Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : OR04 - OR07 Full Version

COVID-19 Associated Guillain-Barré Syndrome- A Case Series

Published: April 1, 2022 | DOI:
Pankaj Kumar Saini, Rahul Gupta, Gaurav Kumar Gupta

1. Assistant Professor, Department of Neurology, JLN Medical College, Ajmer, Rajasthan, India. 2. Assistant Professor, Department of Neurology, SMS Medical College, Jaipur, Rajasthan, India. 3. Resident Doctor, Department of Internal Medicine, JLN Medical College, Ajmer, Rajasthan, India.

Correspondence Address :
Rahul Gupta,
79/06, Shipra Path, Mansarovar, Jaipur, Rajasthan, India.


The outbreak of Coronavirus Disease-2019 (COVID-19) infection with associated Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) caused modified and compromised immune system that gave rise to various immune mediated disease. Various studies on both central and peripheral nervous system involvement has been reported. The common syndromes reported are meningoencephalitis, myelitis and Guillain-Barré Syndrome (GBS) etc. This case series reports four cases (41-years-old male, 35-years-old female, 50-years-old male and 65-years-old male patients) presenting with the duration from onset of viral illness to neurologic manifestations ranging from 4-60 days. One patient had a typical course of viral symptoms preceding GBS findings and two patient presented with GBS later. A patient was found to be IgG seropositive for SARS-CoV-2 and presented 2 months later of recovery from infection while one case had onset of weakness while having respiratory symptoms. These cases had Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) who presented with acute flaccid paralysis two to three weeks following COVID-19 infection. All the patients received Intravenous Immunoglobulin (IVIG) as treatment and showed significant improvement. It can be concluded that COVID-19 viral infection is probably related as a causal factor for immune mediated illness like GBS and early identification and treatment has good recovery.


Acute inflammatory demyelinating polyradiculoneuropathy, Coronavirus disease-2019, Pandemic

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), the causative agent for COVID-19 has manifested from asymptomatic to acute respiratory distress syndrome and severe inflammatory response leading to multiple organ dysfunction and death. According to the currently available resources, SARS-CoV-2 can affect every organ in the body, leading to acute organ damage and long-term effects, the latter effects recently being observed (1). The upper and lower respiratory tracts are the main sites of involvement of SARS-CoV-2 infection. Pneumonia, with typical ground glass opacities in High-Resolution Computed Tomography (HRCT) thorax, has been noticed as the typical presentation. Recently increasing reports have shown that SARS-CoV-2 infection is associated with involvement of the Central Nervous System (CNS) and the Peripheral Nervous System (PNS) (2),(3),(4),(5). It is either due to direct invasion from virus or indirectly from modified immune response (2). In this case series, the Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) proven SARS-COV2 cases were diagnosed with GBS based on clinical findings, Cerebrospinal Fluid (CSF) and electrophysiological findings according to the case definitions described by World Health Organisation (WHO) (3).

Case Report

Case 1

A 41-year-old male patient, without co-morbidity, presented with complaints of fever, cough and mild breathlessness on exertion for three days. His RT-PCR from nasopharyngeal swab for SARS-COV2 was positive. HRCT severity score was 7/25. The patient was isolated and symptomatic treatment was started. These symptoms recovered in seven days.

After next 10 days, he noticed paresthesia in both feet and both hands. The symptoms progressed and he found difficulty in getting up from squatting position, climbing upstairs and noticed slippage of footwear. In the next three to four days, he noticed difficulty in doing overhead activities, buttoning, unbuttoning, and facial weakness and was hospitalised in non-ambulatory state.

On examination, his vitals were normal and oxygen saturation was 95% by pulse oximetry. His single breath count was 30. Cranial nerve examination showed bilateral lower motor neuron facial palsy. The tone was reduced in all four limbs. The Medical Research Council scale (MRC scale) power grading system showed grade 4/5 power in both upper limbs at all joints and reduced handgrip. In both lower limbs, powergrade was 4/5 at hip and knee joints and 3/5 at both ankle joints. All deep tendon reflexes were absent. The plantar response was flexor bilaterally. On sensory examination, joint position sense was impaired upto both ankles in lower limbs and upto both wrists in upper limbs; rest sensations were normal. In the setting of rapidly progressive ascending weakness, generalised areflexia and preceding viral illness, provisional diagnosis of GBS was kept.

On further investigations, Complete Blood Count (CBC), sugar, renal function test and serum electrolytes were normal. Serum bilirubin was 1.4 mg%, Aspartate Aminotransferase (AST) (57 U/L), Alanine Transaminase (ALT) 104 (U/L), triglyceride (337 mg%) and C-reactive Protein (CRP) (12 mg/L). CSF showed 5 cells/mm3 (100% lymphocytes), protein 300 mg/dL (reference range 15-45 mg/dL), sugar 70 mg/dL (blood sugar 96 mg/dL). The serological tests for Human Immunodeficiency Virus (HIV), syphilis, Cytomegalovirus (CMV), Epstein-Barr virus (EBV) were negative. The nerve conduction study showed reduced or absent compound muscle action potentials and sensory nerve action potentials in the lower limbs and upper limbs, absent F wave response in the lower limbs, and prolonged F wave response in the upper limbs. This was suggestive of sensory-motordemyelinating polyradiculoneuropathy (AIDP). MRI lumbosacral spine was normal.

He was treated with Intravenous Immunoglobulin (IVIG) with a total dose of 2 g/kg in divided doses for five days along with physiotherapy. On fifth day his power improved more than 4/5 in all four limbs and he started walking with minimal support of a person. He was discharged on seventh day with symptomatic treatment and over a month he had near complete recovery except having some paresthesia in both feet.

Case 2

A 35-year-old female patient, without co-morbidity, presented with three day history of low grade fever, cough, sore throat and shortness of breath. RT-PCR for COVID-19 from nasopharyngeal swab was advised and found positive. Her HRCT thorax showed severity score of 13/25. The patient was advised home isolation for 14 days, but she started experiencing tingling and numbness in her legs from two days of starting isolation. Overnext two to three days, she developed significant weakness of both lower limbs, both upper limbs and face on both sides. Later her condition worsened, and she became bedbound over next two to three days, for which she was taken to hospital.

On examination, her vitals were normal. Single breath count was 20 and oxygen saturation dropped to 92% by pulse oximetry without oxygen support (initial day one reading was 95%). She was conscious and cranial nerve examination showed bilateral Lower Motor Neuron (LMN) facial palsy. The tone was reduced in all four limbs. Power grading by MRC scale was 3/5 in both upper limbs at all joints with reduced handgrip (4). In lower limbs, power was 1/5 at both hip joint, 1/5 at the right knee joint, 2/5 at the left knee joint, and 2/5 at both ankle joints. All deep tendon reflexes were absent. The plantar response was flexor bilaterally. On sensory examination, joint position sense was impaired upto both knee ankles in lower limbs and up to both wrists in upper limbs. Provisional diagnosis of GBS was kept based on clinical examination and preceding viral infection.

On further investigations, CBC, sugar, renal function test and serum electrolytes were normal. CSF showed 5 cells/mm3 (100% lymphocytes), protein 190 mg/dL (reference range 15-45 mg/dL), sugar 68 mg/dL (blood sugar 84 mg/dL). The serological tests for HIV, syphilis, CMV, Epstein-Barr virus (EBV) were negative. The nerve conduction study showed reduced or absent compound muscle action potentials in all four limbs with normal distal latency, normal sensory nerve action potentials in all four limbs and prolonged F wave response in the lower limbs and upper limbs. The nerve conduction study was suggestive of sensory-motor axonal polyradiculoneuropathy.

The patient was given IVIG (2 g/kg) in divided doses for five days, along with other symptomatic treatment and physiotherapy. On day seventh, her power improved to 4/5 in upper limbs and 3/5 in lower limbs. She was discharged on 10th day but she needed support to walk. At three months, she had significant improvement with residual foot drop in both her feet.

Case 3

A 50-year-old male patient, without any co-morbid illness, was suffering with low-grade fever, cough and sore throat for fourth days. He presented to emergency room with progressive weakness of all four limbs and pins and needle sensation in both lower limbs. Weakness started symmetrically in both lower limbs and progressed to involve upper limbs over four days to an extent that he could not walk even with support. The weakness was accompanied by bilateral facial weakness, difficulty in swallowing and slurring of speech, which developed one day after hospitalisation.

On examination, his single breath count was 20. Bilateral asymmetric Lower Motor Neuron (LMN) type facial palsy was present (left >right). On motor examination, the tone was reduced in all four limbs; power was 3/5 in the upper extremities (both proximal and distal groups) with reduced handgrip. In lower limbs, it was 1/5 in both hip and knee joint and 2/5 at both ankle joints. There was generalised areflexia with bilateral flexor. Vibration was impaired upto both knee and elbow. Provisional diagnosis of GBS was kept looking his rapidly progressive ascending illness and generalised areflexia-hyporeflexia. His COVID-19 RT-PCR was positive suggesting COVID-19 infection in recent past.

On investigations, CBC, sugar, renal function test and serum electrolytes were normal. AST was 76 units/l, ALT122 units/l, CRP 45 mg/lL. CSF showed 5 cells/mm3 (100% lymphocytes), protein 195 mg/dL (reference range 15-45 mg/dL), sugar 71 mg/dL. The serological tests for HIV, syphilis, cytomegalovirus (CMV), Epstein–Barr virus (EBV) were negative. The nerve conduction study showed reduced or absent compound muscle action potentials, prolonged distal latency; normal sensory nerve action potentials in the lower limbs and upper limbs and absent F wave response in the lower limbs, and prolonged F wave response in the upper limbs. The nerve conduction study was suggestive of sensorimotor primary axonal and secondary demyelinating polyradiculoneuropathy. Magnetic Resonance Imaging (MRI) lumbosacral spine was normal.

The patient was started on Intravenous Immunoglobulin (IVIG) (2 g/kg) in divided doses for five days with regular physiotherapy and other symptomatic treatment. He got discharged on 10th day with improvement of muscle power to grade 3. After three months of illness, he was ambulatory but had residual weakness.

Case 4

A 65-year-old male patient, presented with chief complaint of generalised body weakness (all 4 limbs), low back pain radiating to both legs (right >left) and numbness of all four limbs for five days. He was unable to stand up without support during admission. He was a known case of long standing diabetes mellitus and hypertension. In the past, he had history of fever, cough, and sore throat two months back for which he was hospitalised at local hospital and underwent RT-PCR for COVID-19 (nasopharyngeal swab examination), which was positive for SARS-CoV-2. Isolation along with symptomatic treatment was carried out, and later, he was discharged with improvement.

On admission, his vitals were normal. His single breath count was 22 and oxygen saturation was 98% by pulse oximetry. On motor system examination, the tone was reduced in all four limbs, power of 4/5 in the upper extremities (proximal and distal groups), reduced handgrip bilaterally and power 1/5 in both lower extremities (hip, knee and ankle joint). The deep tendon reflexes were absent in all four limbs. In sensory examination, joint position was impaired upto both ankles.

Investigations showed normal CBC, renal function test and serum electrolytes. Blood sugar was 156 mg/dL. SARS-CoV-2 (COVID-19) IgG antibody was positive (400 AU/mL). CSF showed 5 cells/mm3 (90% lymphocytes), protein 207 mg/dL (reference range 15-45 mg/dL),
sugar 83 mg/dL protein. The serological tests for HIV, syphilis, CMV, Epstein–Barr virus (EBV) were negative. The nerve conduction study showed reduced or absent compound muscle action potentials and sensory nerve action potentials in the lower limbs and upper limbs, absent F wave response in the lower limbs and upper limbs. The nerve conduction study was suggestive of sensorimotor Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP). MRI lumbosacral spine was normal.

The patient was started on Intravenous Immunoglobulin (IVIG) 2 g/kg in divided doses for five days with regular physiotherapy. The power of the lower limbs increased 2/5 and remained same in upper limbs during discharge on 10th day from admission.

The (Table/Fig 1) summarises clinical manifestations, lab findings, treatment given and outcome of all four COVID-19 associated GBS cases.


The SARS-CoV-2 is a novel coronavirus detected in Wuhan, China, in December 2019 and is the causative pathogen for COVID-19. It targets the respiratory system via fusion with Angiotensin-Converting Enzyme 2 (ACE2) receptor (4). Earlier in the pandemic a case series was published by Mao L et al., in Wuhan, China, that showed neurologic manifestations in patients with COVID-19; they concluded that patients with severe COVID-19 illness were more likely to have neurologic symptoms (5). Thereafter, many cases studies reported neurological involvement in COVID-19 infection that worsens the clinical outcome (6),(7). Both CNS (including headache, epileptic seizure, impaired consciousness and dizziness) and PNS (such as Guillain-Barré syndrome, anosmia and neuralgia) involvement have been described divided as para infectious and post infectious (8). The mechanism described is either direct invasion affecting cerebrovascular endothelium or brain parenchyma or indirectly through overproduction of cytokines and modulation of immune system (9).

The first case of GBS following SARS-CoV-2 was reported by Zhao H et al., in a 61-year-old female patient, who developed demyelinating polyneuropathy during her visit to Wuhan, China (10). Following this, many of studies have shown GBS association with COVID-19 and there has been rise in incidence of GBS after the COVID-19 pandemic (6),(11),(12),(13),(14). In India also, COVID-19 associated GBS has been reported (13). According to the WHO, GBS is a polyradiculoneuropathy that occurs when the body immune system attacks part of the peripheral nervous system and it is usually preceded mostly by respiratory or gastrointestinal infection (15). Viruses have been found associated with GBS, include Campylobacter jejuni, CMV, Epstein-Barr, Zika virus; GBS was also reported following Middle East Respiratory Syndrome and Severe Acute Respiratory Syndrome caused by coronavirus (16),(17). The possible mechanism with this virus is same as described with previous infection associated GBS. An auto-reactive immune response that triggers molecular mimicry between microbial and neural antigens is a major driving force in this disorder. The interaction between microbial agents and the host that dictates the immune response to the unwanted auto reactivity is not well understood yet (18),(19).

In the indexfour cases the duration from onset of viral illness to neurologic manifestations have ranged from 4-60 days. One had a typical course of viral symptoms preceding GBS findings (case 3) and two patient presented with GBS later (case 1, 4). Case 4 found to have IgG seropositivefor SARS CoV 2 and presented two months later of recovery from infection. One case (Case 2) had onset of weakness while having respiratory symptoms. Few cases have been reported with concurrent respiratory and neurologic symptoms (14). Two patients were of AIDP variant while two were of axonal. Toscano G et al., reported five patients from Italy; three with an axonal variant of GBS and two with demyelinating neuropathy (12). The initial symptoms in all cases were lower limb paresthesia and all followed typical ascending pattern of progression of weakness. The duration from symptoms onset to nadir was four to five days. No patient required assisted ventilation. In all cases, CSF albumino-cytological dissociation were seen. CSF cell count was less than 10 cells/mm?sup3 in all four cases and CSF protein ranged from 190-300 mg/dL
(reference range 15-45 mg/dL). All 4 cases received 2 gram/kg dose of IVIG in five days divided dose and noticed improvement. One patient had complete improvement while three had residual weakness till there last follow-up (from 1-3 months).

These four cases draw attention to GBS occurrence in patients with COVID-19 who experience mild respiratory and general symptoms preceding the onset of GBS. It emphasises that SARS-CoV-2 induces immunological reaction as a post infectious or para infectious process. The recovery varied from a mild change in extremity function to full neurologic recovery. Early identification and management with immune therapy (IVIG or plasma exchange) not only prevents respiratory failure but also ensures good and rapid recovery.


There has been rise in neurological manifestations in proportion to number of COVID-19 patients in this pandemic and GBS is one alike. Therefore physicians and health care professionals should be aware of GBS association with COVID-19 and more clinical and epidemiological studies needed to reach expertise and define its pattern in comparison to previous reported post or para infectious GBS.


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Tables and Figures
[Table / Fig - 1]
DOI and Others

DOI: 10.7860/JCDR/2022/56035.16281

Date of Submission: Mar 02, 2022
Date of Peer Review: Mar 15, 2022
Date of Acceptance: Mar 17, 2022
Date of Publishing: Apr 01, 2022

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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