LAUSR

W ith interest we read the article by Mohamed et al about a 26-year-old primigravida in her 34th week of gestation who developed Guillain-Barre syndrome (GBS) 17 days after having tested positive for SARS-CoV-2. GBS was initially classified as Miller-Fisher syndrome (MFS) and later revised to acute, motor, and axonal neuropathy (AMAN). The patient achieved partial recovery upon application of intravenous immunoglobulin (IVIG) at discharge from the intensive care unit (ICU). The study is promising but raises concerns that require further discussion. It is not comprehensible why MFS was suspected. MFS is characterized by ophthalmoplegia, areflexia, and ataxia. The index patient had ophthalmoparesis but no ophthalmoplegia and no ataxia. Furthermore, there was involvement of several cranial nerves, including cranial nerve III, IV, VI, VII, IX, and X. Therefore, MFS should not be considered as a differential diagnosis and the condition should be rather classified as AMAN with multiple cranial nerve involvement. We disagree with the statement in the discussion that “management of GBS is mainly supportive.” On the contrary, management of GBS is mainly therapeutic and only exceptionally supportive. Therapy of GBS should be started as soon as the diagnosis is confirmed and should include either IVIG or plasmapheresis. Early treatment of GBS is crucial, as the outcome is better the earlier treatment is initiated. The speed of recovery strongly depends on the latency between onset of symptoms and the nadir of the clinical manifestations. The earlier the nadir is reached, the longer the time until complete recovery. It is unclear when paraparesis of the lower limbs changed to quadriparesis. On admission the patient had paraparesis, but at discharge on hospital day 16 the patient had quadriparesis (3–4/5). We should know whether IVIG was ineffective or whether the patient additionally developed critically ill neuropathy during the stay in the ICU. It is also conceivable that progression to quadriparesis was the natural course. Missing is the long-term follow-up after 4 weeks on the rehabilitation unit. We should know whether quadriparesis resolved completely, remained unchanged, or worsened. Did involvement of cranial nerves completely resolve at discharge from the ICU? It should be discussed whether respiratory insufficiency was due to pneumonia from the SARS-CoV-2 infection, due to affection of the phrenic nerve in the context of the GBS, or due to myocarditis, a common complication of SARSCoV-2 infections. Glucose was elevated in the index patient. Was gestational diabetes diagnosed or was there diabetes already prior to the pregnancy? Knowing whether the patient had diabetes is crucial, as preexisting polyneuropathy may favor the development of GBS. The difference between AMAN and AIDP is due to different targets of antibody attack. In AMAN, antibodies are deposited on the nodal and internodal axolemma, whereas in AIDP antibodies are deposited on the myelin sheath. Overall, the study carries obvious limitations that require reevaluation and discussion. Clarifying these shortcomings would strengthen the conclusions and could improve the study. GBS is a common complication of SARS-CoV-2 infections and should be diagnosed and treated as early as possible to improve the outcome of these patients.