Case presentation:
A previously healthy 70-year-old male (without hypertension or diabetes)
presented (on the 25th of June, 2020) at the Emergency Department with
complaints of lower limb weakness with an acute onset of numbness and
the feeling of dead lower limbs preceded by a cough, which was dry and
paroxysmal, accompanied by mild chest discomfort and a high-grade fever
without sweating or rigours. The fever and cough lasted for 7 days
before the occurrence of weakness. His condition progressed over a day
involving the upper limbs, neck and facial muscles, and the patient was
unable to turn in bed, stand, walk independently, move his upper limbs
or close his eyes. Difficulty swallowing, nasal regurgitation or choking
was not seen, and he had normal sensations and sphincters. Additionally,
no convulsions, loss of consciousness or other symptoms related to
cranial nerves or higher functions were seen.
On examination, the patient was conscious, alert, and orientated to
time, place and person. A mini-mental status examination (MMSE) was at
30. A cranial nerves examination revealed bilateral facial nerve palsy
on the right side with facial deviation to the left, and the inability
to close both eyes and blow his cheeks to whistle. Nystagmus,
ophthalmoplegia, diplopia, cerebellar symptoms and bulbar palsy were not
detected. He had a normal jaw jerk with weak neck flexion. Furthermore,
an upper limbs examination showed hypotonia with absent reflexes and a
muscle power assessment (MRC) was at grade 3 proximally and grade 2
distally, with normal sensations and absent tendon reflexes. A lower
limbs examination also revealed hypotonia with an MRC of grade 2
proximally and distally, absent reflexes, normal sensations, a flexor
plantar response with normal coordination, and the patient was unable to
walk.
General investigations were conducted with complete blood counts showing
haemoglobin (Hb) 11g, total white blood cells 6, lymphocytes 12%,
C-reactive protein (CRP) 110, erythrocyte sedimentation rate 70,
platelets 396, serum ferritin 1000 ng/ml, blood urea 40 mg/dL, serum
creatinine 0.9mg/dL, serum potassium 3.5 mmol/L, sodium 135 mmol/L,
alanine transferase 40, aspartate transaminase 20, alkaline phosphatase
150, random blood sugar 120 mg/dL, and a positive COVID-19 test. A
computerized tomography (CT) chest scan showed a ground-glass appearance
(fig 1&2), and a nerve conduction study (NCS) reported demyelinating
neuropathy consistent with acute inflammatory demyelinating
polyradiculoneuropathy. Although it is a rare finding, a cerebrospinal
fluid (CSF) examination was positive for both COVID-19 & supporting the
diagnosis of Guillain-Barre syndrome.