Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: CSF protein increased, CSF white blood cell count negative, Diplegia, Dysarthria, Dysphagia
Clinical narrative: FACIAL DIPLEGIA RARE VARIANT OF GUILLAIN-BARRE SYNDROME; This spontaneous report was received from literature: This report concerned a 65 year old female. The objective of this study was Facial Diplegia: A Rare, Atypical Variant of Guillain-Barre Syndrome and Ad26.COV2.S Vaccine. The patient's height, and weight were not reported. The patient's concurrent conditions included hypertension, diabetes mellitus type 2, hyperlipidemia, penicillin allergy, and egg white allergy. The patient experienced drug allergy when treated with ciprofloxacin, and codeine.  The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: Unknown, and expiry: Unknown) dose, frequency 1 total, start therapy date were not reported for prophylactic vaccination. The batch number was not reported and has been requested. No concomitant medications were reported. The patient received the Ad26.COV2.S vaccine presented to the emergency department (ED) as she endorsed a headache in the frontal and periorbital regions for four days, along with left neck and shoulder pain from day 15 post-vaccination. Simultaneously, she experienced ageusia and hyposalivation. On day 19 post-vaccination, the patient woke up with dysarthria, dysphagia, dysphasia, and bilateral facial weakness, which prompted the patient to visit the ED the following day. Neurological assessment upon arrival showed that the patients' Glasgow Coma Scale was 15/15, and the patient had significant dysarthria. Gag reflex was weak and there was a bilateral loss of power in the distribution of the facial nerve. The remainder of the central and peripheral neurological examination was normal. Chest X-ray and computed tomography (CT) of the head were negative. Magnetic resonance imaging (MRI) of the head demonstrated no acute infarct, hydrocephalus, acute intracranial hemorrhage, or mass effect. CT angiography of the head and neck demonstrated less than 50 percent stenosis in left and right internal carotid arteries. A stroke code was activated on patient arrival to the ED, which was ruled out by the neurology team. Due to the bilateral cranial nerve (CN) VII lower motor neuron lesions, the patient was promptly admitted to the intensive care unit. A lumbar puncture was performed to rule out the Miller Fisher variant of Guillain Barre Syndrome (GBS). Results of CSF showed protein of 302 mg/mL, and absence of white blood cell yielding albuminocytologic dissociation with IgA level of 163 mg/dL. Following diligent clinical and physical assessment, and analyzing CSF results via lumbar puncture, empiric treatment was initiated for GBS, and the patient was diagnosed with facial diplegia, a rare variant of GBS. The patient was administered intravenous immunoglobulin (IVIG) (0.4 g/kg) for 10 days followed by 10 sessions of plasmapheresis. She was provided with supplemental oxygen and close monitoring for potential diaphragmatic paralysis. On day 3 of hospitalization, the patient was awake, alert, oriented, and able to follow commands. She denied any respiratory distress; however, slurred speech with mild dysarthria was noted. On examination of CN II to XII, the pupils reacted light bilaterally. Extraocular muscles were intact bilaterally, and nystagmus/diplopia was absent. When asked to close her eyes, there was a bilateral loss of power in the orbicularis oculi muscles. There was a significant CN VII lower motor neuron lesion bilaterally. The patient exemplified bilateral upper and lower facial motor weakness and decreased gag reflex. The tongue and uvula were in the midline, and there was a normal, symmetric movement of the soft palate. Motor examination showed a normal muscle tone throughout all four extremities. Power was 4/5 in the left lower extremity. Deep tendon reflexes were 0 at the left upper extremity, 1 plus at the right upper extremity, bilateral knees, and left ankle were 0, and the right ankle had 2 plus reflex present. Sensory examination was normal, and toes were down-going bilaterally. Acetylcholine receptor binding and modulating antibodies were negative, and anti-GQ1b antibodies less than 1:100 (normal titer is less than 1/200). On day 9 of hospitalization, the patient showed notable improvement in her speech. CN examination showed an improvement in the power in the orbicularis oculi muscles. There was notable bilateral CN VII lower motor neuron lesion, bilateral upper and lower facial weakness, and decreased gag reflex. Muscle tone was normal in all four extremities; however, power in the left lower extremity was 4/5. Deep tendon reflexes of the left upper extremity and right upper extremity were 0 and 1 plus, respectively. Furthermore, that of bilateral knees, left ankle, and right ankle were 1 plus, 0, and 2 plus, respectively. Sensory examination was intact. The remainder of the CN exam was the same as day 3. On day 12 of hospitalization, the patient's speech was slightly slurred with mild dysarthria, and the patient was able to close her eyes and keep them closed, which she was unable to do before. Nasolabial folds were slightly deeper. Bilateral CN VII lower motor neuron lesion signs were still present with bilateral upper and lower facial weakness and decreased gag reflex. The patient had negative titers of IgG anti-GQ1b antibody and normal findings for MRI of brain, thus ruling out Bickerstaff's brainstem encephalitis (BBE) or Fisher syndrome. On an unspecified date, the patient experienced neck pain. On day 14, the patient was discharged and outpatient follow-up with a neurologist was recommended. Treatment with IVIG and plasmapheresis was observed to be successful with the patient being able to return to her normal baseline health at the time of discharge.  The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient was recovering from facial diplegia rare variant of guillain-barre syndrome. The purpose of the article was to bring awareness to the facial diplegia variant of GBS and the importance of reporting the potential adverse reactions post-COVID-19 vaccination. Prompt management with IVIG should be initiated if facial diplegia was diagnosed. Adverse events after vaccination must be reported as they need to be further investigated, considering the fact that vaccination was needed to control the ongoing pandemic situation. This report was serious (Hospitalization Caused / Prolonged).; Sender's Comments: V0: 20210903117- COVID-19 VACCINE AD26.COV2.S- Facial diplegia rare variant of guillain-barre syndrome. This event is labeled per Agency and is therefore considered potentially related.