ OR ‘COVID-19’ OR ‘nCoV 2019’ OR ‘SARS-CoV-2’) AND (‘Guillain-Barré syndrome’ OR ‘GBS’ OR ‘Miller Fisher syndrome’ OR ‘MFS’ OR ‘Miller Fisher-GBS overlap syndrome’ OR ‘MFS-GBS overlap syndrome’ OR ‘acute inflammatory demyelinating polyneuropathy’ OR ‘AIDP’ OR ‘acute motor axonal neuropathy’ OR ‘AMAN’ OR ‘acute motor sensory axonal neuropathy’ OR ‘AMSAN’) AND [‘Child’(Mesh) OR pediatric* OR children].
Reference lists of all articles were manually searched for cross-references and additional cases were identified from the references of the case reports.
We reviewed 41 articles, 14 of which were included. We have included only articles that reported original case reports involving pediatric subjects with a form of GBS associated with SARS-CoV-2 infection.
We excluded articles that repeated cases already included in our reviewed, those involving subjects aged >18, infections other than SARS-CoV-2, those written before 2020 and those not in English.
We obtained the full text of each case we included. Each article was selected and analysed for inclusion by two authors in parallel.
For each case, the following data were extracted by the two authors: Publication data: title and authors of the article, name and year of the journal; patient information: age, gender, underlying clinical condition, medical history and SARS-CoV-2 exposure, signs and symptoms of GBS; and diagnostic tests for SARS-CoV-2 infection and for GBS, treatment type and duration, outcome.
At the end of June 2021, a 9-year-old girl presented to the pediatric emergency department of the Chivasso Civic Hospital for progressive weakness and gait instability over the last month. She claimed no infectious or febrile episodes in the last months, no COVID-19-contacts. Her family history was negative for autoimmune or neurological disease.
General examination showed good general condition, T 36.5˚C, bilateral inferior limb weakness with gait instability, altered sensitivity and complete absence of the patellar reflexes. Cranial nerves examination was normal, and she showed no difficulties in breathing and swallowing.
Lumbar puncture showed increased protein level with normal cell count (CSF appearance: clear; pressure: normal, glucose: 52 mg/dl; proteins 1.884 g/l, WBC: 2/mm3). CSF isoelectric focusing was negative for intrathecal oligoclonal immunoglobulin G synthesis (Table I).
Cranial and spinal MRI (Philips Ingenia 1,5T; Spin-echo, Turbo Spin-Echo, Inversion Recovery, Gradient Echo, Echo Planar with T1, T2, DP weighted sequences, pre and post-contrast) showed marked enhancement of cauda equina roots after contrast injection, both in the sagittal (Fig. 1) and axial (Fig. 2) views, according to the clinical hypothesis of Guillain-Barré polyradiculonevritis.
Sagittal T1w turbo spin echo (A) pre- and (B) post-contrast magnetic resonance imaging. The marked contrast enhancement of cauda equina roots, suggestive of Guillain-Barré syndrome, is indicated by the arrows in (B).
Axial T1w turbo spin echo (A) pre- and (B) post-contrast magnetic resonance imaging showing marked contrast enhancement of cauda equina roots, suggestive of Guillain-Barré syndrome, is indicated by the arrows in (B).
Nerve conduction study (NCS) pattern was consistent with acute inflammatory demyelinating polyradiculoneuropathy of moderate/marked degree in the lower limbs and of a more modest degree in the upper limbs.
A panel for CSF paraneoplastic and autoimmune antibodies was negative, in particular we excluded the presence of IgG anti-GM1 and anti-GQ1b antibodies, respectively frequently described in AMAN and MFS.
Molecular rhino-pharyngeal swab for SARS-CoV-2 was negative. Extensive virological and microbiological PCR searches on CSF, including SARS-CoV-2, and Campylobacter search on stools were negative. Epstein Barr Virus, Citomegalovirus and Borrelia serology were negative, while COVID-19 serology was positive (45.2 AU/ml, nv<12.0) (Table II). We did not perform specific test for Influenza virus for the absence of suggestive symptoms (no fever, headache, dizziness, malaise, rhinitis nor cough) and epidemiological data to support this suspect (https://www.epicentro.iss.it/influenza/flunews).
The girl was initially treated with two courses of intravenous immunoglobulins (IVIG, 2 g/kg per time, repeated after 7 days) with mild improvement of the clinical picture. She was discharged after 15 days of hospitalization.
Two months later, shortly after summer holidays, she experienced a mild recrudescence of gait instability and ataxia with NCS worsening, and a third course of IVIG was administered.
The girl is now on strict neurological follow up and undergoes regular physiotherapy. She underwent the last neuropsychiatric evaluation in February 2022. Motor and sensory deficits (hypotonia and hyporeflexia) persisted mainly in the lower limbs, despite the slight improvement. There was no evidence of deficits in the cranial nerves. Given the slow clinical improvement, an additional course of IV immunoglobulin will be given over the next few weeks.
Clinical description of the 19 pediatric cases is detailed in Table III. Our case is reported as the 20th.
Patient information, SARS-CoV-2 exposure, signs and symptoms of GBS, diagnostic tests for SARS-CoV-2 infection and for GBS, treatment type and duration, clinical outcome of 21 paediatric patients with GBS-associated with SARS-CoV-2 infection.
The GBS reported cases (12-25) come from Africa (Morocco, Tanzania), Asia (Saudi Arabia, India, Iran), South America (Brasil), North America (USA). The case we describe is the first from Europe.
Past history showed a recent (1 week to 1 month before the onset of neurological symptoms) infection suggestive for COVID-19, or a proven exposure to SARS-CoV-2, in 16/20 children. 17 children were tested for SARS-CoV-2 (antigenic or molecular swab) on admission, 9/17 were positive. Serology for SARS-CoV-2 was performed in 14/20 children, resulting positive in all cases. CSF PCR for SARS-CoV-2 was performed only in 4 cases, resulting positive in one child.
In our case, we found no history of respiratory or intestinal symptoms in the previous months. Other two children out of the reported cases were completely asymptomatic for COVID-19, had a negative SARS-CoV-2 swab on admission but were proven to have met the virus by serology (at that time, no vaccine against COVID-19 had been approved for pediatric age).
This finding is in line with COVID-19 presentation at pediatric age, often with an asymptomatic course (4).
Our patient did not receive recent vaccinations; she showed negativity of the common infectious researches on CSF and serum. In particular, Epstein Barr Virus, Citomegalovirus and Borrelia serology were negative, as well as Campylobacter search on stools.
We did not perform specific test for Influenza virus, because the girl had no suggestive symptoms (no fever, headache, dizziness, malaise, rhinitis nor cough) in the previous months. Moreover, during winter 2020-2021, virtually no cases of Influenza were reported in our region, perhaps thanks to the prevention measures taken during the COVID pandemic (https://www.epicentro.iss.it/influenza/flunews).
In our girl, the only positive infective result was the presence of SARS-CoV-2 antibodies in serum.
At the time of her hospital admission, in Italy, 400,000-700,000 total children aged 0-12 years have experienced COVID-19 since the beginning of the current pandemic, and no COVID-19 vaccine had been licensed for pediatric age. The positivity of our patient's SARS-Cov2 serology test in such epidemiological frame prompts us to consider an asymptomatic COVID-19 infection as a possible trigger of GBS.
Regarding the diagnostic challenge, GBS remains a clinical diagnosis that can be sustained by laboratory and instrumental tests.
CSF analysis was reported in 14/20 children of the reported series, showing the classical pattern of albumin-cytologic dissociation in 13/14. CSF was normal in one case.
In our case, the CSF examination showed the typical increase of total proteins without cellular reaction. We excluded, by the GanglioCombiTM ELISA kit, the presence of anti-ganglioside antibodies, frequently described in AMAN (IgG anti-GM1 antibodies) and MFS (anti-GQ1b antibodies) (26). The panel for CSF paraneoplastic syndromes (EUROLINE paraneoplastic neurological syndromes 12 Ag) was negative too.
Central nervous system MRI was reported in 10/20 children, with different results: abnormal enhancement of the cauda equina nerve roots was the most common finding (6/10), 2/10 were negative, one case was compatible with acute disseminated encephalomyelitis (ADEM), one case with posterior reversible encephalopathy syndrome (PRES) and one with longitudinally extensive transverse myelitis associated.
NCS was performed in 17/20 children, showing alterations consistent with demyelinating polyneuropathy in all cases. In 6 of these children, the NCS pattern was compatible with the acute motor axonal form of GBS (AMAN). One case presented the rare Miller Fisher variant of GBS. In our case, NCS pattern was consistent with AIDP.
From 2020, several reports (2-6) have described the possible causal association between SARS-CoV-2 infection and GBS. A recent systematic review has reported 99 cases of GBS with confirmed COVID-19 infection, with an average age of 56.07 years (7).
A study in Northern Italy has suggested an increased incidence of GBS during the pandemic period (from 0.077/100,000/month to 0.202/100,000/month) (27). In contrast, other studies have reported a reduction in GBS incidence during the pandemic period, probably due to the influence of lockdown measures on conventional GBS-inducing pathogens (28).
A clear relationship between specific autoantibodies and the occurrence of GBS in patients with SARS-CoV-2 infection, such as that observed in GBS associated with Campylobacter jejuni, has not yet been shown (28).
The common absence of SARS-CoV-2 in cerebrospinal fluid reinforces the hypothesis of a post-infectious immune-mediated mechanism, rather than a para-infectious etiology (3). However, in one of the cases reviewed here, SARS-CoV-2 PCR was positive on CSF, indicating a possible direct action of the virus in the SNC system.
GBS associated with SARS-CoV-2 infections have shown a distribution of clinical variants and electrophysiological subtypes resembling those of classic GBS, with a higher prevalence of the classic sensorimotor form and the acute inflammatory demyelinating polyneuropathy, although rare variants such as Miller Fisher syndrome have also been reported (4).
Progressive symmetrical muscle weakness starting from lower limbs and marked reduction of deep tendon reflexes remain the hallmark of this syndrome, as reported in the totality of cases. In 3 cases, lower back pain preceded the onset of muscle weakness by a few days.
Altered sensitivity was expressly reported in 9/20 cases, described as altered proprioception, decreased perception of light touch, position, and vibration, paresthesia or bowel and bladder dysfunction.
A more severe course requiring mechanical ventilation was reported in 7 children. Involvement of the cranial nerves was described in 4 cases, all of which required mechanical ventilation.
The therapy of GBS is focused on supportive treatment. Treatment with IVIG is recommended in children and adolescents with severe GBS (9) and should preferably begin as soon as possible after diagnosis, within 4 weeks of the onset of symptoms, since early treatment positively affects prognosis (29).
Among the 19 pediatric cases described in Table III, the therapeutic management required pediatric intensive care unit admission for 7 children in the first phase of the disease.
All cases in which treatment was detailed (13/20) were treated with IVIG with different schedules (mainly 400 mg/kg for 5 days or 1 g/kg for 2 days). Three children required some sessions of plasma-exchange therapy.
The overall long-term prognosis for children with GBS is more favorable than that in adults, whereby the majority of children largely regain motor function. The AMAN variant has a more acute and severe course than AIDP, with a higher rate of ventilated patients and delayed recovery. Nonetheless, it has been repeatedly shown that the long-term prognosis for both variants is equally favorable in children (9). The SARS-CoV-2 associated form had a good prognosis in more than 70% of patients, especially after treatment with intravenous immunoglobulins (4): 19/20 children of the reported series were dismissed from the hospital with varying degrees of motor improvement. One child died from respiratory complications. In one case, a familial recurrence of GBS (father of the young girl) was reported.
In conclusion, the SARS-CoV-2 infection is proving capable of extremely varied clinical pictures at pediatric age, especially concerning neurological complications. Interestingly, a substantial similarity has been observed in clinical and laboratory presentation of COVID-19-associated GBS compared to the clinical pictures described before the characterization of this novel virus.
In the absence of universally accepted diagnostic criteria, the cases we reviewed and the one described above were attributed to COVID-19 because of the finding of a positive swab test on admission or a positive serology and the exclusion of other possible diagnoses, such as infections, autoimmune diseases (in particular with the exclusion of anti-ganglioside antibodies, frequently described in AMAN and MFS) and malignancies (paraneoplastic syndromes).
We suggest our findings need further research for confirmation, and the clinical suspicion of a possible association with SARS-CoV-2 infection must remain high to allow a greater understanding of the disease, its prevention and therapy at pediatric age.
We thank the following individuals for their help in the diagnostic research: Dr Andrea Piceghello (Laboratory of Microbiology and Virology, Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy); Dr Francesca Rumbolo (Clinical Biochemistry Laboratory, Department of Laboratory Medicine, Città della Salute e della Scienza Hospital, Turin, Italy); and Dr Nicolò Li Vigni (Laboratory of Microbiology and Virology, Ivrea Hospital, ASL To 4, Ivrea, Italy).
Funding: No funding was received.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
All authors substantially contributed to the present work, both in the clinical setting and in the elaboration of the present article. MI, MB, EG and FT were involved in the diagnosis of the patient through the acquisition, analysis and interpretation of data. IM, CB, MMC, AC, MI, MB and FT were involved in diagnosis and clinical management of the patient. IM and CB acquired, analyzed and interpreted the literature data. IM, CB and FST wrote and edited the manuscript. FT supervised the study. FT and IM confirm the authenticity of all data. All authors have read and approved the final manuscript, and agree to be accountable for all aspects of the work.
Ethics approval and consent to participate
The publication of the case report has been approved by the local ethics committee AOU San Luigi Gonzaga AA SS LL TO3-TO4-TO5 (approval no. 722; 17/01/2022).
Patient consent for publication
Written informed consent to publication has been obtained from the parents on behalf of the patient.
The authors declare that they have no competing interests.
Dr Fabio Timeus, ORCID 0000-0003-0095-283X.
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