Case Presentation: A 59-year-old Caucasian male eight months post liver transplant on Tacrolimus and Prednisone and one month post COVID-19 infection presented to our hospital with progressive weakness. Ten days prior to presentation he noted paresthesias of bilateral upper and lower extremities. This progressed to distal 4/5 weakness in all extremities, dysphagia, dysarthria, severe lower back pain, and complete unilateral Bell’s Palsy. Diagnosis of Guillain-Barré Syndrome (GBS) was made based on clinical history and physical exam findings and was later confirmed with testing of cerebrospinal ganglioside antibodies and nerve conduction testing. A five-day course of Intravenous Immunoglobulins (IVIG) 0.4 g/kg (2g/kg total) was prescribed with mild clinical improvement in his dysphagia within a few days of initiating therapy. Despite his symptom progression, he did not require mechanical ventilation and was discharged to acute rehab in stable condition.The patient returned to our hospital nearly 1.5 months after initial hospital discharge due to concern for a cerebrovascular accident in the setting of new unilateral weakness. At this time, he had residual left sided facial droop and areflexia in all extremities. He endorsed significant neuropathic pain in all extremities only marginally controlled with Gabapentin 800 mg four times daily. Neuroimaging on re-admission did not reveal acute intracranial or cervical spine pathology. He was diagnosed with a GBS relapse and received an additional five-day course of IVIG at the same dosing schedule as prior, but demonstrated minimal clinical improvement.

Discussion: Guillain-Barré Syndrome is a rare neurological disorder which typically presents with diminished reflexes and ascending paralysis beginning at the distal extremities. The mechanism of action is due either to autoimmune destruction of myelin nerve sheaths or an attack on nerve axons, depending on the subtype. Immunosuppressed populations often have significantly impaired native immunological function and have difficulty clearing infectious agents. Thus, they are frequently subject to a host of opportunistic infections as well as an extended disease time course. This patient’s presentation is phenotypically unique in its rapidity of onset and symptom progression, bulbar involvement, and asymmetric weakness between upper and lower extremities. Furthermore, a flare of GBS is exceedingly rare.This patient may have been predisposed to GBS due to his immunosuppression, as multiple case reports indicate a possible causal association between Tacrolimus and GBS.1-3 Additionally, it has been demonstrated that peptides embedded in immunoreactive epitopes of COVID-19 share the same sequence with human heat shock proteins 90 and 60 that are associated with GBS and other autoimmune diseases.4 Post-COVID-19 associated cases of GBS are well documented, but there is a paucity of cases of COVID-19-associated GBS in immunosuppressed patients.5,6

Conclusions: This case highlights the importance of recognizing atypical presentations of disease in immunocompromised or immunosuppressed populations as their clinical presentations may vary drastically from immunocompetent patients. Understanding a patient’s immunocompetence assists providers less familiar with managing transplant patients in arriving at the correct diagnosis and prescribing appropriate prophylactic regimens which are typically not indicated for immunocompetent populations.