4  Guillian-Barrė syndrome (GBS) secondary to COVID-19
GBS is a progressive, ascending, symmetrical flaccid limbs paralysis, along with areflexia or hyporeflexia with or without cranial nerve involvement which can progress over days to weeks. The disease may be triggered by respiratory or intestinal infections or vaccinations. The known triggering infections include Influenza; Chlamydia; CMV; varicella; mumps; rubella; HIV; Polio; Hepatitis E; Borrelia; Mycoplasma pneumonia as well as Campilobacter Jejuni. GBS is an immune-mediated disorder with molecular mimicry playing an important role in its autoimmune disorder in which the immune system attacks gangliosides on the peripheral nervous system [34,35]. There are so far 2 reports of GBS associated with Covid-19 infection [36,37]. It is yet unclear whether Covid-19 induces the production of antibodies against these specific gangliosides. The first is a report of five out of 1200 patients hospitalized between February 28th and March 21st, 2020 in Northern Italy hospitals. The onset of neurological symptoms began 7–10 days after the initial respiratory symptoms. Four out of the 5 patients had lower-limb weakness and paresthesia and one was with facial diplegia followed by ataxia and paresthesia. Generalized, flaccid tetraparesis or tetraplegia evolved over a period of 36 h to 4 days in 4 of the patients. Three of them required mechanical ventilation. Anti-ganglioside antibodies were either negative or not done. All patients received IVIG (1 of then required 2 cycles) and one had started plasma exchange. The second report from Iran describes a 65 year old male patient admitted to hospital because of acute progressive symmetric ascending quadriparesis, two weeks after a history of cough, fever and dyspnea. Covid-19 was diagnosed by RT-PCR. The patient was treated by hydroxychloroquine, Lopinavir/Ritonavir, and Azithromycin. GBS was confirmed by EMG. The patient was treated by IVIG for 5 days. Another early report of a single GBS patient came from China during the SARS-CoV-2 epidemic, although there is some concern regarding the causality in this particular case [38].