Discussion:
Guillain-Barre syndrome (GBS) is an immunologically mediated, acute
inflammatory demyelinating polyneuropathy.33 It is the
most common cause of acute flaccid paralysis, associated with an
antecedent infection, especially viral infections.4,32Other causative agents include bacterial infections such as Mycoplasma;Campylobacter jejuni , Haemophilus influenza , andRickettsia rickettsi are well-recognized bacterial
agents.3 Furthermore, GBS has been reported to be
associated with parasitic infections including Leishmania
donovani , Plasmodium falciparum, and P.
vivax. 5
In Sudan, the diagnosis of GBS is challenging due to the limited
resources and diagnostic capacity in the country, therefore, most of
physicians relies heavily on the clinical diagnosis.32Unfortunately, this implies that many other cases of GBS might have been
missed due to the lack of experienced physicians during patients’
presentations, particularly in the remote areas of the country.
This study reported a case of typical GBS preceded by classic signs and
symptoms of biologically confirmed COVID-19 and malaria caused byPlasmodium falciparum . In this case, the development of GBS could
be attributed to the confirmed infections, as both were reported to
contribute in GBS manifestation.1,5,32
The first symptoms of GBS in this case, were lower limb weakness, back
pain and paraesthesia. Generalized flaccid paraparesis, or tetraplegia,
evolved over a period of one to two days in our patient. Furthermore,
she had leucopenia, which is associated with malaria and COVID-19
infections.34,35
Malaria can be associated with atypical neurological manifestations
which may include cerebellar ataxia and post-malaria neurological
syndrome, and a few studies have reported the association of P.
falciparum and P. vivax with GBS.36–38Unfortunately, most of Sudan is hyperendemic with
malaria.17,29,31 This combined with the recent
emergence and spread of COVID-19 is alarming and requires that
healthcare providers in theses hyperendemic areas to pay extra attention
to the neurological syndromes and the possible involvement of GBS.
Immune-mediated damage is considered the mechanism of developing
GBS.39 In malaria infection, the asexual stage of the
parasite is accompanied by release of cytokines and other mediators,
which in turn trigger an inflammation that affects the axons leading to
demyelination. This might explain the involvement of malaria infection
in developing GBS, alternative explanation is that the occurrence of GBS
is attributed to the occlusion of vasa-nervosum by the malaria parasites
or by the formed immune complex.36–38
More studies are needed to further understand the mechanisms of
developing GBS due to malaria and/or COVID-19 infections, and the
severity and clinical course of GBS. This will impact case management
strategies, especially in cases where GBS is more severe.
Countries endemic with several infectious diseases that are associated
with GBS are facing huge diagnostic challenge, particularly countries
with limited resources like Sudan. The wide spectrum of GBS-associated
infections endemic in Sudan is beyond the country current capacity to
prevent and control. This is further indicated by the persistently
increased rate of infectious diseases outbreaks in the
country.17–20,22,29,31,40–42 Therefore, it would be
more realistic and achievable to invest more resources on improving the
diagnostic capacity, surveillance systems, case management, and early
reporting to engage partners and collaborating institutes in the
response.43 This could be achieved the integration of
diseases control programs.44 Particularly people lives
in humanitarian crisis settings with severe gaps in essential services
are crucial need for such integration.
Building healthcare professionals’ capacity to recognise the early signs
and symptoms of GBS, as well as the potential relationship between GBS
and preceding infections such as malaria and COVID-19 will enable
earlier diagnosis, prompt treatment and case managment might lead to
better disease outcomes. There is also a need for a national GBS
differential diagnosis protocol and treatment guideline to ensure that
patients are timely identified and receive a high quality care.