Clinical Features of Guillain-Barre Syndrome in COVID-19 Patients: Aria and Naft Private Hospitals in Ahvaz, Iran

INTRODUCTION

Coronaviruses are a large family of viruses ranging from the common cold virus to those that cause serious diseases, such as SARS, MERS, and Covid-19. New coronavirus (SARS - CoV-2) is primarily associated with non-specific symptoms such as nausea, fatigue and body aches, fever, and dry cough. Patients shortly before the onset of fever may initially have symptoms of nausea and diarrhea or headache or vomiting of blood or might be even asymptomatic. Fever, shortness of breath, dry cough, and radiological findings such as lung glassy opacities are common symptoms of this disease [1, 2]. The major cause of Guillain-Barre syndrome is unknown, but the onset of the disease is seemingly associated with the emergence of antibodies against peripheral nerve myelin. The major clinical manifestation of Guillain-Barre syndrome is weakness, which occurs symmetrically from several days to two weeks. Proximal muscles as distal muscles are involved, and weakness of respiratory muscles might result in death. Other complaints include paresthesia, numbness, and loss of sensation, pain, and muscle discomfort. In this disease, autonomic dysfunction is common but rarely lasts more than one or two weeks [3]. There is no definitive cure for Guillain-Barre, but there are ways to improve symptoms, most of which include IVIG and plasmapheresis [4, 5]. Guillain-Barre syndrome is an autoimmune disorder characterized by a group of different clinical and pathological findings. It is believed that different infections stimulate the immune system and cause a cross-reaction on nerves and demyelination of the myelin membrane. After eradication of polio, Guillain-Barre syndrome is the most common cause of acute flaccid paralysis at all ages, especially in childhood, [6]. The annual rate of this disease around the world is 1 to 4 percent per thousand people and it is higher in males than females, while some reports suggest its prevalence in males and females. The mechanism of this disease has not been understood completely so far, but the involvement of autoimmune processes in it has been proven. In 75% of cases, before paralysis, a history of viral or microbial disease of the respiratory or gastrointestinal tract is seen [7]. Although various clinical events have been reported before Guillain-Barre, infections, and vaccines have received more attention as potential underlying factors. The prevalence of different types of infections reported before the onset of Guillain-Barre syndrome varies in different geographical and social regions. The most common infection reported in some regions with high latitude and countries with better socio-financial status is infection with Campylobacter jejuni with gastrointestinal symptoms [8, 9]. By recognizing the immunological basis of Guillain-Barre Syndrome (GBS), the use of plasmapheresis, Intravenous Immunoglobulin (IVIG) has become more common. The new classification and the use of the mentioned therapeutic methods have caused several studies to be done on the outcome of a disease based on these classifications and therapeutic methods. Some of these studies suggest that the use of intravenous immunoglobulin improves the prognosis of this disease [10, 11]. Campylobacter jejuni is a gram-negative organism that is a common cause of bacterial diarrhea in developed and developing countries and is known as an infectious agent before the onset of neurological symptoms of Guillain-Barre syndrome. It is thought that due to the molecular similarity of the membrane antigens of this bacterium with peripheral nerve gangliosides, antibodies made against the bacterial membrane antigen cause damage to the peripheral nerves [12, 13]. In addition to causing clinical symptoms, Guillain-Barre syndrome may be mistaken with poliomyelitis and since polio is close to eradication, all cases of acute flaccid paralysis, including Guillain-Barre syndrome, are being carefully examined [14]. Rapid diagnosis and rejection of multiple possible diagnoses and the selection of appropriate treatment methods have high importance. After the eradication of polio, it is the most important cause of acute paralysis in most developing countries [15]. Despite several studies on this issue in different parts of the world, no study has been conducted in Iran, especially in the Khuzestan province. Given what was stated above, the present research was conducted to evaluate the clinical features of Guillain-Barre syndrome in patients with COVID-19 in private Aria and Naft hospitals in Ahvaz.

MATERIALS AND METHODS

This study is descriptive in terms of the type of study and cross-sectional in terms of time. The statistical population of this study included all patients (8 patients) with COVID-19-induced Guillain-Barre referred to Aria and Naft private hospitals in Ahvaz in 2020 and 2021. Due to the limited population (8 people), no sampling was performed. Inclusion criteria of the study included Guillain-Barre diagnostic criteria based on clinical examination, electrodiagnostic study, and spinal fluid, positive RT-PCR test, and lung CT. Exclusion criteria of the study were negative RT-PCR test, lack of lung CT and Guillain-Barre criteria in the clinical examination, electrodiagnostic study, and unwillingness to participate in the study. All GBS patients were evaluated based on international diagnostic criteria according to electro-diagnostic criteria and clinical signs, including upper limb weakness, lower limb weakness, dysfunction, and inability to walk within one year. Patients' data was collected from their medical records, which included a medical history based on a standard checklist. The validity of the checklist was examined by 3 relevant experts. The reliability of the checklist was obtained at 0.85. Studied variables included gender, age of onset, duration of hospital stay, patient age, clinical symptoms such as early symptoms and neurological findings during the study period, laboratory findings and other medical conditions, specific therapies such as plasmapheresis and intravenous immunoglobulin. All patients’ recorded reports were reviewed and the required data were extracted.

During the research, all ethical principles were observed and the necessary permissions were obtained from the Clinical Research Development Unit of Aria private hospital.

Data was described through charts, tables, and numerical indices. Paired t-test and Chi-square test were used to determine the relationship between variables. Data was analyzed in SPSS24 software.

RESULTS AND DISCUSSION

The average age of the patients was 47 years. Most patients were male (75%). Besides, 75% of patients had a history of hospitalization. The highest percentage of patients (87.5%) had paresthesia and lower and upper limb weakness (75%). The lowest percentage was premature fatigue and weakness with 50%. The results of Table 1 show it is higher in males than females.

Table 1. Frequency Distribution of Demographic Variables Separately for Different Levels of Variables

In the present study, based on the information obtained from patients' medical records, after the diagnosis of the disease, drugs were prescribed and measures were taken to improve the disease. Table 2 shows the treatment measures after hospitalization of patients with COVID-19-induced Guillain-Barre syndrome.

Table 2. Frequency Distribution of Post-hospital Measures in Patients with COVID-19-induced Guillain-Barre

The results of Table 2 show that 62.5% (n = 5) of patients received IVIg, 12.5% ​​(n = 1) received plasmapheresis and 25% (n = 2) received physiotherapy after hospitalization. The results also indicated that the lowest mean age of the plasmapheresis group was 39 years and the highest mean age of the physiotherapy group was 57 years. Moreover, the relationship between age and any of the variables was not significant (P> 0.05). Table 3 shows the relationship between gender and symptoms at diagnosis time.

Table 3. The Relationship between Gender and Symptoms at Diagnosis Time in the Subjects