Dear Editor,

The clinical presentation of dengue fever may vary from minimal symptoms to high fever, joint and muscle pain, headache and skin rashes, and even to hemorrhagic or shock syndromes. Neurological manifestations of this disease may come as a result of direct dengue virus invasion in the central nervous system (CNS)¹1. Puccioni-Sohler M, Rosadas C. Advances and new insights in the neuropathogenesis of dengue infection. Arq Neuropsiquiatr. 2015;73(8):698-703. doi:10.1590/0004-282X20150074, and/or as neuroimmunological syndromes affecting either the CNS or the peripheral nerves²2. Verma R, Sahu R, Holla V. Neurological manifestations of dengue infection: a review. J Neurol Sci. 2014;346(1-2):26-34. doi:10.1016/j.jns.2014.08.044. There is a paucity of data on cases like these, particularly regarding the discussion on therapy and prognosis. The present study reports on a series of 10 patients with Guillain-Barré syndrome (GBS) in association with dengue fever in Brazil and discusses therapeutic approaches and prognostic data on these cases. The study was approved by the Ethics Committee of Universidade Metropolitana de Santos. Data on patients with GBS in association with dengue fever were collected by neurologists from seven different Brazilian institutions in areas where dengue fever is epidemic. Only cases with complete data were included in this series.

The data on 10 patients with GBS in association with dengue fever are summarized in the Table. The clinical manifestations were variable and often severe, but recovery was mostly complete and fast. Acute motor sensory axonal neuropathy was identified in all cases. All the patients were treated with a five-day pulse of immunoglobulin and responded well. However, full recovery took a variable amount of time, ranging from nine days to one year.

We highlight that GBS in association with dengue fever is a rare condition, with less than 20 cases described in detail in the literature. A recent report on three cases in New Caledonia showed findings similar to those reported here³3. Simon O, Billot S, Guyon D, Daures M, Descloux E, Gourinat AC, et al. Early Guillain-Barré Syndrome associated with acute dengue fever. J Clin Virol. 2016;77:29-31. doi:10.1016/j.jcv.2016.01.016, while fatal cases have recently been described in India⁴4. Mishra V, Harbada R.Fatal Guillain-Barre Syndrome (GBS) in dengue. J Assoc Physicians India. 2015;63:94-6. and Pakistan⁵5. Assir MZ, Ahmad HI, Masood MA, Kamran U, Yusuf NW. Deaths due to dengue fever at a tertiary care hospital in Lahore, Pakistan. Scand J Infect Dis. 2014;46(4):303-9. doi:10.3109/00365548.2013.877155. In Brazil, which has been an endemic region for dengue fever for over two decades, very few cases of associated GBS have been reported⁶6. Gonçalves E. Acute inflammatory demyelinating polyradiculoneuropathy (Guillain-Barré syndrome) following dengue fever. Rev Inst Med Trop Sao Paulo. 2011;53(4):223-5. doi:10.1590/S0036-46652011000400009^,77. Puccioni-Sohler M, Soares CN, Papais-Alvarenga R, Castro MJ, Faria LC, Peralta JM. Neurologic dengue manifestations associated with intrathecal specific immune response. Neurology. 2009;73(17):1413-7. doi:10.1212/WNL.0b013e3181bd8258^,88. Santos NQ, Azoubel AC, Lopes AA, Costa G, Bacellar A. Guillain-Barré syndrome in the course of dengue: case report. Arq Neuropsiquiatr. 2004;62(1):144-6. doi:10.1590/S0004-282X2004000100025^,99. Ferreira ML, Cavalcanti CG, Coelho CA, Mesquita SD. [Neurological manifestations of dengue: study of 41 cases]. Arq Neuropsiquiatr. 2005;63(2B):488-93. Portuguese. doi:10.1590/S0004-282X2005000300023. These authors believe that GBS in association with dengue fever may be underdiagnosed, even in endemic areas. It is a relatively benign condition that can successfully be treated with pulses of immunoglobulin if diagnosed early.

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