Letter to the Editor
Ample evidence suggests SARS-CoV-2 triggers polyradiculitis
Una amplia evidencia sugiere que el SARS-CoV-2 desencadena la polirradiculitis
Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
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Esteban Molina, M. Mata Martínez, P. Sánchez Chueca" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Esteban Molina" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Mata Martínez" ] 2 => array:2 [ "nombre" => "P." 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On the right, a yellow line is illustrating the catheter path and the position of the tip in the axillary region (axillary vein). Modified from Blanco P. The midline venous catheter. Rev Hosp Emilio Ferreyra. 2021; 1(1):e3–e9. <span class="elsevierStyleInterRef" id="intr0005" href="http://revista.deiferreyra.com/index.php/RHEF/article/view/31/89">http://revista.deiferreyra.com/index.php/RHEF/article/view/31/89</span>. (CC BY 4.0).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Blanco, L. Figueroa, M.F. Menéndez, B. Berrueta" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Blanco" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Figueroa" ] 2 => array:2 [ "nombre" => "M.F." "apellidos" => "Menéndez" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Berrueta" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569121001972?idApp=WMIE" "url" => "/02105691/0000004600000010/v2_202210200805/S0210569121001972/v2_202210200805/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Ample evidence suggests SARS-CoV-2 triggers polyradiculitis" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "594" "paginaFinal" => "595" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Finsterer, F.A. Scorza" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Finsterer" "email" => array:1 [ 0 => "fifigs1@yahoo.de" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F.A." "apellidos" => "Scorza" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Una amplia evidencia sugiere que el SARS-CoV-2 desencadena la polirradiculitis" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We eagerly read the review article by Esteban Molina et al. about SARS-CoV-2 associated Guillain–Barre syndrome (GBS).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The authors collected 39 patients with SARS-CoV-2 associated GBS reported from 14 countries all over the world between January 2020 and June 2020.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Half of the patients were older than 60 years and almost 70% were male.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The most common GBS subtypes were acute, inflammatory demyelinating polyneuropathy (AIDP) (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>27) and acute, motor and sensory, axonal neuropathy (AMSAN) (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> One third of these patients required ventilatory support.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Most patients profited from immunoglobulins or plasmapheresis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The study is appealing but raises concerns that require discussion.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We do not agree with the question mark at the end of the title. There is ample evidence that not only the virus but also the vaccination can trigger GBS. Arguments for a causal association between SARS-CoV-2 infections and GBS are that as per the end of June 2021 at least 300 cases with SARS-CoV-2 associated GBS have been reported [Finsterer, submitted for publication], that there is a line-safe connex between the infection and the onset of GBS,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> that even the vaccination can trigger GBS, and that the cytokine storm, characteristic for the immune response against the virus, can not only be documented in the serum but also in the cerebro-spinal fluid (CSF).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> We do not agree with the notion that the annual incidence of GBS needs to increase to serve as an argument for a causal relation between infection and GBS. If the population to which the number of GBS cases is related is high, an increase in the number of GBS cases may be hardly comprehensible.</p><p id="par0015" class="elsevierStylePara elsevierViewall">An indirect argument for a causal relation between the virus and GBS is that the prevalence of SARS-CoV-2 associated GBS is most likely underestimated. This is because mild cases can go unrecognised, work-up for suspected GBS is frequently not initiated because of limited resources or restrictions with the application of certain diagnostic tools to infected patients, and because GBS may not be suspected in patients on the intensive care unit (ICU) undergoing mechanical ventilation. Indications for GBS in ICU patients are if weaning from the respirator is not feasible despite absence of pneumonia, if there is muscle weakness and missing tendon reflexes despite discontinuation of the sedation, and if there are cranial nerve lesions in the absence of a central nervous system lesion.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We partially agree with the results of the index study. In a recent review about the frequency of SARS-CoV-2 associated GBS between the beginning of January 2020 and the end of June 2020, 33 patients, aged 21–84 years, with SARS-CoV-2 associated GBS were collected [Finsterer, submitted for publication]. The male to female ratio was 1.8. In two cases did GBS occur prior to clinical manifestations of the SARS-CoV-2 infection, most likely due to initially subclinical infection with the virus. The latency between onset of COVID-19 and the GBS ranged between −9 and 24 days. Contrary to the index review four patients with acute motor, axonal neuropathy (AMAN) and two with Miller–Fisher syndrome (MFS) were found in addition to 22 patients with AIDP and 2 with AMSAN. Immunoglobulines were given to 27 patients and plasmapheresis was applied in six cases. Nine patients required mechanical ventilation. Complete recovery was achieved in nine patients and partial recovery in 19 cases.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Overall, the review by Esteban Molina rather supports than questions the causal link between infection and GBS. Intensive care doctors and neurologist should be encouraged to initiate work-up for GBS if there is the slightest suspicion as early treatment may shorten rehabilitation and can prevent fatal outcomes.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">No funding was received.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author contribution</span><p id="par0035" class="elsevierStylePara elsevierViewall">JF: design, literature search, discussion, first draft, critical comments, FS: literature search, discussion, critical comments, final approval.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Author contribution" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SARS-CoV-2, a new causative agent of Guillain–Barré syndrome?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Esteban Molina" 1 => "M. Mata Martínez" 2 => "P. Sánchez Chueca" 3 => "A. Carrillo López" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medine.2021.11.014" "Revista" => array:3 [ "tituloSerie" => "Med Intensiva (Engl Ed)" "fecha" => "2021" "numero" => "November" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guillain-Barre syndrome in 220 patients with COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Finsterer" 1 => "F.A. Scorza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s41983-021-00310-7" "Revista" => array:5 [ "tituloSerie" => "Egypt J Neurol Psychiatr Neurosurg" "fecha" => "2021" "volumen" => "57" "paginaInicial" => "55" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33967575" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "HLA and immunological features of SARS-CoV-2-induced Guillain–Barré syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.L. Gigli" 1 => "A. Vogrig" 2 => "A. Nilo" 3 => "M. Fabris" 4 => "A. Biasotto" 5 => "F. Curcio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10072-020-04787-7" "Revista" => array:6 [ "tituloSerie" => "Neurol Sci" "fecha" => "2020" "volumen" => "41" "paginaInicial" => "3391" "paginaFinal" => "3394" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33006723" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000004600000010/v2_202210200805/S0210569122000018/v2_202210200805/en/main.assets" "Apartado" => array:4 [ "identificador" => "93771" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000004600000010/v2_202210200805/S0210569122000018/v2_202210200805/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569122000018?idApp=WMIE" ]
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