Case presentation:
A 61-year-old gentleman presented to the emergency department with a 3-day history of bilateral upper limb weakness, mainly distally involving the hands, described as an inability to perform fine hand movements such as buttoning his shirt and holding the pen properly when writing. He denied having any numbness or pain. There were no other neurological deficits. There was no antecedent respiratory tract infection or diarrheal illness. No history of a similar attack before. His symptoms started four days after receiving the second dose of the COVID-19 vaccine (Moderna)
On examination, the patient had normal vital signs. Neurological examination was remarkable for
Decreased Power was 5/5 in proximal muscles and 4/5 in distal muscles. Both upper limbs showed no fasciculation, no abnormal movements, normal tone. He had normal deep tendon reflexes all over. The sensory and cerebellar examinations were normal. Neurological examination of the lower limbs was normal. Cardiac, respiratory, and abdominal examinations were normal. Complete blood count, urea,
creatinine, electrolytes, C-reactive protein, procalcitonin, vitamin B12, folic acid, and thyroid function tests were normal (Table 1).
Lumbar puncture was performed, CSF analysis revealed pink fluid, RBC 3000/ul , WBC 4/ul [corrected is 6 when using 1 WBC: 500 RBC ratio], Glucose 4.27 mmol/l , protein 0.5 gm/l [normal range 0.15- 0.45 gm/l] indicating albumin-cytologic dissociation. (Table 2)
Nerve conduction studies showed electrophysiological evidence of pure motor neuropathy with primary demyelinating features suggestive of demyelinating polyneuropathy. (Figure (1). The patient received IV immunoglobulin therapy total of 2gm/kg; IVIG 0.4gm/kg per day for 5 days. His power improved throughout his hospital stay and he was discharged home.
Discussion : COVID 19 has affected the world in many ways. It created a high burden on countries and populations and currently remains a challenge as it is associated with high morbidity and mortality rates. The impact of the pandemic resulted in a considerable change in day-to-day life (7). since Its emergence, researchers have been working robustly to find a cure. COVID 19 vaccines were introduced recently after extensive work to find a method to halt the progression of this pandemic. New technology was introduced, which is the development of mRNA-based vaccines; BNT162B2 and mRNA-1273 being the primary examples. mRNA vaccines work by inducing a T-cell mediated immune response to a protein that is translated from the mRNA. They have been shown to exhibit a significant level of immunity. (8) However, data regarding the safety of these vaccines is still lacking, and further studies are needed to uncover all the potential side effects (9). It is not uncommon to have neurological side effects following vaccination, as described in the literature. (10) COVID 19 vaccines have been linked to several CNS side effects as observed in trials, as well as they are being reported in case reports. The incidence Is yet to be confirmed. As more and more people are being vaccinated, more side effects will be noticed (11). side effects that were reported included weakness, numbness, ataxia, and more severe presentations such as encephalitis, myelitis, and demyelination with Guillain barre syndrome. (12) GBS development secondary to vaccines has been described before in literature (13). however, its development after the COVID 19 vaccine is not well reported, and further studies are needed to expand on it (14).
Guillain-Barré syndrome (GBS) is an acute immune mediated disease of peripheral nerves and nerve roots that is usually preceded by respiratory or gastrointestinal infection. It presents with progressive, ascending, symmetrical limb weakness, and paresthesia with diminished or absent deep tendon reflexes, with or without respiratory and cranial nerves involvement (15). It is a rare condition (estimated 1 - 2 cases per 100,000 person-years worldwide [16]. In approximately two-thirds of patients with GBS, an episode of acute infection precedes the neurological symptoms by 1 - 3 weeks [17]. Infectious organisms recognized as potential triggers are diverse and include Campylobacter jejuni , cytomegalovirus, influenza viruses, herpes simplex virus (HSV), and human immunodeficiency virus (HIV).
Additionally, there is some evidence to suggest a temporal relationship between GBS and the receipt of various vaccines, including those for rabies, hepatitis (Hep) A and B, polio, and influenza [18]. Such cases are infrequent and the establishment of causality in most of these cases has proved controversial. However, a small increased risk of developing GBS specifically after influenza vaccination is relatively well established [19]. Recently there have been multiple case reports temporal relationship between COVID-19 vaccination and GBS development.
Our patient presented with bilateral upper extremity weakness and numbness four days following the vaccine. Initial evaluation revealed normal CSF studies and normal CBC, KFT, LFT. Nerve conduction studies were done, and they showed features of demyelinating disease. He was admitted to the hospital as a case of GBS. Following the diagnosis, he was started on Intravenous immunoglobulins for five days, which resulted in improvement of his symptoms on the following days. Which further confirmed the diagnosis. He continued to improve and was finally discharged with Follow-ups.
Patients with neurological findings should be enquired about recent vaccination history. It is of enormous importance, especially after the COVID 19 mRNA vaccine, which is newly introduced as it might have a link to the development of a widespread variety of neurological presentations. The risks of the vaccines are not fully understood; however, the benefits of the vaccines appear to outweigh the risks that might be encountered.
more patients gain access to the coronavirus disease
2019 (COVID-19) vaccines, neurologists are facing
questions about potential neurological complications, ben-
ets, and timing of vaccination
The GBS/Chronic Inam-
matory Demyelinating Polyneuropathy (CIDP) Founda-
tion provides the following guideline: for the rare person
who develops GBS within 4 to 6 weeks of receiving an
immunization, it seems prudent to avoid that vaccination
in the future. For those whose GBS did not follow soon
after a vaccination, there are no reliable data to indicate
the risk of developing GBS after a vaccination.
10
The GBS/Chronic Inam-
matory Demyelinating Polyneuropathy (CIDP) Founda-
tion provides the following guideline: for the rare person
who develops GBS within 4 to 6 weeks of receiving an
immunization, it seems prudent to avoid that vaccination
in the future. For those whose GBS did not follow soon
after a vaccination, there are no reliable data to indicate
the risk of developing GBS after a vaccination.
10
The GBS/Chronic Inam-
matory Demyelinating Polyneuropathy (CIDP) Founda-
tion provides the following guideline: for the rare person
who develops GBS within 4 to 6 weeks of receiving an
immunization, it seems prudent to avoid that vaccination
in the future. For those whose GBS did not follow soon
after a vaccination, there are no reliable data to indicate
the risk of developing GBS after a vaccination.
10
The GBS/Chronic Inam-
matory Demyelinating Polyneuropathy (CIDP) Founda-
tion provides the following guideline: for the rare person
who develops GBS within 4 to 6 weeks of receiving an
immunization, it seems prudent to avoid that vaccination
in the future. For those whose GBS did not follow soon
after a vaccination, there are no reliable data to indicate
the risk of developing GBS after a vaccination.
10
The GBS/Chronic Inam-
matory Demyelinating Polyneuropathy (CIDP) Founda-
tion provides the following guideline: for the rare person
who develops GBS within 4 to 6 weeks of receiving an
immunization, it seems prudent to avoid that vaccination
in the future. For those whose GBS did not follow soon
after a vaccination, there are no reliable data to indicate
the risk of developing GBS after a vaccination.
10
conclusion :
COVID 19 pandemic has burdened many countries and created many changes in the physical, social and economic aspects. COVID 19 vaccines are an essential tool to help contain the pandemic. They have been proven to be very effective and safe, but at the same time, it is crucial to keep in mind the potential side effects of these vaccines. Patients who present with neurological complaints following the vaccine should be investigated for other causes first while keeping in mind that the vaccine can be a cause. As more patients are getting access to the coronavirus 2019 (COVID-19) vaccines, neurologists are facing questions about neurological complications, benefits and appropriate time of vaccination. GBS is one of the possible side effects that might be encountered after the COVID 19 vaccine. If it occurs, it appears to be responsive to the treatment, and the benefits of administering the vaccine outweigh the risks. The frequency of its occurrence is still needed to be studied.
Data availability statement:The data that support the findings of this study are available from the corresponding author upon reasonable request.
Conflict of interest: The authors have no conflict of interest to declare.