COVID-19 was found in a patient's cerebrospinal fluid who pr
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A previously healthy 70-year-old man (without hypertension or diabetes) presented at the Emergency Department with complaints of lower limb weakness with an acute onset of numbness and the feeling of dead lower limbs preceded by a cough, which was dry and paroxysmal, accompanied by mild chest discomfort and a high-grade fever without sweating or rigors. The fever and cough lasted for 7 days before the occurrence of weakness. His condition progressed over a day involving the upper limbs, neck, and facial muscles, and the patient was unable to turn in bed, stand, walk independently, move his upper limbs, or close his eyes. Difficulty swallowing, nasal regurgitation, or choking was not seen, and he had normal sensations and sphincters. Additionally, no convulsions, loss of consciousness, or other symptoms related to cranial nerves or higher functions were seen.

On examination, the patient was conscious, alert, and orientated to time, place, and person. A mini-mental status examination (MMSE) was at 30. A cranial nerve examination revealed bilateral facial nerve palsy on the right side with facial deviation to the left, and the inability to close both eyes and blow his cheeks to whistle. Nystagmus, ophthalmoplegia, diplopia, cerebellar symptoms, and bulbar palsy were not detected.

He had a normal jaw jerk with weak neck flexion. Furthermore, an upper limb examination showed hypotonia with absent reflexes and a muscle power assessment (MRC) was at grade 3 proximally and grade 2 distally, with normal sensations and absent tendon reflexes. A lower limb examination also revealed hypotonia with an MRC of grade 2 proximally and distally, absent reflexes, normal sensations, a flexor plantar response with normal coordination, and the patient was unable to walk.

General investigations were conducted with complete blood counts showing hemoglobin (Hb) 11 g, total white blood cells 6, lymphocytes 12%, C-reactive protein (CRP) 110, erythrocyte sedimentation rate 70, platelets 396, serum ferritin 1000 ng/ml, blood urea 40 mg/dl, serum creatinine 0.9 mg/dl, serum potassium 3.5 mmol/L, sodium 135 mmol/L, alanine transferase 40, aspartate transaminase 20, alkaline phosphatase 150, random blood sugar 120 mg/dl, and a positive COVID-19 test. A computerized tomography (CT) chest scan showed a ground-glass appearance (Figures 1 and 2), and a nerve conduction study (NCS) reported demyelinating neuropathy consistent with acute inflammatory demyelinating polyradiculoneuropathy. Although it is a rare finding, a cerebrospinal fluid (CSF) examination was positive for both COVID-19 and supporting the diagnosis of Guillain-Barre syndrome.