Age: 71.0
Sex: M
Vaccine: FLUX
Symptoms: Areflexia, Autonomic nervous system imbalance, CSF protein increased, Faecal incontinence, Guillain-Barre syndrome
Clinical narrative: This case was reported in a literature article and described the occurrence of Guillain Barre syndrome in a 71-year-old male subject who was vaccinated with Influenza vaccine ((unspecified), manufacturer unspecified). This case corresponds to patient 2 in the literature article. On an unspecified date, the subject received an unspecified dose of Influenza vaccine (unspecified) (administration site and route unknown, batch number not provided). 1 week after vaccination with Influenza vaccine (unspecified), the subject experienced dysautonomia, facial palsy, perianal numbness, paresthesia in tongue, bilateral upper and lower extremities and oropharynx and weakness of limbs. The subject was hospitalised. After admission, the subject experienced a rapidly progressive ascending quadriparesis. On neurological examination, he had reduced sensation to touch, pinprick, temperature and joint position in bilateral upper and lower extremities (worse distally). The motor strength rapidly worsened to very minimal movements of all 4 extremities over 12 hours after admission. Deep tendon reflexes diminished to 1+ throughout, worsened to areflexia. Bladder and bowel control were normal at admission but progressed to complete bowel incontinence and urinary retention. Cerebrospinal fluid protein was 82 mg/dl. 17 days after vaccination with Influenza vaccine (unspecified), the electrodiagnostic was suggestive of acute inflammatory demyelinating polyneuropathy (absent F responses, A waves in all 4 limbs, absent sural and peroneal responses). The subject was treated with normal immunoglobulin (IVIG). The motor strength was improved but sensory loss was unchanged after the first course of IVIG. 2 weeks after the first course of IVIG, the subject experienced a relapse manifesting as right facial palsy in addition to increasing limb weakness. On day 50, he had a relapse with severe axonal sensorimotor polyneuropathy. At the time of discharge, motor strength in arms significantly improved but sensory loss, bowel incontinence and leg weakness improved very slowly. Non-ambulating with bowel incontinence at 8 months. The outcome of the other events was unspecified. Summary of the literature article: Recent epidemiological studies established extremely rare incidence of Guillain-Barre syndrome after contemporary H1N1-influenza vaccine. The authors reported five subjects with 'atypical? GBS variants that started within four weeks of 2010/2011 H1N1-influenza vaccine. There was no evidence for other etiologies of GBS. The subjects presented with sensory ataxia, areflexia, extremity and oropharyngeal paresthesias, numbness, pain, weakness, sphincteric disturbances, and dysautonomia. One subject had Miller Fisher syndrome. All had elevated cerebrospinal fluid protein, and classic electrodiagnostic finding suggestive of GBS. All received the treatment with intravenous immunoglobulin with variable response. The author's conclusion stated that this series of subjects did not necessarily establish cause-effect relationship between the vaccination and the disease. They also emphasized that they couldn't draw general conclusion concerning the types of GBS after H1N1-influenza vaccine in larger populations. Epidemiological studies with large cohort were necessary to confirm excess cases of atypical GBS after H1N1-influenza vaccination. They also speculated the possibility that more "typical" cases of GBS after H1N1-influenza vaccine did not reach their attention at tertiary-care center but were treated by community neurologists. Nevertheless, the main message that we can draw from this study is that high index of suspicion and screening for atypical variant of GBS was warranted for the H1N1-influenza vaccinees who present with neuropathic manifestations within four weeks of vaccination.