Case Presentation: A 48-year-old man with alcohol use disorder presented with midsternal chest pain and progressive bilateral leg weakness following diarrhea and upper respiratory symptoms. Examination showed proximal weakness without sensory loss. Imaging and labs were unremarkable. Suspecting acute inflammatory demyelinating polyneuropathy (AIDP), IVIG was initiated after lumbar puncture; MRI spine was normal.Within 24 hours, weakness ascended to involve the upper limbs and respiratory muscles, necessitating intubation. After the second IVIG dose, he developed acute hypoxemia (SpO₂ 88%), wheezing, and fever (101.4°F) without cardiac dysfunction or volume overload—consistent with TRALI. IVIG was discontinued, and plasmapheresis was started, leading to transient respiratory improvement.Despite stabilization, he remained unresponsive and developed severe autonomic instability marked by labile blood pressure, heart rate fluctuations, and refractory hyperthermia up to 41.2°C. Despite maximal supportive and immunotherapy measures, he succumbed to complications of fulminant GBS with irreversible autonomic failure.
Discussion: This case underscores two critical complications in GBS:1. TRALI as a Complication of IVIGTRALI is a rare but potentially fatal complication of transfusion, including IVIG. It presents within 6 hours of infusion with acute hypoxemia, non-cardiogenic pulmonary edema, and fever. Unlike fluid overload, TRALI is not responsive to diuretics and requires prompt recognition and cessation of the offending agent. In this case, the temporal association with IVIG and absence of infection or cardiac overload strongly supported TRALI. Transitioning to plasmapheresis halted further pulmonary deterioration.2. Autonomic Dysfunction in GBSSevere forms of GBS may involve the autonomic nervous system, leading to labile blood pressure, cardiac arrhythmias, and central fever. This patient developed persistent encephalopathy and autonomic instability, culminating in hyperthermia resistant to standard interventions. These signs reflected a catastrophic neurologic insult that ultimately proved fatal
Conclusions: In patients with GBS, vigilance is required for both treatment-related and disease-related complications. This case highlights the importance of:• Recognizing TRALI early in patients receiving IVIG who develop hypoxemia and fever• Considering plasmapheresis as a safer alternative in high-risk or deteriorating patients• Understanding that autonomic failure and central fever are markers of severe GBS with poor prognosisDespite optimal respiratory support and immunotherapy, this patient succumbed to the neurologic and autonomic sequelae of fulminant GBS.