In the last days of 2019, the world faced the novel viral infection pandemic crisis caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1). Although COVID-19 is typically presenting with respiratory symptoms, potential neurological manifestations are increasingly being reported including central and peripheral nervous system involvement (2) .
Acute/subacute immune-mediated polyradiculoneuropathy (Guillain-Barre-Syndrome) mostly occurs after viral or bacterial infections, presenting with flaccid paralysis of limbs and cranial nerves, absent deep tendon reflexes, autonomic dysfunction and respiratory failure (3) .
Here we report a patient with confirmed COVID-19 and acute polyradiculoneuropathy and skin eruptions.
A 37-year-old healthy man was referred to Neurology Department of Ghaem hospital at Mashhad University of Medical Science with acute progressive painless weakness with symmetrical ascending pattern since 1 month ago. The patient had a history of fever and respiratory symptoms about 2 weeks before developing weakness and his Lung HRCT scan showed patchy groundglass opacity, but Reverse transcription polymerase chain reaction (RT-PCR) for COVID-19 of nasopharyngeal sample was negative at that time. Widespread maculopapular pigmented and crusted plaques appeared on the limbs and trunk just few days after the weakness had begun. The patient was admitted to the local hospital and was treated with 2 g/kg intravenous Immunoglobulin for 5 continuous days since electrophysiologic study showed acute sensorimotor polyradiculoneuropathy. The patient was referred to our hospital without any improvement. On admission day (30th day of beginning Brain and spine MRI was normal. Skin punch biopsy of right forearm showed interface dermatitis and vasculopathic reaction. One week later after admission in our hospital the patient developed respiratory distress, he was intubated and underwent the mechanical ventilation. After 2 weeks of antibiotic therapy, he was extubated and O2 saturation at room air was above 95% but still has significant weakness in extremities. Skin eruptions were pigmented and crusted with no itching. He was discharged to do rehabilitation. We reported a confirmed case of COVID-19 with acute sensorimotor polyradiculoneuropathy predominantly demyelinating with severe secondary axonal loss and scaling maculopapular pigmented erosive plaques on limbs and trunk. The patient had a history of respiratory syndrome 2 weeks before being tetraparetic, although he was highly suspected to COVID-19, the primary nasopharyngeal SARS-CoV-2 PCR test at that local hospital was reported negative. As the symptoms was typical for COVID19, it might be false negative due to The skin lesions that appeared just a few days after limbs weakness had begun, were maculopapular pigmented and crusted plaques on the limbs and trunk. The patient did not have history of taking any drug. Punch biopsy showed interface dermatitis and vasculopathic reaction, which can be seen in drug reaction or viral exanthem. The most common reported dermatologic presentations in confirmed or highly suspected patients are morbilliform, pernio-like, urticaria, macular erythema, vesicular, papulosquamous and retiform purpura.(11) We had limitation of antiganglioside antibody testing to identify a specific target of autoimmune process and also SARS-Cov-2 PCR on CSF, but it has been reported negative in all the other published cases (7).
In summary the causal association between Guillen-Barre-Syndrome and COVID19 is uncertain yet, but physicians and neurologists should be aware of early diagnosis and treatment of acute polyradiculoneuropathy that may cause fatal dysautonomia and respiratory failure in the context of COVID19 pandemic. 