Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), originating from Wuhan, is spreading around the world and the outbreak continues to escalate. Patients with coronavirus disease 2019 (COVID-19) typically present with fever and respiratory illness.1 However, little information is available on the neurological manifestations of COVID-19. Here, we report the first case of COVID-19 initially presenting with acute Guillain-Barré syndrome.
On Jan 23, 2020, a woman aged 61 years presented with acute weakness in both legs and severe fatigue, progressing within 1 day. She returned from Wuhan on Jan 19, but denied fever, cough, chest pain, or diarrhoea. Her body temperature was 36·5°C, oxygen saturation was 99% on room air, and respiratory rate was 16 breaths per min. Lung auscultation showed no abnormalities. Neurological examination disclosed symmetric weakness (Medical Research Council grade 4/5) and areflexia in both legs and feet. 3 days after admission, her symptoms progressed. Muscle strength was grade 4/5 in both arms and hands and 3/5 in both legs and feet. Sensation to light touch and pinprick was decreased distally.
Laboratory results on admission were clinically significant for lymphocytopenia (0·52 × 109/L, normal: 1·1–3·2 × 109/L) and thrombocytopenia (113 × 109/L, normal: 125–300 × 109/L). CSF testing (day 4) showed normal cell counts (5 × 106/L, normal: 0–8 × 106/L) and increased protein level (124 mg/dL, normal: 8–43 mg/dL). Nerve conduction studies (day 5) showed delayed distal latencies and absent F waves in early course, supporting demyelinating neuropathy (Table 1, Table 2). She was diagnosed with Guillain-Barré syndrome and given intravenous immunoglobulin. On day 8 (Jan 30), the patient developed dry cough and a fever of 38·2°C. Chest CT showed ground-glass opacities in both lungs. Oropharyngeal swabs were positive for SARS-CoV-2 on RT-PCR assay. She was immediately transferred to the infection isolation room and received supportive care and antiviral drugs of arbidol, lopinavir, and ritonavir. Her clinical condition improved gradually and her lymphocyte and thrombocyte counts normalised on day 20. At discharge on day 30, she had normal muscle strength in both arms and legs and return of tendon reflexes in both legs and feet. Her respiratory symptoms resolved as well. Oropharyngeal swab tests for SARS-CoV-2 were negative.