Guillain–Barré syndrome after Chikungunya infection: A case in Colombia

To the Editor,

Chikungunya virus (CHIKV), an arthropod-borne virus (arbovirus) of the family Togaviridae, genus Alphavirus, is transmitted by mosquitoes of the Aedes genus; especially Ae. aegypti and Ae. albopictus. This has emerged in tropical areas of Latin America as a public health threat since 2014, when significant expansion, of imported, but particularly autochthonous cases in previously dengue-endemic region begun to be reported and extended over the territories.^1,2

Chronic inflammatory rheumatism, mild hemorrhage, myocarditis, and hepatitis are well known complications of disease, but neurological manifestations, including Guillain–Barré syndrome (GBS), not.³ Cases of GBS have been described in many reports in association with the arboviruses dengue and West Nile but very few with CHIKV. We report here one case of acute and severe GBS related to infection with CHIKV.

Patient was a 77-year-old woman who was admitted to the Clínica Santa María (a third level, private hospital; high level of care in the city), Sincelejo, Sucre, northern Colombia. Sincelejo, the capital of Sucre, is a city where a cumulated CHIKV infection incidence of 190.2 cases/100,000 inhabitants for 2014 was reported. She presented fever, cephalea, myalgia, abdominal pain, paresthesias in lower limbs, edema, arthralgias, exanthema in back, arms and lower limbs. Patient referred that two relatives at home presented and were confirmed diagnosed cases of CHIKV infection. One day after admission, she rapidly presented progressing motor weakness and sensory disturbances, with bilateral hemiparesia. Her tendon reflexes were significantly decreased at that moment. Lumbar puncture was performed, obtaining a cerebrospinal fluid (CSF) sample containing increased protein (800 mg/L), normal glucose (59 mg/dL) but not increased leukocytes (0/mm³). Electromyography displayed typical signs of distal demyelinating sensorimotor neuropathy. Patient also presented pyelonephritis due to Escherichia coli, successfully treated with intravenous ceftriaxone. Anti-CHIKV IgM and IgG were found positive in serum. Polymerase chain reaction (PCR) was positive for CHIKV. She was given standard intravenous immunoglobulin for 5 days. She recovered and was discharged on day 30 post-admission. Eight weeks after onset of symptoms, the patient reported a satisfactory full recovery. She was able to walk and her sensory disturbances rapidly disappeared.

GBS diagnosis was based on a typical clinical acute motor and sensory polyradiculoneuropathy.⁴ Normal CSF counts, increased CSF proteins, and electromyography data are also typical of GBS. As in other studies published before,³ these findings strongly supported a disseminated acute CHIKV infection and enabled us to conclude that CHIKV was probably responsible for the GBS.

We have estimated the incidence rate of GBS in Colombia during the last previous 5 years (2009–2013) (no published data) in a median rate of 1.61 cases/100,000 inhabitants. However, if we consider the potential increase observed in 2006 after 2005 La Réunion (France, Indian Ocean) outbreak, of approximately 22%, we can expect for next years around 1.96 cases/100,000 inhabitants in Colombia. Despite all these considerations, GBS associated with CHIKV infection has been rarely reported yet. But given those experiences during 2005 La Réunion outbreak, more detailed studies on this association should be made in the context of the current outbreak in Colombia and other countries in Latin America. Neither in the country nor in the region, GBS has been previously reported in association with CHIKV infection.

Previous to the current case, only five publications described GBS in patients who suffered CHIKV infection.^3,5–8 Besides one single-case report,⁷ a two cases report,³ the other three reports, consisted of two series of cases in which patients with CHIKV infection presented with GBS. Also in a series of 33 cases, one of the patients (3%) presented GBS.⁵ In other studies GBS was also reported.⁶ Of particular interest is the finding at one observational study, including 610 cases, in which 4 of them (1%) presented GBS.⁸ Of note, in the series of 33 cases, three patients (9%) presented pyelonephritis, two of them due to E. coli,⁵ as occurred in our case.

As has been reported, neurological manifestations of CHIKV and other arboviral infections are more likely to occur among children and older individuals (as occurred in this case).^9,10 However, there are many aspects of the neurovirulence of CHIKV, that although appears to be limited, we do not know yet and deserve more basic, epidemiological and clinical research.

Funding

None declared.

Conflict of interests

None declared.