Case presentation:
A 41-year-old female with a pre-existed medical history of type 2 diabetes has arrived at the emergency unit of Royal Care Hospital in Khartoum state, Sudan presented with fever, chills, headache, productive cough, diarrhoea, lower limb weakness, and back pain.
The weakness progressed to the upper limbs within 24 hours. She reported that, in the previous seven days, she experienced fatigue, headache, fever and chills, and she received paracetamol. She had a normal pulse rate (76/min), respiratory rate (17/min), blood pressure (90/50), and temperature (39°C). Neurological examinations showed generalized areflexia and down-going plantar reflexes. The muscle power assessment scale (MRCS) was 0/5 in the upper limbs and the lower limbs. A computed tomography scan of the thorax revealed bi-basilar consolidation and patchy peripheral ground-glass opacities in line with classic COVID-19 infection. Her nasopharyngeal swab was positive for SARS Cov-2 with real-time polymerase chain reaction assay (RT-PCR). Other viral infections associated with developing GBS were excluded using multiple RT-PCR assays. Similarly for the associated parasitic infections, they were excluded except for malaria which was positive. Her full blood count revealed leucopenia, high C-reactive protein (40mg/L), blood film showed asexual stage trophozoites of Plasmodium falciparum and ICT was also positive (Figure 1). The CSF showed E-protein without cells. The electromyography (EMG), on the 2nd day after admission, showed a demyelinating pattern.
For the treatment, the patient received intravenous immunoglobulin (IVIG) (0.4 g/kg/day for five days), and a paracetamol infusion for the back pain. For the malaria infection, the patient received artemether/lumefantrine four tablets (20 mg artemether; 120 mg lumefantrine per tablet) orally (PO) as an initial dose, followed by four tablets PO 8 hours after the initial dose, then four tablets PO twice daily (morning and evening) for two days for a total course of 24 tablets. She responded well after three days. Upper and lower limbs showed an improved power grade (3/5).