Guillain-Barre Syndrome, a Rare Neurological Disorder, Linked to COVID-19
By Sherry H-Y. Chou, Aarti Sarwal and Neha S. Dangayach
The patient in the case report (let's call him Tom) was 54 and in good health. For two days in May, he felt unwell and was too weak to get out of bed. When his family finally brought him to the hospital, doctors found that he had a fever and signs of a severe infection, or sepsis. He tested positive for SARS-CoV-2, the virus that causes COVID-19 infection. In addition to symptoms of COVID-19, he was also too weak to move his legs.
When a neurologist examined him, Tom was diagnosed with Guillain-Barre Syndrome, an autoimmune disease that causes abnormal sensation and weakness due to delays in sending signals through the nerves. Usually reversible, in severe cases it can cause prolonged paralysis involving breathing muscles, require ventilator support and sometimes leave permanent neurological deficits. Early recognition by expert neurologists is key to proper treatment.
We are neurologists specializing in intensive care and leading studies related to neurological complications from COVID-19. Given the occurrence of Guillain-Barre Syndrome in prior pandemics with other corona viruses like SARS and MERS, we are investigating a possible link between Guillain-Barre Syndrome and COVID-19 and tracking published reports to see if there is any link between Guillain-Barre Syndrome and COVID-19.
Some patients may not seek timely medical care for neurological symptoms like prolonged headache, vision loss and new muscle weakness due to fear of getting exposed to virus in the emergency setting. People need to know that medical facilities have taken full precautions to protect patients. Seeking timely medical evaluation for neurological symptoms can help treat many of these diseases.
What Is Guillain-Barre Syndrome?
Guillain-Barre syndrome occurs when the body's own immune system attacks and injures the nerves outside of the spinal cord or brain – the peripheral nervous system. Most commonly, the injury involves the protective sheath, or myelin, that wraps nerves and is essential to nerve function.
Without the myelin sheath, signals that go through a nerve are slowed or lost, which causes the nerve to malfunction.
To diagnose Guillain-Barre Syndrome, neurologists perform a detailed neurological exam. Due to the nerve injury, patients often may have loss of reflexes on examination. Doctors often need to perform a lumbar puncture, otherwise known as spinal tap, to sample spinal fluid and look for signs of inflammation and abnormal antibodies.
Studies have shown that giving patients an infusion of antibodies derived from donated blood or plasma exchange – a process that cleans patients' blood of harmful antibodies - can speed up recovery. A very small subset of patients may need these therapies long-term.
The majority of Guillain-Barre Syndrome patients improve within a few weeks and eventually can make a full recovery. However, some patients with Guillain-Barre Syndrome have lingering symptoms including weakness and abnormal sensations in arms and/or legs; rarely patients may be bedridden or disabled long-term.
Guillain-Barre Syndrome and Pandemics
As the COVID-19 pandemic sweeps across the globe, many neurologic specialists have been on the lookout for potentially serious nervous system complications such as Guillain-Barre Syndrome.
Though Guillain-Barre Syndrome is rare, it is well known to emerge following bacterial infections, such as Campylobacter jejuni, a common cause of food poisoning, and a multitude of viral infections including the flu virus, Zika virus and other coronaviruses.
Studies showed an increase in Guillain-Barre Syndrome cases following the 2009 H1N1 flu pandemic, suggesting a possible connection. The presumed cause for this link is that the body's own immune response to fight the infection turns on itself and attacks the peripheral nerves. This is called an "autoimmune" condition. When a pandemic affects as many people as our current COVID-19 crisis, even a rare complication can become a significant public health problem. That is especially true for one that causes neurological dysfunction where the recovery takes a long time and may be incomplete.
Though there is clear clinical suspicion that COVID-19 can lead to Guillain-Barre Syndrome, many important questions remain. What are the chances that someone gets Guillain-Barre Syndrome during or following a COVID-19 infection? Does Guillain-Barre Syndrome happen more often in those who have been infected with COVID-19 compared to other types of infections, such as the flu?
The only way to get answers is through a prospective study where doctors perform systematic surveillance and collect data on a large group of patients. There are ongoing large research consortia hard at work to figure out answers to these questions.
Understanding the Association Between COVID-19 and Guillain-Barre Syndrome
While large research studies are underway, overall it appears that Guillain-Barre Syndrome is a rare but serious phenomenon possibly linked to COVID-19. Given that more than 10.7 million cases have been reported for COVID-19, there have been 10 reported cases of COVID-19 patients with Guillain-Barre Syndrome so far – only two reported cases in the U.S., five in Italy, two cases in Iran and one from Wuhan, China.
It is certainly possible that there are other cases that have not been reported. The Global Consortium Study of Neurological Dysfunctions in COVID-19 is actively underway to find out how often neurological problems like Guillain-Barre Syndrome is seen in hospitalized COVID-19 patients. Also, just because Guillain-Barre Syndrome occurs in a patient diagnosed with COVID-19, that does not imply that it was caused by the virus; this still may be a coincident occurrence. More research is needed to understand how the two events are related.
Due to the pandemic and infection-containment considerations, diagnostic tests, such as a nerve conduction study that used to be routine for patients with suspected Guillain-Barre Syndrome, are more difficult to do. In both U.S. cases, the initial diagnosis and treatment were all based on clinical examination by a neurological experts rather than any tests. Both patients survived but with significant residual weakness at the time these case reports came out, but that is not uncommon for Guillain-Barre Syndrome patients. The road to recovery may sometimes be long, but many patients can make a full recovery with time.
Though the reported cases of Guillain-Barre Syndrome so far all have severe symptoms, this is not uncommon in a pandemic situation where the less sick patients may stay home and not present for medical care for fear of being exposed to the virus. This, plus the limited COVID-19 testing capability across the U.S., may skew our current detection of Guillain-Barre Syndrome cases toward the sicker patients who have to go to a hospital. In general, the majority of Guillain-Barre Syndrome patients do recover, given enough time. We do not yet know whether this is true for COVID-19-related cases at this stage of the pandemic. We and colleagues around the world are working around the clock to find answers to these critical questions.
Sherry H-Y. Chou is an Associate Professor of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh.
Aarti Sarwal is an Associate Professor, Neurology, Wake Forest University.
Neha S. Dangayach is an Assistant Professor of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai.
Disclosure statement: Sherry H-Y. Chou receives funding from The University of Pittsburgh Clinical Translational Science Institute (CTSI), the National Institute of Health, and the University of Pittsburgh School of Medicine Dean's Faculty Advancement Award. Sherry H-Y. Chou is a member of Board of Directors for the Neurocritical Care Society. Neha S. Dangayach receives funding from the Bee Foundation, the Friedman Brain Institute, the Neurocritical Care Society, InCHIP-UConn Center for mHealth and Social Media Seed Grant. She is faculty for emcrit.org and for AiSinai. Aarti Sarwal does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Reposted with permission from The Conversation.
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By Joe Roman and Taylor Ricketts
The COVID-19 pandemic in the United States is the deepest and longest period of malaise in a dozen years. Our colleagues at the University of Vermont have concluded this by analyzing posts on Twitter. The Vermont Complex Systems Center studies 50 million tweets a day, scoring the "happiness" of people's words to monitor the national mood. That mood today is at its lowest point since 2008 when they started this project.
The Hedonometer measures happiness through analysis of key words on Twitter, which is now used by one in five Americans. This chart covers 18 months from early 2019 to July 2020, showing major dips in 2020. hedonometer.org<p>These same tweets also indicate a potential salve. Before pandemic lockdowns began, doctoral student <a href="https://scholar.google.com/citations?user=0P0ZYbIAAAAJ&hl=en" target="_blank">Aaron Schwartz</a> <a href="https://doi.org/10.1002/pan3.10045" target="_blank">compared tweets before, during, and after visits to 150 parks, playgrounds and plazas</a> in San Francisco. He found that park visits corresponded with a spike in happiness, followed by an afterglow lasting up to four hours.</p><p>Tweets from parks contained fewer negative words such as "no," "not" and "can't," and fewer first-person pronouns like "I" and "me." It seems that nature makes people more positive and less self-obsessed.</p><p>Parks keep people happy in times of global crisis, economic shutdown and public anger. Research has also shown that transmission rates for COVID-19 are <a href="https://www.sfchronicle.com/news/article/Is-risk-of-coronavirus-transmission-lower-15287602.php" target="_blank">much lower outdoors than inside</a>. As scholars who study <a href="https://scholar.google.com/citations?user=yFzb2EUAAAAJ&hl=en" target="_blank">conservation</a> and how nature <a href="https://scholar.google.com/citations?user=CCnUeN8AAAAJ&hl=en" target="_blank">contributes to human well-being</a>, we see opening up parks and creating new ones as a straightforward remedy for Americans' current blues.</p>
Park Visits Are Up During the Pandemic<p>According to the Hedonometer, sentiments expressed online started trending lower in mid-March as the impacts of the pandemic became clear. As lockdowns continued, they registered the lowest sentiment scores on record. Then in late May, effects from George Floyd's death in police custody and the following protests and police response once again could be seen on Twitter. May 31, 2020 was the saddest day of the project.</p><p>Recent surveys of park visitors around the University of Vermont have shown people <a href="https://osf.io/preprints/socarxiv/sd3h6" target="_blank">using green spaces more</a> since COVID-19 lockdowns began. Many people reported that parks were highly important to their well-being during the pandemic.</p>
<div id="4c7e4" class="rm-shortcode" data-rm-shortcode-id="bc0ac146ab2a94228f32d973fc2ab272"><blockquote class="twitter-tweet twitter-custom-tweet" data-twitter-tweet-id="1289428912879964160" data-partner="rebelmouse"><div style="margin:1em 0">#Goldengatepark #sf #quarantinemood https://t.co/9l3ufnbkt6</div> — Suvd (@Suvd)<a href="https://twitter.com/Suvd19486406/statuses/1289428912879964160">1596258783.0</a></blockquote></div><p>The powerful effects of nature are strongest in large parks with more trees, but smaller neighborhood parks also provide a significant boost. Their impact on happiness is real, measurable and lasting.</p><p>Twitter records show that parks increase happiness to a level similar to the bounce at Christmas, which typically is the happiest day of the year. Schwartz has since expanded his <a href="https://arxiv.org/pdf/2006.10658.pdf" target="_blank">Twitter study</a> to the 25 largest cities in the U.S. and found this bounce everywhere.</p><p>Parks and public spaces won't cure COVID-19 or stop police brutality, but they are far more than playgrounds. There is growing evidence that parks contribute to mental and physical health in a range of communities.</p><p>In a 2015 study, for example, Stanford researchers sent people out for one of two walks: through a local park or on a busy street. Those who walked in nature showed <a href="https://doi.org/10.1016/j.landurbplan.2015.02.005" target="_blank">improved moods and better memory performance</a> compared to the urban group. And a team led by <a href="https://penniur.upenn.edu/people/eugenia-gina-south" target="_blank">Gina South</a> of the University of Pennsylvania showed in a 2018 study that greening and cleaning up blighted vacant lots in Philadelphia <a href="http://dx.doi.org/10.1001/jamanetworkopen.2018.0298" target="_blank">reduced local residents' feelings of depression, worthlessness and poor mental health</a>.</p>
Creative Strategies<p>It isn't easy to create new parks on the scale of San Francisco's Golden Gate Park or the Washington Mall, but smaller projects can expand outdoor space. Options include greening vacant lots, closing streets and investing in existing parks to make them safer, greener and shadier and support wildlife.</p><p>These initiatives don't have to be capital-intensive. In the University of Pennsylvania study, for example, renovating a vacant lot by removing trash, planting grass and trees and installing a low fence cost only about US$1,600.</p><p>Urban green space is most needed in neighborhoods that have lacked funding for parks, especially given <a href="https://www.nytimes.com/2020/04/08/nyregion/coronavirus-race-deaths.html" target="_blank">COVID-19's disproportionate impact on Black and Latinx people</a>.</p><p>Cities can also create parklike spaces by <a href="https://theconversation.com/with-fewer-cars-on-us-streets-now-is-the-time-to-reinvent-roadways-and-how-we-use-them-140408" target="_blank">closing streets to cars</a>. Many cities worldwide are currently retooling their transportation systems for the post-COVID-19 world in order to <a href="https://thecityfix.com/blog/bicycles-slower-speeds-livable-city-paris-mayor-anne-hidalgo-plans-ambitious-second-term-dario-hidalgo/" target="_blank">reallocate public space</a>, widen sidewalks and make more space for nature.</p><p>Urban designers, artists, ecologists and other citizens can play a direct role, too, creating pop-up parks and green spaces. Some advocates <a href="https://www.bloomberg.com/news/articles/2017-09-15/a-brief-history-of-park-ing-day" target="_blank">transform parking spaces into mini-parks</a> with grass, potted trees and seating for just the time on the meter, to make a larger point about turning so much public space over to cars.</p><p>Or cities can invest a little more. Minneapolis, Cincinnati and Arlington, Virginia, have won <a href="https://www.tpl.org/parkscore" target="_blank">national recognition</a> for their ambitious investments in public park systems. These areas could serve as models for neighborhoods that lack access to parks.</p>
<div id="25fd0" class="rm-shortcode" data-rm-shortcode-id="383f0d2df0237e9359c30dcce6cd6c42"><blockquote class="twitter-tweet twitter-custom-tweet" data-twitter-tweet-id="1276558744835379201" data-partner="rebelmouse"><div style="margin:1em 0">Looking to safely get outside? Check out the best parks for social distancing in this year's top ten ParkScore citi… https://t.co/HJjEtDsrTD</div> — The Trust for Public Land (@The Trust for Public Land)<a href="https://twitter.com/tpl_org/statuses/1276558744835379201">1593190296.0</a></blockquote></div>
A New Park Deal?<p>The United States has historically driven economic recovery with major infrastructure investments, like the New Deal in the 1930s and the 2009 <a href="https://www.investopedia.com/terms/a/american-recovery-and-reinvestment-act.asp" target="_blank">American Reinvestment and Recovery Act</a>. Such investments could easily include nature-positive spaces.</p><p>Parks are not panaceas, as evidenced by the widely publicized <a href="https://www.nytimes.com/2020/07/06/nyregion/amy-cooper-false-report-charge.html" target="_blank">racist confrontation between a white woman and a Black birder</a> in New York's Central Park in early July. But Hedonometer data add to a <a href="https://advances.sciencemag.org/content/5/7/eaax0903?utm_source=miragenews&utm_medium=miragenews&utm_campaign=news" target="_blank">growing body of evidence</a> that they provide <a href="https://doi.org/10.1073/pnas.1807504116" target="_blank">clear mental health benefits</a>. Creating and expanding parks also <a href="https://www.nrpa.org/contentassets/f568e0ca499743a08148e3593c860fc5/economic-impact-study-summary.pdf" target="_blank">generates jobs and economic activity</a>, with much of the money spent locally.</p><p>We believe investments in nature are well worth it, offering both short-term solace in difficult times and long-term benefits to health, economies and communities.</p>
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By Gianna-Carina Grün
While the first countries are easing their lockdowns, others are reporting more and more new cases every day. Data for the global picture shows the pandemic is far from over. DW has the latest statistics.
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