Case Presentation: A 76-year old female presented to the emergency department (ED) with fever, chills, nausea, vomiting, diarrhea, back pain and weakness in lower extremities.
Two weeks earlier, patient received her first dose of Shingrix vaccine. Just one day after receiving the vaccine, she developed fever and gastrointestinal symptoms. She was admitted to the hospital one week later for continued symptoms and was managed for possible viral gastroenteritis as lab testing and imaging were unremarkable. A few days after discharge, her symptoms worsened and by this time she had also developed acute onset sharp back pain with radiation into the anterior thighs bilaterally (b/l). Patient reported that symptoms had progressed to the point where she could not walk, stand up from the bed/chair, go up or down the stairs. She denied weakness in the b/l upper extremities or respiratory symptoms. On exam, patient was afebrile. Neurological exam was remarkable for symmetric weakness in b/l lower extremities, proximal>distal; iliopsoas 3/5, quads 4/5, hamstrings 4/5, ankle dorsiflexion 4+/5, ankle plantar flexion 4+/5. Sensation to light touch was decreased in anterior thighs. Deep tendon reflexes were absent in lower extremities. No neurological deficits were noted in the upper extremities. On presentation, patient’s labs were largely unremarkable. MRI L-spine revealed no acute pathology. A lumbar puncture was performed with CSF positive for cytoalbuminologic dissociation (WBCs 5, Protein 246mg/dl). Since patient’s symptoms and CSF findings were suggestive of GBS, plasmapheresis was initiated and five cycles were completed. Patient started to show improvement in her motor strength and was discharged to a rehabilitation facility. She was seen in the clinic at regular intervals and showed significant improvement.

Discussion: Shingrix is a non-live, recombinant subunit vaccine for the prevention of shingles (herpes zoster) in adults aged 50 years and older. Shingrix was approved by FDA in October of 2017 and is presently the preferred vaccine for prevention of shingles as it appears to provide greater protection with less concern for waning immunity. Reported local adverse reactions include pain, redness and swelling at the injection site. General adverse effects include myalgia, fatigue, headache, fever, and gastrointestinal symptoms. To the best of our knowledge, GBS or other autoimmune conditions have not been reported to be associated with or exacerbated by this recombinant zoster vaccine. Our patient developed GBS within a few days after receiving Shingrix. GBS, a potentially fatal autoimmune condition, is considered to be most severe acute paralytic neuropathy. The most common known etiology of GBS is infection with Campylobacter Jejuni. A small percentage of patients develop GBS, though rarely, after immunization with meningococcal, poliovirus, rabies and influenza vaccines. However, Shingrix or traditional Zostavax have not been shown to increase the risk of GBS. Common clinical manifestations of GBS include progressive ascending paralysis with varying degrees of motor weakness, sensory abnormalities or autonomic dysfunction. If not diagnosed and treated early, GBS can progress to respiratory failure and death.

Conclusions: Even though GBS secondary to vaccines is rare, clinicians should be aware of this potential serious adverse event. Shingrix is a new vaccine with limited known adverse effects. It will be interesting to see if more cases of GBS are reported in future after Shingrix administration.