Discussion:
Guillain-Barre syndrome (GBS) is an immunologically mediated, acute inflammatory demyelinating polyneuropathy.33 It is the most common cause of acute flaccid paralysis, associated with an antecedent infection, especially viral infections.4,32Other causative agents include bacterial infections such as Mycoplasma;Campylobacter jejuni , Haemophilus influenza , andRickettsia rickettsi are well-recognized bacterial agents.3 Furthermore, GBS has been reported to be associated with parasitic infections including Leishmania donovani , Plasmodium falciparum, and P. vivax. 5
In Sudan, the diagnosis of GBS is challenging due to the limited resources and diagnostic capacity in the country, therefore, most of physicians relies heavily on the clinical diagnosis.32Unfortunately, this implies that many other cases of GBS might have been missed due to the lack of experienced physicians during patients’ presentations, particularly in the remote areas of the country.
This study reported a case of typical GBS preceded by classic signs and symptoms of biologically confirmed COVID-19 and malaria caused byPlasmodium falciparum . In this case, the development of GBS could be attributed to the confirmed infections, as both were reported to contribute in GBS manifestation.1,5,32
The first symptoms of GBS in this case, were lower limb weakness, back pain and paraesthesia. Generalized flaccid paraparesis, or tetraplegia, evolved over a period of one to two days in our patient. Furthermore, she had leucopenia, which is associated with malaria and COVID-19 infections.34,35
Malaria can be associated with atypical neurological manifestations which may include cerebellar ataxia and post-malaria neurological syndrome, and a few studies have reported the association of P. falciparum and P. vivax with GBS.36–38Unfortunately, most of Sudan is hyperendemic with malaria.17,29,31 This combined with the recent emergence and spread of COVID-19 is alarming and requires that healthcare providers in theses hyperendemic areas to pay extra attention to the neurological syndromes and the possible involvement of GBS.
Immune-mediated damage is considered the mechanism of developing GBS.39 In malaria infection, the asexual stage of the parasite is accompanied by release of cytokines and other mediators, which in turn trigger an inflammation that affects the axons leading to demyelination. This might explain the involvement of malaria infection in developing GBS, alternative explanation is that the occurrence of GBS is attributed to the occlusion of vasa-nervosum by the malaria parasites or by the formed immune complex.36–38
More studies are needed to further understand the mechanisms of developing GBS due to malaria and/or COVID-19 infections, and the severity and clinical course of GBS. This will impact case management strategies, especially in cases where GBS is more severe.
Countries endemic with several infectious diseases that are associated with GBS are facing huge diagnostic challenge, particularly countries with limited resources like Sudan. The wide spectrum of GBS-associated infections endemic in Sudan is beyond the country current capacity to prevent and control. This is further indicated by the persistently increased rate of infectious diseases outbreaks in the country.17–20,22,29,31,40–42 Therefore, it would be more realistic and achievable to invest more resources on improving the diagnostic capacity, surveillance systems, case management, and early reporting to engage partners and collaborating institutes in the response.43 This could be achieved the integration of diseases control programs.44 Particularly people lives in humanitarian crisis settings with severe gaps in essential services are crucial need for such integration.
Building healthcare professionals’ capacity to recognise the early signs and symptoms of GBS, as well as the potential relationship between GBS and preceding infections such as malaria and COVID-19 will enable earlier diagnosis, prompt treatment and case managment might lead to better disease outcomes. There is also a need for a national GBS differential diagnosis protocol and treatment guideline to ensure that patients are timely identified and receive a high quality care.