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-
ets, and timing of vaccination
The GBS/Chronic Inam-
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 Inam-
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 Inam-
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 Inam-
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 Inam-
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.