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Case seriesGuillain barre syndrome with COVID-19Case series

DOI: 103126/JNPS.V4113

Guillain Barre Syndrome as a Presentation of post Covid-19 
Infection among Children: A Case Series

During the second wave of Covid-19 pandemic, children presented with 
myriad of central nervous system manifestations and one of them was 
Guillain-Barré syndrome (GBS). It is caused by various viruses including 
recent Covid-19 infection by either direct invasion or post infectious process. 
Most of these cases were reported in adults and very few in children. Here, 
we report a case series of five children with GBS along with positive Covid-
19 antibodies. All patients responded well to intravenous immunoglobulin 
without any residual weakness. We could probably link casual association 
of Covid-19 infection with GBS.

Abstract

1 Associate Professor, Department of Paediatrics, D.Y. Patil Medical College, D Y Patil Education Society (Deemed to be University), 
Kolhapur (416003), Maharashtra, India. 
2 Consultant Paediatric Neurologist, Vimal Pediatric Neurology Clinic, Kolhapur (416012), Maharashtra, India. 
3 Junior Resident, Department of Paediatrics, D.Y. Patil Medical College, D Y Patil Education Society (Deemed to be University), 
Kolhapur (416003), Maharashtra, India. 
4 Consultant Paediatric Neurologist, Arya Children’s  Neurology Super Speciality Clinic, Kolhapur (416003), Maharashtra, India.
5 Professor, Department of Paediatrics, D.Y. Patil Medical College, D Y Patil Education Society (Deemed to be University), 
Kolhapur(416003), Maharashtra, India. 
6 Professor and HOD, Department of Paediatrics, D.Y. Patil Medical College, D Y Patil Education Society (Deemed to be University), 
Kolhapur (416003), Maharashtra, India.

Kavthekar Saiprasad Onkareshwar1, Patil Rahul Ravso2, Narahari Venkata Susmitha3,   
Jadhav Vilas Maruti4, Patil Nivedita Balasaheb5, Kurane Anil Bapurao6 

*Corresponding Author

Rahul Ravso Patil, 
Consultant Paediatric Neurologist , 
Vimal Pediatric Neurology Clinic, 
Kolhapur (416012), 
Maharashtra, India. 
Email:drrahulpatil1980@gmail.com

Article History 
Received On: 18 May, 2022
Accepted On: 10 Apr, 2023

Funding sources: None

Conflict of Interest: None

Keywords: 
Acute Flaccid Paralysis, Children, Covid-
19, Guillain Barre Syndrome

Online Access

DOI:
https://doi.org/10.3126/jnps.v42i3.45157 

Copyrights & Licensing © 2022 by author(s). This is an Open Access article dis-
tributed under Creative Commons Attribution License (CC BY NC )

Introduction
The second wave of Covid-19 pandemic had affected all age groups 
including children in many countries of the world including India. Covid-19 
patients presented with myriad of central nervous system manifestations 
in children and one of them was Acute Flaccid Paralysis (AFP). The 
commonest cause of AFP is Guillain-Barre Syndrome (GBS) in India.1 It 
occurs by damage of lower motor neurons in the anterior horn cell of the 
spinal cord or peripheral nerves either by direct invasion or para-infectious 
and /or post-infectious immune mediated mechanisms.2 The triggers could 
be minor respiratory or gastrointestinal illness due to viral or bacterial 
infections.2 Amongst viruses, polioviruses, enterovirus71, flavivirus, herpes 
virus and rabies virus are well known.2  However, few case reports from 
various western countries, more in adults than children, reported  Covid-19 
and GBS as either post or para infectious presentation.3

Till date to our knowledge, there were limited case studies of GBS in 
children with concurrent Covid-19 positivity from India.4 As there is 
paucity of literature, here we report a case series of five children with 
GBS presentation with positive Covid-19 antibodies suggestive of recent 
Covid-19 infection. Interestingly, they all were presented within a span 
of three months (May 2021 - July 2021) during the peak of Covid-19 
pandemic which leads to suspicion of causal association of Covid-19 and 
GBS.



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  202262

Case series Guillain barre syndrome with COVID-19

Cases Presentation: All five cases are presented in Table 1.

Particulars Case 1 Case 2 Case 3 Case 4 Case 5

Age (Years) 14 8 12 9 11

Gender Male Male Male Male Male

Clinical Features Ascending symmet-
rical paralysis

 Ascending symmetrical
paralysis

 Ascending symmetrical
paralysis

Ascending symmetri-
cal paralysis

Ascending sym-
metrical paralysis

 Cranial nerve
involvement

Bulbar palsy  Bilateral LMN facial
palsy

 No  Bilateral LMN facial
palsy

Bulbar palsy

 Power
(MRC Grading)

Upper Limbs 1/5
Lower Limbs 1/5

Upper Limbs 3/5
Lower Limbs 2/5

Upper Limbs 3/5
Lower Limbs 2/5

Upper Limbs 2/5
Lower Limbs 1/5

Upper Limbs 1/5
Lower Limbs 1/5

Tone  Hypotonia in all
limbs

Hypotonia in all limbs Hypotonia in all limbs  Hypotonia in all
limbs

 Hypotonia in all
limbs

DTR Absent Absent Absent Absent Absent

 Autonomic
instability

 No No No No  Present
 Tachycardia and
 hypertension

CSF analysis Proteins 95 mg/dl, 
No cells

Proteins 59 mg/dl, 
No cells

Proteins 52 mg/dl, 
No cells

Proteins 85 mg/dl, 
No cells

Proteins100 mg/
dl, 
No cells

Nerve Conduc-
tion Studies

Not done  Acute demyelinating
polyneuropathy

 Acute Motor Axonal
Neuropathy

 Acute Motor Axonal
Neuropathy

Not done

 Laboratory
 Inflammatory
Markers

NAD D-Dimer 950 ng/ml 
(Raised)

NAD NAD NAD

Covid-19 anti-
body

Positive (IgG 4.02) Positive Positive Positive (IgG 9.66)  Positive

Covid-19 RTPCR Negative Positive Negative Negative Negative

Mechanical 
Ventilation

 Required for 30
days

Not required  Not required Not required  Required for 45
days

Hospital Stay days 45 days 10 days 12 days 14 days 65

Status at Dis-
charge

Off Ventilator
Power
Upper Limbs 4/5
Lower Limbs 3/5

 No progression of
weakness

 No progression of
weakness

 No progression of
weakness

Off Ventilator
Power
Upper Limbs 3/5
Lower Limbs 2/5

Table 1: Clinical Presentation of cases.                  

CSF: Cerebrospinal Fluid, DTR: Deep Tendon Reflexes, LMN: Lower Motor Neuron, MRC: Medical Research Council, 
NAD: No Abnormality Detected

Discussion
All these five cases of GBS with Covid-19 antibodies 
positivity presented during the peak of second wave of 
Covid-19 pandemic from Kolhapur, Maharashtra, India 
during May 21 to July 21. During that period, children 
were highly affected due to Covid-19 and few children 
presented with central nervous system manifestations 
like headache, anosmia, febrile seizures, stroke, acute 
encephalitis and GBS. From our case series of GBS, all 
five patients were males, with age group between eight 
to 14 years (10.8 ± 2.39 years). They all presented with 

acute flaccid, symmetrical, ascending paralysis along 
with albumin-cytological dissociation and four had cranial 
nerve involvement (Two with bilateral lower motor neuron 
facial palsy while two with bulbar palsy). One patient 
had autonomic instability in the form of tachycardia and 
hypertension. We could perform nerve conduction velocity 
studies and MRI spine in only three (Two had acute motor 
axonal neuropathy and one had acute postinfectious 
polyneuropathy) and one patient respectively due to 
financial constraints and logistic issues. A study done by 
Sen S et1 al in his non Covid-19 GBS cohort from India 
observed demyelinating variety more common than axonal 



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  2022 63

Case seriesGuillain barre syndrome with COVID-19

subtype. All patients were tested positive for Covid-19 
antibodies while a single patient also tested positive for 
Covid-19 RTPCR. Rarely, Covid-19 RT-PCR test may remain 
positive longer even after recovery from primary SARS-CoV-2 
infection.5 Also, all patients received immunotherapy in the 
form of intravenous immunoglobulin (IVIG) in the dose of 1 
gm / kg / day for two days immediately on admission after 
confirming clinical diagnosis. Three patients responded well 
to IVIG therapy, while two patients progressed further with 
respiratory muscle paralysis needing mechanical ventilation 
support in the Intensive Care Unit. One patient who was 
on mechanical ventilator support received repeat second 
dose of IVIG. All patients recovered completely eventually 
without any residual weakness over the period of next three 
to four months with good prognosis.

Initial case reports of Covid-19 and GBS with its variants 
were documented in adults, and supposed to be as a post 
infectious process.6-8 Curtis M3 and Das KY5 reported a first 
case of Covid-19 and GBS in children from Indianapolis from 
United States (para-infectious) and India (post-infectious) 
respectively. Both these cases were responded well to IVIG 
therapy without any mortality and morbidity. The average 
duration to develop post Covid-19 GBS was less than two 
weeks.9 The exact mechanism for association of Covid-19 
and GBS is still not clear. The possible mechanisms 
include neurotropism and post infectious aberrant immune 
response.10 

From our case series, we could link probable casual 
association of Covid-19 infection with GBS. The reason 
could be firstly, we haven’t seen a single case of GBS at 
our institute in the previous year and we got all five cases 
within a span three months during Covid-19 second wave. 
Secondly, no past history of other viral or bacterial illness 
obtained within one month in all patients which ruled out 
other etiological causes of GBS. Also, we could not able to 
perform CSF RT-PCR for Covid-19 and other viral antigen 
markers due to financial constraints. Even, GBS is post 
infectious autoimmune condition, viral markers may not be 
positive at the time of presentation. Most of the antibody 
tests for viruses other than Covid-19 are also costly and 
not available, we couldn’t perform these tests. Further 
studies and research may be necessary to establish causal 
association of Covid-19 with GBS.

Conclusions
We could link probable casual association of Covid-19 
infection with GBS. All children responded well to IVIG and 
supportive treatment without any residual muscle weakness 
which was suggestive of good prognosis. 

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