Case Presentation: 49-year-old female with past medical history of hypertension & bipolar disorder presented to hospital with complaints of worsening weakness involving her lower extremities for 8 weeks. The weakness began 10 days after receiving the first dose of mRNA-1273 (Moderna Vaccine). Her weakness started in her bilateral feet, gradually ascended up to involve waist and upper extremities. Physical examination was remarkable for decreased power of 2/5 in bilateral lower extremities involving proximal and distal muscles and 4/5 in bilateral upper extremities throughout. Sensations were diminished to light touch throughout in lower and upper extremities. Deep tendon reflexes were absent in the lower and upper extremities.Spinal tap revealed albumino-cytological dissociation. Routine screening of SARS-CoV-2 was negative. Few hours into admission, patient’s respiratory status declined with drop in forced vital capacity (FVC) requiring emergency endotracheal intubation. Plasma exchange was initiated subsequently. MRI of cervical, thoracic and lumbar spine showed no evidence of myelopathy. Serology was negative for GQ1B antibodies. Her symptoms gradually improved and the patient was subsequently extubated. The hospital course was further complicated by autonomic symptoms such as hypotension that was managed with midodrine. She was subsequently discharged to a facility for continued rehabilitation.
Discussion: Vaccines against COVID-19, in general are well-tolerated. Neurological adverse events such as cerebral sinus venous thrombosis that are associated with thrombocytopenia (Vaccine-induced thrombocytopenia with thrombosis), Guillain-Barré syndrome are increasingly reported after receiving COVID-19 vaccines, particularly ChAdOx1 nCoV-19 (Oxford/AstraZeneca) [1] and Ad26.COV 2.S [2]. Few cases of GBS after receiving BNT162b2 are reported [3-5]. In the past, cases of GBS post-vaccination were initially reported in 1976 during a mass vaccination campaign after an influenza outbreak.Our patient developed symptoms acutely 10 days after being inoculated with the first dose of covid-19 vaccine. But, the nadir of symptoms reached sometime between 10 and 12 weeks. This protracted course of development of symptoms (‘sub-acute’) is atypical for a classical case of GBS. The presence of albuminocytologic dissociation confirms the diagnosis of immune-mediated polyneuropathy. The diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) is also a possibility given the prolonged course of symptoms. However, the features such as the precise onset of symptoms, presence of an antecedent event, the autonomic symptom hypotension and the need for ventilator support suggests the diagnosis of GBS than CIDP. This is the first known case of ‘sub-acute’ onset of GBS to be reported that has developed post mRNA-1273 vaccination. The true relationship between the occurrences of these cases with COVID-19 vaccines is unknown at this time.
Conclusions: Vaccination is an effective strategy in reducing the risk of acquiring COVID-19 infection, its severity, hospitalizations, and deaths. Neurological adverse events such as Guillain-Barré syndrome post-vaccination are being reported. However, the causal relationship between GBS and any of these COVID-19 vaccines is not established. Increased vigilance, surveillance, and reporting of such cases post-vaccination are needed to estimate their true prevalence, and further studies are needed to establish their relationship.
