Age: 81.0
Sex: M
Vaccine: FLUX
Symptoms: CSF immunoglobulin increased, CSF protein increased, CSF white blood cell count increased, Computerised tomogram abdomen normal, Computerised tomogram head normal
Clinical narrative: Case number PHHY2014US056236, is a combined initial and follow up literature report received on 07 May 2014 and 09 May 2014 respectively. In this article the author reported a case of Guillain-Barre syndrome (GBS) in an older man following influenza vaccination. This report refers to an 81 year old male patient. His medical history included chronic obstructive pulmonary disorder (he had not taken any medicine for COPD), loss of weight few months before hospitalization. He was a cigarette smoker and claimed to smoke about 10 cigars per day. There was no recent history of fever, diarrhea or upper respiratory symptoms as well as no history of head trauma. He had hernia, foot and cataract surgeries in the past. He did not have any recent hospitalizations and his previous admissions were considered noncontributory. He had no vaccination history or drug allergies. His concomitant medication included dronabinol at a dose of 2.5 mg as needed for appetite stimulation approximately 06 weeks before hospitalization. On an unknown date, he was vaccinated with a trivalent seasonal influenza vaccine (manufacturer and batch number not reported. Hence, conservatively taken as seasonal influenza INN) via intradermal route. Two weeks after vaccination, he began to experience numbness and tingling in both feet. He was hospitalized when the numbness and tingling began ascending toward the waistline. It was reported that he discontinued the use of dronabinol three weeks before admission because he thought the medication might have been responsible for his symptoms. The patient then complained of intense neuropathic pain in his lower extremities. On presentation, his gait and coordination were not entirely intact. At the time of hospitalization his blood pressure was 155-169/74-92 mmHg, respiratory rate was 16 to 18 breaths/min, heart rate was 64 to 92 beats/min and body temperature of 36.3 to 36.5 degree Celsius. Heart and lung examinations were normal. During the neurologic examination, he was noted to be calm alert and oriented. He displayed no weakness in all four extremities but he lacked deep tendon reflexes in his ankles. Whereas, magnetic resonance imaging of the lumbar and thoracic spine and computed tomography of thorax, brain, head, abdomen and pelvis were all negative for pathogenic signs of neuropathy as well as for alternative diagnoses. His metabolic panel and complete blood count were all within normal limits with the exception of an elevated serum creatinine of 1.5 mg/dL. His creatinine level decreased to 1.2 mg/dL on hospital day 03, with a calculated Cockcroft-Gault creatinine clearance estimate of 46.7 mL/min. A lumbar puncture revealed clear and colorless cerebrospinal fluid (CSF) with a slightly elevated GSL protein of 66 mg/dL. Lumbar puncture also revealed an elevated CSF white blood cell count of 17 cells/mm and elevated CSF immunoglobulin G (IgG) with a value of 19.4 mg/dL. Other values of the lumbar puncture included red blood count: 0, monocytes: 24, albumin: 24.8 g/L, and CSF index: 2.61. All CSF and blood cultures were negative and common viral studies (cytomegalovirus, Epstein-Barr, varicella) that have been associated with GBS were also negative. Based on the Brighton Collaboration's case definitions of GBS, clinical, laboratory, and electrophysiological criteria must be assessed to determine with certainty that a patient has GBS. The patient exhibited clinical findings of symmetrical bilateral ascending paralysis and loss of deep tendon reflexes with an onset of symptoms within 02 weeks of vaccine administration. On electrophysiological studies, the patient's EMG was positive for sensorimotor axonal polyneuropathy. While a low CSF total white cell count was not observed. Elevated CSF protein, elevated CSF IgG and elevated CSF index were noted despite the absence of albuminocytologic dissociation. He met Brighton level 03 diagnostic certainties as a result of meeting only clinical criteria for GBS along with electrophysiological findings. On day 05 of hospitalization, he was treated with intravenous immunoglobulin (IVIG) 0.4 g/kg/d and continued for 5 days. The patient also received amlodipine at a dose of 2.5 mg daily for hypertension, docusate at a dose of 100 mg daily for constipation, enoxaparin at a dose of 30 mg daily for deep-vein thrombosis prophylaxis and gabapentin at a dose of 100 mg at bedtime for neuropathic pain. He was given morphine at a dose of 04 mg and hydrocodone/acetaminophen at a dose of 7.5/325 mg as needed for pain management. After receiving the IVIG and other supportive therapies including intravenous fluids, he had progressively improved sensation in his extremities as well as improved gait. He was discharged after a 10 day hospital admission, approximately 07 weeks after the administration of the seasonal influenza vaccine. He was discharged with a prescription for gabapentin 100 mg at bedtime to help with any persistent neuropathic pain. In conclusion the author stated that although GBS was rare, it should be considered in older patients who experienced adverse reactions after administration of the influenza vaccine. Despite the seriousness of GBS, the benefits of an annual influenza vaccination outweigh the risk of developing GBS. As the number of patients receiving the annual influenza vaccine increased, further research was needed to understand which patient populations were at the highest risk for development of this possible life-threatening disease.