Progressive Paraplegia After Bariatric Surgery: Micronutrient Deficiency Versus COVID-19

| July 1, 2022

by Tiffany Son, MD, MS; Kevin Bain, DO; Joseph Heller, DO; Emil Graf, MD; Albert Chen, MD; and David Podkameni, MD

All authors are with the Department of Surgery, Banner Gateway Medical Center in Gilbert, Arizona.

Funding: No funding was provided for this article.

Disclosures: The authors have no conflicts of interest relevant to this article.

Bariatric Times. 2022;19(7):14.

Abstract

Although uncommon, neurological complications after bariatric surgery must be promptly recognized. Surgeons should utilize a multidisciplinary approach to help establish a diagnosis. These complications are most commonly related to micronutrient deficiencies. However, in today’s climate, one must also remember the neurologic effects of COVID-19. Prompt diagnosis is imperative in all circumstances to avoid long-term disability.

Keywords: COVID-19, micronutrient, paraplegia, bariatric surgery, sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric procedure performed in the United States (US).1 With over 250,000 LSGs performed annually, a broad array of postoperative complications can arise.1 Awareness of these postoperative complications has allowed us to effectively treat our patients. Neurologic complications are known complications for bariatric surgery.2 In addition, neurologic symptoms are known in coronavirus disease 2019 (COVID-19).3 The interwoven nature might continue to play a role in our patient care. The following case report illustrates the interplay of postoperative neurologic complications and COVID-19. 

Case Report

A 22-year-old female patient with a body mass index (BMI) of 43.8kg/m2 underwent LSG. During follow-up, she had persistent vomiting. At postoperative Week 5, the patient was admitted for intractable nausea. She was tested for COVID-19, which came back positive. Supportive care was provided, and the patient was discharged home. 

At postoperative Week 10, the patient developed numbness and tingling in her bilateral lower extremities (BLE), with progressive weakness and difficulty standing. She began having severe dysesthesia of her feet, with loss of BLE reflexes and proprioception. Her symptoms then progressed to weakness in her distal upper extremities. Due to her progressive paraplegia, she was admitted to the hospital and started on high dose intravenous thiamine, multi-vitamin injection, and vitamin B. Workup included a vitamin panel, zinc, copper, rapid plasma reagin, erythrocyte sedimentation rate, C-reactive protein test, and magnetic resonance imaging of the spinal cord and brain. All results came back normal. A lumbar puncture demonstrated mildly elevated protein. With a presumed diagnosis of Guillain-Barré syndrome (GBS), she was treated with intravenous (IV) immune globulin and subsequently discharged to rehab.

Discussion

Complications from bariatric surgery are often associated with micronutrient deficiencies.4,5 The most common deficiencies include iron, folate, vitamin B1, and vitamin B12. These complications tend to occur more commonly after gastric bypass; however, they can manifest after LSG as well. Neurologic symptoms after LSG are often preceded by rapid weight loss, persistent vomiting, or a lack of dietary or supplemental intake of micronutrients.5 Rapid weight loss itself might play a multifactorial role by contributing a toxin from rapid fat metabolism.  

Neurological complications after LSG range from 1 to 16 percent and most commonly manifest as peripheral neuropathies. Other complications include Wernicke encephalopathy, GBS, myelopathy, and paresthesia. Timely diagnosis and early intervention are required to prevent permanent impairment.4

To further complicate matters, one must also consider that COVID-19 can manifest with neurologic symptoms.6 Many people are aware of the associated anosmia and dysgeusia. However, other symptoms could affect the central and peripheral nervous systems. Specifically, GBS, GBS variants, and other peripheral neuropathies have been associated with COVID-19.7 Again, expeditious diagnosis and timely interventions are critical.

Conclusion

Although uncommon, neurological complications after bariatric surgery, must be promptly recognized. Surgeons should utilize a multidisciplinary approach to help establish a diagnosis. These complications are most commonly related to micronutrient deficiencies. However, in today’s climate, one must also remember the neurologic effects of COVID-19. Prompt diagnosis is imperative in all circumstances to avoid long-term disability. 

References

  1. Sarkhosh K, Birch DW, Sharma A, Karmali S. Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide. Can J Surg. 2013;56(5):347–352.
  2. Algahtani HA, Khan AS, Khan MA, et al. Neurological complications of bariatric surgery. Neurosciences (Riyadh). 2016;21(3):241–245. 
  3. Ellul MA, Benjamin L, Singh B, et al. Neurological associations of COVID-19. Lancet Neurol. 2020;19(9):767–783.
  4. Berger JR. The neurological complications of bariatric surgery. Arch Neurol. 2004;61(8):1185–1189. 
  5. Tabbara M, Carandina S, Bossi M, et al. Rare neurological complications after sleeve gastrectomy. Obes Surg. 2016;26(12):2843–2848.
  6. Varatharaj A, Thomas N, Ellul MA, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study [published correction appears in Lancet Psychiatry. 2020;7(10):e64]. Lancet Psychiatry. 2020;7(10):875–882. 
  7. Zubair AS, McAlpine LS, Gardin T, et al. Neuropathogenesis and neurologic manifestations of the coronaviruses in the age of coronavirus disease 2019: a review. JAMA Neurol. 2020;77(8):1018–1027. 

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Category: Case Report, Past Articles

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