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CASE REPORT
Year : 2021  |  Volume : 65  |  Issue : 4  |  Page : 422-424  

Post coronavirus disease-2019 vaccination Guillain-Barré syndrome


1 Senior Resident, Department of Physical Medicine and Rehabilitation, AIIMS, Patna, Bihar, India
2 Additional Professor and Head, Department of Physical Medicine and Rehabilitation, AIIMS, Patna, Bihar, India
3 Associate Professor, Department of Physical Medicine and Rehabilitation, AIIMS, Patna, Bihar, India
4 Assistant Professor, Department of Nephrology, AIIMS, Patna, Bihar, India

Date of Submission27-Aug-2021
Date of Decision29-Sep-2021
Date of Acceptance21-Oct-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Sanjay Kumar Pandey
Department of Physical Medicine and Rehabilitation, AIIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1716_21

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   Abstract 


Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating disorder of the peripheral nerve. Different variants of GBS can produce a wide array of symptoms among which motor weakness, areflexia without bladder-bowel involvement are commonly encountered. ChAdOx1 nCoV-19 is a recombinant Corona Virus Vaccine and it is incorporated into India's coronavirus disease-2019 (COVID-19) vaccination program. Few rare instances of serious neurological complications have been reported following COVID-19 vaccination. Our case received 2 dose of COVID-19 vaccine. After receiving 1st dose he had rapid onset of ascending paralysis without any sensory and bladder bowel involvement. He received Intra Venous Immuno Globulin and Injection prednisolone for 5 days. Following that his lower limb weakness resolved rapidly but there was no improvement in upper limb weakness. Nerve conduction study showed demyelinating etiology and along with clinical features, it was appeared to be a case of GBS. However, more evidence is needed before establishing the causal relationship between COVID-19 vaccines and GBS.

Keywords: Coronavirus disease-19 vaccine, Guillain-Barré syndrome, post coronavirus disease vaccination paralysis, post vaccination paralysis, vaccine associated complications


How to cite this article:
Biswas A, Pandey SK, Kumar D, Vardhan H. Post coronavirus disease-2019 vaccination Guillain-Barré syndrome. Indian J Public Health 2021;65:422-4

How to cite this URL:
Biswas A, Pandey SK, Kumar D, Vardhan H. Post coronavirus disease-2019 vaccination Guillain-Barré syndrome. Indian J Public Health [serial online] 2021 [cited 2022 Jan 22];65:422-4. Available from: https://www.ijph.in/text.asp?2021/65/4/422/333973




   Introduction Top


Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating disorder of peripheral nerve having features like rapidly progressive ascending sensory-motor involvement, hyporeflexia or areflexia, occasional cranial nerve involvement. Clinical features may vary according to different variants of GBS. Bladder bowel involvement is not seen in classical GBS.[1],[2]

ChAdOx1 nCoV-19 is a recombinant Corona Virus Vaccine and it is incorporated into India's coronavirus disease-2019 (COVID-19) vaccination program. Different neurological adverse effects like transverse myelitis, multiple sclerosis, GBS, facial palsy following ChAdOx1 nCoV-19 vaccination have been reported in different parts of the world.[3],[4],[5]

We are reporting this case because of the uniqueness and rarity of COVID-19 vaccine associated with GBS.


   Case Report Top


Our patient was a 49-year-old male, presented with weakness of bilateral upper limb with difficulty in performing activities of daily living (ADL) like combing, buttoning of the shirt, holding objects. He was also unable to abduct and flex his left shoulder overhead. In history, he had no apparent weakness before receiving the 1st dose of the COVID-19 vaccine. He received 2 doses of the ChAdOx1 nCoV-19 vaccine at 7-week gap. He received the 1st dose of vaccine on 25th March and the 2nd dose on May 13, 2021. After 1 week from receiving 1st dose of the vaccine, he developed weakness in bilateral lower limb that progressed rapidly and within 2–3 days he also noticed weakness of the bilateral upper limb with the inability to perform fine finger movement. At the same time, he was having bilateral facial muscle weakness, leading to difficulty in speech and swallowing. For these complaints, he was admitted in hospital where magnetic resonance imaging (MRI) of the whole spine and brain was done along with nerve conduction study (NCS) of bilateral upper and lower limb and other associated blood investigations. MRI showed diffuse disc bulge at C5-C6 level with effacing anterior thecal sac and encroaching into the bilateral neural foramina and no presence of myelopathy [Figure 1]. NCS showed demyelinating involvement of upper and lower limbs with preganglionic axonal involvement. Cerebrospinal fluid (CSF) study was not done at that time. The patient was given intravenous immune globulin (IVIG) 0.4 g/kg bodyweight per day along with injection Prednisolone 500 mg/day for 5 days. The patient was provided speech therapy, occupational therapy, hand function training, and strengthening exercises simultaneously with the medication. After 5 days, there was a significant recovery of the lower limb and facial muscle strength. The patient was taken home after 13 days of the hospital stay and continued therapeutic rehabilitation exercises for facial muscle and all four limbs at home. There was complete recovery of lower-limb and facial muscle strength but there was no improvement in upper-limb strength. On a follow-up visit after 3 months from discharge, power of all muscles of both lower limbs is 5/5 according to the Medical Research Council scale. There was weakness in both the upper limb (left > right) and weakness was more profound at distal upper-limb muscles [Table 1].
Figure 1: MRI report

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Table 1: Power of upper limb muscles (Medical Research Council Scale)

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Fine and crude touch, temperature sensation, joint position, and vibration were intact in all limbs. Deep tendon reflexes were absent in all limbs. The Sulcus sign was positive at the left shoulder with restriction of abduction, flexion, and rotational movements.

We advised shoulder sling along with physiotherapy and occupational therapy to prevent and treat shoulder subluxation, to improve the strength of weak muscles and to improve ADL. This patient is still being followed up at regular intervals at our outpatient department for subsequent supervision and monitoring.


   Discussion Top


Along with the vaccination drive for COVID-19, side effect profiles of different COVID vaccines are under the strict scrutiny of the researchers. Few adverse effects of those vaccines like febrile reaction, local site pain, swelling, fatigue, altered liver function are already established in different studies. Few rare complications like myocarditis, GBS, myelitis were also reported.[3],[4],[5],[6],[7]

GBS is an immune-mediated demyelination of peripheral nerves and it has different variants depending upon presenting clinical features and investigations. It is known to occur as rare adverse effects of different viral vaccines such as polio, influenza, hepatitis A and B, rabies.[8],[9] Multiple cases of GBS already been reported from different parts of the world after the Oxford/AstraZeneca COVID-19 vaccine which is also a ChAdOx1 nCoV-19 vaccine (recombinant). Although an MRI study in our case shows compression at C5-C6 level, it does not explain the rapid onset of symptoms in the form of ascending weakness without sensory involvement. There was no bladder-bowel involvement and rapid improvement after IVIG and IV steroid injection. NCS also suggested demyelination of peripheral nerves. CSF study was not done as the patient did not give consent for the same. However, the history, clinical feature, NCS, and recovery pattern indicate that our patient was a case of postvaccination GBS. Similar to our case, facial palsy can also be seen in GBS.[2]

GBS has been reported in past with adeno virus-based vaccines. The hypothesis behind the possible mechanism is that viral vector vaccines can trigger systemic immunological reactions through molecular mimicry. Most adults have immunity against adenoviruses due to repeated previous infections. Adeno virus-based COVID vaccine acts as antigen and reactivates anti adeno effector memory T-cell and produces antibodies that probably cross-reacts with neural tissue.

There are very few case reports globally regarding post COVID vaccination GBS. All have one finding in common that is in every case, the vaccine was adeno virus-based vaccine. There is no study present to establish causal relationship between COVID-19 vaccine and GBS. No particular risk factor is identified regarding this association of GBS with vaccination.

Similar to other reports our patient did not have any respiratory and G. I infection before the onset and the disease course was also similar. Our patient was also having the involvement of facial nerve which is not seen yet in reported cases of postCOVID vaccine-associated GBS.

We need more articles reporting the rare Neurological adverse effect of the ChAdOx1 nCoV-19 vaccine in India, before coming to conclusion about the association of GBS with COVID-19 vaccination. The exact pathophysiology behind the findings of our case is still not clear. As these neurological findings are very rare after COVID-19 vaccination and COVID-19 imposes serious threat on public health, benefits of vaccines significantly outweigh the risk.


   Conclusion Top


Presently with the ongoing drive for COVID-19 vaccination worldwide different rare complications of the vaccine are being reported. GBS is one of those rare complications which need to be diagnosed at the earliest for a better outcome. As these types of complications are very rare, it should not have any negative impact on the present COVID-19 vaccination program. The association of GBS with the COVID-19 vaccine is yet to be established beyond doubt.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Guillain G, Barré JA, Strohl A. Radiculoneuritis syndrome with hyperalbuminosis of cerebrospinal fluid without cellular reaction. Notes on clinical features and graphs of tendon reflexes. 1916. Ann Med Interne (Paris) 1999;150:24-32.  Back to cited text no. 1
    
2.
Inaloo S, Katibeh P. Guillain-barre syndrome presenting with bilateral facial nerve palsy. Iran J Child Neurol 2014;8:70-2.  Back to cited text no. 2
    
3.
Lu L, Xiong W, Mu J, Zhang Q, Zhang H, Zou L, et al. The potential neurological effect of the COVID-19 vaccines: A review. Acta Neurol Scand 2021;144:3-12.  Back to cited text no. 3
    
4.
Singh Malhotra H, Gupta P, Prabhu V, Garg RK, Dandu H, Agarwal V. COVID-19 vaccination-associated myelitis. QJM: Monthly Journal of the Association of Physicians 2021 Mar. DOI: 10.1093/qjmed/hcab069.  Back to cited text no. 4
    
5.
Razok A, Shams A, Almeer A, Zahid M. Post-COVID-19 vaccine Guillain-Barré syndrome; first reported case from Qatar. Ann Med Surg (Lond) 2021;67:102540.  Back to cited text no. 5
    
6.
Kaur RJ, Dutta S, Bhardwaj P, Charan J, Dhingra S, Mitra P, et al. Adverse events reported from COVID-19 vaccine trials: A systematic review. Indian J Clin Biochem 2021;36:1-13. [doi: https://doi.org/10.1007/s12291-021-00968-z].  Back to cited text no. 6
    
7.
Abu Mouch S, Roguin A, Hellou E, Ishai A, Shoshan U, Mahamid L, et al. Myocarditis following COVID-19 mRNA vaccination. Vaccine 2021;39:3790-3.  Back to cited text no. 7
    
8.
Schonberger LB, Bregman DJ, Sullivan-Bolyai JZ, Keenlyside RA, Ziegler DW, Retailliau HF, et al. Guillain-Barre syndrome following vaccination in the National Influenza Immunization Program, United States, 1976–1977. Am J Epidemiol 1979;110:105-23.  Back to cited text no. 8
    
9.
Chang KH, Lyu RK, Lin WT, Huang YT, Lin HS, Chang SH. Gulllain-Barre syndrome after trivalent influenza vaccination in adults. Front Neurol 2019;10:768.  Back to cited text no. 9
    


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