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• Guillain-Barré syndrome in developing countries in the COVID-19 era
  Zhahirul Islam, Imran Hasan and Quazi D Mohammad
  Published on: 4 September 2020

• Published on: 4 September 2020

  Guillain-Barré syndrome in developing countries in the COVID-19 era

  • Zhahirul Islam, Neuroscientist Laboratory of Gut-Brain Signaling, Laboratory Sciences and Services Division, icddr,b, Dhaka, Bangladesh
  • Other Contributors:
    • Imran Hasan, Neuro-epidemiologist
    • Quazi D Mohammad, Neurologist

  Dear sir,

  Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become one of the most severe pandemic the world has ever seen. Based on data from Johns Hopkins University, around 26.3 million cases have been detected and around 0.9 million patients have died of COVID-19 globally as of September 04, 2020. The neurological sequelae of COVID-19 include a para/post-infectious, immune or antibody-mediated phenomenon, which classically manifests as Guillain-Barré syndrome (GBS).[1, 2]

  We read the systematic review by Uncini et al with great interest. In an instant systematic review, the authors reported 42 patients of GBS associated with COVID-19 from 33 retrieved articles. All of these articles had been reported from 13 developed countries.[3] The authors mentioned regarding the chronology of publication of case reports/series starting from China followed by Iran, France, Italy, Spain and USA which seemed to be related to the track of SARS-CoV-2 infection spread. However, the authors did not discuss why such cases/series had remained under-reported from developing countries. A comprehensive, advanced search of PubMed using the terms ‘SARS-CoV-2’ OR ‘COVID-19’ AND ‘Guillain-Barré syndrome’ on September 04, 2020, led to retrieval of two additional articles from developing countries, one each from Brazil and Morocco.[4 ,5] As of September 04, 2020, Brazil and India had the 2nd and 3rd highest number of COVI...

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  Dear sir,

  Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become one of the most severe pandemic the world has ever seen. Based on data from Johns Hopkins University, around 26.3 million cases have been detected and around 0.9 million patients have died of COVID-19 globally as of September 04, 2020. The neurological sequelae of COVID-19 include a para/post-infectious, immune or antibody-mediated phenomenon, which classically manifests as Guillain-Barré syndrome (GBS).[1, 2]

  We read the systematic review by Uncini et al with great interest. In an instant systematic review, the authors reported 42 patients of GBS associated with COVID-19 from 33 retrieved articles. All of these articles had been reported from 13 developed countries.[3] The authors mentioned regarding the chronology of publication of case reports/series starting from China followed by Iran, France, Italy, Spain and USA which seemed to be related to the track of SARS-CoV-2 infection spread. However, the authors did not discuss why such cases/series had remained under-reported from developing countries. A comprehensive, advanced search of PubMed using the terms ‘SARS-CoV-2’ OR ‘COVID-19’ AND ‘Guillain-Barré syndrome’ on September 04, 2020, led to retrieval of two additional articles from developing countries, one each from Brazil and Morocco.[4 ,5] As of September 04, 2020, Brazil and India had the 2nd and 3rd highest number of COVID-19 cases (Johns Hopkins data), yet only one case of COVID-19-associated GBS had been reported from Brazil and no case had been reported from India. An Italian study reported a 5.4-fold increase in the incidence of GBS during this pandemic.[2] In contrast, the number of GBS cases in Bangladesh, a developing country, had decreased during the pandemic (personal communication with country coordinator (Bangladesh) of International GBS Outcome Study (IGOS), August 2020), even though Bangladesh reported the highest number of GBS cases worldwide in the IGOS.

  The lack of or inadequate testing facilities and structural barriers to getting tested for COVID-19, i.e., excessive waiting time or lack of one-stop services may contribute to under-reporting of COVID-19-associated GBS in developing countries. We assume that some patients with GBS in developing countries did not seek hospital care due to the lock-down, lack of public transport services, social stigma and fear of nosocomial infection. However, it requires further exploration if truly there were no COVID-19-associated GBS cases in developing countries or these cases had remained under-reported.

  Patients of GBS associated with COVID-19 may not present with typical symptoms. For instance, the first reported case of GBS associated with SARS-CoV-2 infection was para-infectious, rather than the classical post-infectious presentation.[1] Some cases of GBS may also be negative for SARS-CoV-2 in reverse transcriptase polymerase chain reaction (RT-PCR) tests, as reported by an Italian study.[2] Moreover, if a patient develops GBS long after the acute infection subsides, RT-PCR testing for SARS-CoV-2 may also be negative. Analysis of serum IgG and IgM for SARS-CoV-2 may help to confirm or exclude antecedent SARS-CoV-2 infection, though such tests may not be available in developing countries—which may also result in underreporting of COVID-19-associated GBS.

  The high number of reported cases of COVID-19-associated GBS worldwide provides evidence of a possible association between GBS and COVID-19. Therefore, during this pandemic, clinicians and neurologists should be aware that patients presenting with GBS, even in the absence of cough, fever, respiratory distress or any systemic symptoms, may represent the first manifestation of COVID-19. During this global pandemic, the differential diagnosis of COVID-19-associated GBS should be considered for all cases of GBS, until and unless confirmed otherwise. We call for attention of the clinicians, especially neurologists in developing countries to strengthen surveillance system for identification, reporting and better management of COVID-19-associated GBS.

  References

  1. Zhao H, Shen D, Zhou H, et al. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence? Lancet Neurol 2020;19(5):383-84. doi: 10.1016/s1474-4422(20)30109-5
  2. Gigli GL, Bax F, Marini A, et al. Guillain-Barré syndrome in the COVID-19 era: just an occasional cluster? J Neurol 2020:1-3. doi: 10.1007/s00415-020-09911-3
  3. Uncini A, Vallat J-M, Jacobs BC. Guillain-Barré syndrome in SARS-CoV-2 infection: an instant systematic review of the first six months of pandemic. Journal of Neurology, Neurosurgery & Psychiatry 2020:jnnp-2020-324491. doi: 10.1136/jnnp-2020-324491
  4. El Otmani H, El Moutawakil B, Rafai MA, et al. Covid-19 and Guillain-Barré syndrome: More than a coincidence! Revue neurologique 2020;176(6):518-19. doi: 10.1016/j.neurol.2020.04.007
  5. Frank CHM, Almeida TVR, Marques EA, et al. Guillain-Barré Syndrome Associated with SARS-CoV-2 Infection in a Pediatric Patient. J Trop Pediatr 2020 doi: 10.1093/tropej/fmaa044

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  Conflict of Interest:
  None declared.

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