(623) Resistant Acute Motor Sensory Axonal Neuropathy Following COVID-19 Infection

Introduction: COVID-19 is associated with a myriad of neurological complications. Guillain Barre syndrome (GBS) is one such post-infectious consequentiality involving acute inflammatory polyradiculoneuropathy with flaccid ascending limb paralysis. The signs and symptoms can range from proximal muscle weakness to life-threatening respiratory failure. Acute Motor-Sensory Axonal Neuropathy (AMSAN) is a variant where both motor and sensory fibers are affected with marked axonal degeneration. Post Covid AMSAN has been reported from Asia but none were reported from North America. We present this as a unique case from North America.

Description: 56-year-old African American male with Hypertension and COVID-19 infection one month prior to the onset of symptoms presented with lower extremity weakness, confusion, and poor oral intake for one week. He was transferred to the ICU for progressively worsening weakness and lethargy. Areflexic paralysis in both lower extremities progressed rapidly to involve the upper extremities. Progressive respiratory difficulty led to need for endotracheal intubation and mechanical ventilation. Magnetic resonance imaging (MRI) of the entire spine showed no evidence of abnormal contrast enhancement of nerve roots or compressive myelopathy. CSF studies showed elevated protein of 56 mg % and 14,000 RBCs with WBC’s 186 (44% neutrophils, 54% lymphocytes, 2% macrophages) with negative cultures. Viral, paraneoplastic, and autoimmune panel were negative. Nerve conduction studies were consistent with AMSAN. The condition was refractory to treatment despite getting 5 days of IVIG, followed by 5 days of plasma exchange, followed by 5 days of high-dose steroids. Lack of any recovery led to a decision by the family to proceed with hospice care and patient passed quickly following withdrawal of life support.

Discussion: In AMSAN, it is thought that the infection produces antibodies against target proteins located on sensory and motor neuronal axons. It has been suggested that COVID-19-associated GBS has a relatively poorer outcome than GBS occurring otherwise. Cases of post covid-19 associated GBS have been reported but a direct causal relationship has not been established yet or to date. We hope that early detection and prompt treatment can lead to better patient outcomes.