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Introduction

Rajkot is one of the leading cities in the western part of India with an 18 lakh population usually observing 4-5 cases of polyneuropathy per year at one of the electrodiagnostic centres in 12 months of span. The city has observed 35+ cases from March 2020 to December 2020 and has alerted medical science to face possible autoimmune neurological disease among people with post-COVID-19 status. Early symptoms mimicked with Post-viral fatigue syndrome may begin suddenly, sometimes after an acute viral infection, and commonly include incapacitating and persistent fatigue, muscle aches, joint pains, weakness after exercise, headaches, swollen glands, digestive disorders, inability to concentrate, memory loss, recurring minor infections or low-grade fevers, depression, an increasing sense of being unable to function, sleep disturbance, light sensitivity, food intolerance and environmental allergies. ^[1,2]

Post  viral - Autoimmune  Neurological diseases 

It has been documented that certain microorganisms are involved in the development of axonal and demyelinating subtypes of Gallium Barre Syndrome (GBS) including Epstein–Barr virus, Campylobacter jejuni, cytomegalovirus, influenza A virus, Haemophilus influenza, and Mycoplasma pneumonia. Previously discovered types of coronavirus (SARS-CoV and MERS) and Zika virus have been associated with demyelinating polyneuropathy (GBS) as well. The mechanism of GBS incidence is based on molecular impression and anti-ganglioside antibodies after an infection in genetically predisposed patients. These antibodies show the highest association with certain forms of GBS. A possible mechanism is an autoimmune reaction in which the antibodies on the pathogen, which are like the protein structures of the peripheral nerve components, lead to damage to the nervous system. This likeness has been termed “molecular mimicry” which is defined as the theoretical possibility that sequence similarities between foreign and self-peptides are enough to lead to the cross-activation of autoreactive B cell or T cell by pathogen-derived peptides ^[3].

Graph 1 – Prevalence Rate of GBS per year at Electrodiagnostic centre at Rajkot

Prevalence of sensorimotor polyradiculoneuropathy

The electrodiagnostic centre at Rajkot usually observes (Graph 1) 4-5 patients per year but during march, 2020 December 2020 noted 42 cases of mild to moderate axonal and demyelinating sensorimotor polyradiculoneuropathy among people with post-COVID-19 Infection were alert for medical fertility about Autoimmune Neurological Disease or GBS. 

Statistical analysis 

Means and standard deviations were calculated using  Statistical analysis software spss 20.0 version for Microsoft window

RETROSPECTIVE DATA ANALYSIS, INTERPRETATION

Neurodiagnostic Center has observed 42 cases (Male 30, Mean Age 39 years) of post-COVID-19 patients from March 2020 to December 2020 with predominant bilateral progressive weakness in lower extremities for electrodiagnostic studies. Electrodiagnostic studies of 42 cases observed the following features suggesting the prevalence of sensorimotor polyradiculoneuropathy.

1. Significant reduction of Compound Muscle Action Potential (CMAP) for bilateral peroneal, mean amplitude reduced to 2.9 mV from normal 5.37 mV (reduced by 36%) and Conduction Velocity (CV) reduced by 38 m/s from normal 49 m/s (reduced by 22%).
2. Bilateral tibial nerve means amplitude has no significant change however, Conduction Velocity (CV) reduced by a mean of 34.5 m/s from the normal 46 m/s (reduced by 23%).
3. In bilateral ulnar nerves, the mean value of amplitude reduced to 5.0 mV from normal 11.38 (reduced by 56%), and Conduction Velocity (CV) reduced by 44 m/s from normal 56 m/s (reduced by 21%).  
4. Bilateral median nerves – mean value of Amplitude reduced to 6.95 mV from normal 11.82 (reduced by 41%), and Conduction Velocity (CV) reduced by 46 m/s from normal 54 m/s (reduced by 14%). 
5. Bilateral Sural nerves, Amplitude (18.00 mV) and Conduction Velocity (54.00) m/s remain within normal limits. 
6. The amplitude of compound muscle action potential showed significant involvement in both the upper and lower extremities.
7. Distal Latency and CV showed insignificant involvement in both upper and lower extremities. 
8. 12-15 NCV Studies observed early demyelinating Pure motor peripheral polyneuropathy affecting both the lower extremities.
9. F-wave observers are prolonged and absent in several cases. 
10. The onset of involvement of both upper and lower extremities with sensorimotor Poly Radiculoneuropathy was noted after 2025 days of COVID-19 infection.

	Nerves	Mean	Std. deviation	Indian Normal Values(5)
	Rt Peroneal   LAT	3.7879	3.07344	04.14 ± 0.36
	Rt Peroneal AMP	3.064	3.7869	05.37 ± 0.97
	Rt Peroneal  NCV	37.95	6.897	49.03 ± 9.01
	Lt Peroneal LAT	3.8374	3.42068	04.14 ± 0.36
	Lt Peroneal AMP	2.695	2.6148	05.37 ± 0.97
	Lt Peroneal NCV	38.27	7.873	49.03 ± 9.01
	Rt Tibial LAT	4.2838	2.64628	04.77 ± 0.36
	Rt Tibial AMP	6.360	6.9193	06.22 ± 0.48
	Rt Tibial NCV	36.61	8.589	45.52 ± 3.04
	Lt Tibial LAT	4.9071	4.63443	04.77 ± 0.36
	Lt Tibial AMP	7.586	9.1557	06.22 ± 0.48
	Lt Tibial NCV	33.86	8.979	45.52 ± 3.04
	Rt Sural LAT	1.9760	1.07190	2.47+0.50
	Rt Sural AMP	17.745	13.3175	15.63+3.57
	Rt Sural NCV	53.57	19.049	50.02+3.45
	Lt Sural LAT	1.9076	1.02690	2.47+0.50
	Lt Sural AMP	18.850	13.9370	15.63+3.57
	Lt Sural NCV	55.4	18.419	50.02+3.45
	Rt Peroneal F Wave LAT	23.64	25.390
	Rt Peroneal F Wave Velo	25.37	23.810
	Lt Peroneal F Wave LAT	23.340	25.1800
	Lt Peroneal F Wave Velo	25.58	23.365
	Rt Ulnar LAT	2.77	1.466	02.44 ± 0.36
	Rt Ulnar AMP	5.04	4.118	11.38 ± 0.87
	Rt Ulnar NCV	44.03	12.446	55.58 ± 3.33
	Lt Ulnar LAT	2.59	1.483	02.44 ± 0.36
	Lt Ulnar AMP	5.06	4.251	11.38 ± 0.87
	Lt Ulnar NCV	43.77	11.479	55.58 ± 3.33
	Rt Median LAT	3.85	2.001	03.53 ± 0.51
	Rt median AMP	7.35	5.214	11.82 ± 0.48
	Rt Median NCV	45.63	10.577	53.62 ± 0.49
	Lt Median LAT	3.73	2.144	03.53 ± 0.51
	Lt Median AMP	6.54	4.801	11.82 ± 0.48
	Lt Median NCV	45.51	9.316	53.62 ± 0.49

Table 1: Descriptive Analysis (mean values) of 42 electrodiagnostic studies of people with post-COVID-19 status. Values are compared with Indian  Motor NCV parameters.

Note: Rt = Right Limb LAT = latency in ms, AMP= Amplitude in mV, NCV = Nerve Conduction Velocity in m/s - bold rows are showing an abnormal pattern

Conclusion

Analysis of post-COVID-19 Infection Cases (after 20-25 days) with ascending type motor weakness reported at a neurodiagnostic centre in Rajkot, Gujarat, India, observing the axonal and demyelinating type of sensorimotor polyradiculoneuropathy affecting both upper and lower extremities, indicative of showing the presence of autoimmune neurological disease associated with GBS. ^[4,6] Moreover, for suspected cases and early detection of such disease, NCV studies must be taken into consideration. Early detection and medical attention may reduce the rate of morbidity and mortality.

Compliance with ethical standards

Conflict of interest

the author declares no conflicts of interest.

Ethical Approval

Ethical approval is not applicable

Literature search strategy

In this study, a literature search was done on PubMed, SCOPUS, Embase, Cochrane database, Ovid, and Google Scholar according to preferred reporting items for Nerve Conduction study (NCV) and Autoimmune Neurological Disorders related to COVID-19 infection. The keywords used were “COVID-19 infection” “autoimmune neurological disorders,” “Nerve Conduction study (NCV)”, “post-viral fatigue syndrome”, and “Guillain-Barré syndrome.”

Funding:

Funding was given by Vishal neurodiagnostic centre, Rajkot, Gujarat, INDIA.

Acknowledgement

Special thanks to Vishal neurodiagnostic centre, Rajkot for allowing this research in their centre and giving data on patients for research purposes.

References

1. Ray Perrin, et al, “Into the looking glass: Post-viral syndrome post COVID-19” Med Hypotheses. 2020 Nov; 144: 110055. Published online 2020 Jun 27. 
2. Moldofsky H, et al, “Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study”. BMC Neurol. 2011;(11):1–7.
3. Kaveh Rahimi, et al, “Guillain-Barre syndrome during COVID-19 pandemic: an overview of the reports”, Neurological Sciences. 
4. Vimal Kumar Paliwal et al “Neuromuscular presentations in patients with COVID-19”, Neurological Sciences. September 2020 
5. Shaikh Shahabuddin, et al, “Normative Values for Nerve Conduction Study among healthy subjects from Aurangabad, INDIA” International Journal of Recent Trends in Science and Technology, 2013,(8 ) 56-61
6. Cristina Daia, et al, “Nerve conduction study and electromyography findings in patients recovering from COVID-19 – Case report” International Journal of Infectious Diseases, 2021,(103)420-422.