Sex: M
Vaccine: COVID19, COVID19
Symptoms: CSF cell count increased, CSF protein decreased, Guillain-Barre syndrome, Immunoglobulin therapy, Lumbar puncture
Clinical narrative: BIFACIAL DIPLEGIA VARIANT OF GUILLIAN- BARRE SYNDROME; ARM SORENESS; CHILLS; MILD FATIGUE; This spontaneous report was received from literature:  A Novel Case of Bifacial Diplegia Variant of Guillain-Barre Syndrome Following Janssen COVID-19 Vaccination. Neurology International. 2021 Aug 13; 13404-409. This report concerned a 41 year old male, race and ethnic origin not reported.   The patient's height, and weight were not reported. The patient's concurrent conditions included: morbidly obese, with no significant medical history. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin, and batch number were not reported) 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 presented to the emergency department (ED) with acute onset of urinary retention twelve days after vaccine administration.  The patient only reported arm soreness, mild fatigue, and chills three days after the vaccination which were self-resolving in a few days. He underwent evaluation in the ED followed by urinary catheterization and was followed up with urology as an outpatient. On day 15 following his COVID-19 vaccination, he returned to the ED with a new onset of left-sided facial droop. He was diagnosed with Bell's palsy and was discharged with prednisone and valacyclovir. His CT brain showed a colloid cyst and, hence, he was referred to see neurosurgeons as an outpatient. On day 21 post-vaccination, he presented to the ED with subjective weakness and paresthesias in all extremities. He had difficulty feeding himself and ambulating due to his weakness. He also had new onset of right facial weakness. His urinary retention had resolved. He denied any blurry vision, dysphagia, and headache. Upon physical examination, his vital signs were stable. Neurological examination, including a cranial nerve examination showed bilateral lower motor neuron facial nerve palsy, more prominent on the left compared to right. His deep tendon reflexes were absent bilaterally at the patella and the Achilles with mute plantar responses. Motor strength was 4+/5 (Medical Research Council grade) in all four extremities.  An MRI of the cervical and thoracic spine did not show any abnormal T2 signal changes and his lumbar spine showed no significant degenerative disc disease.  He underwent lumbar puncture due to suspicion for Guillain-Barre syndrome (GBS) and showed albumino-cytological dissociation with a CSF cell count of 50/uL (lymphocytes 91%, monocyte 9%, red blood cell counts of 123) and CSF protein of 562 mg/dL. Further corrected cerebrospinal fluid (CSF) protein for the presence of RBC was significantly elevated to 562 mg/dL. Other CSF findings included glucose of 67 mg/dL (serum glucose 109 mg/dL) and negative CSF gram stain, CSF lyme polymerase chain reaction (PCR), and viral PCR testing on CSF, including herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus (CMV) and Borrelia burgdorferi IgM and IgG. Given the classic clinical picture of GBS in absence of other identifiable etiology for his neurologic disease, additional supportive testing with EMG showed a prolonged distal latency with conduction block and slow conduction velocity in bilateral tibial, peroneal nerve, and absent F waves were supportive for demyelinating GBS. He was started on intravenous immunoglobulin (IVIG) at 2 g/kg over 5 days. Other notable laboratory findings included a white cell count of 15.0 10*9/L, possibly due to recent steroid use and borderline elevated D-dimer. The erythrocyte sedimentation rate, creatine phosphokinase, blood glucose, hepatic and renal function, vitamin B12, folate levels, and thyroid-stimulating hormones were all within normal values, whereas the serum HIV test was negative. Chest X ray was unremarkable with no hilar or mediastinal lymphadenopathy. Clinically, the patient showed significant improvement after the first dose of 400 mg/kg of IVIG. The patient strength was 5/5 in all muscle groups one day after IVIG treatment. He showed recurrence of his right patellar reflex on day 4 of IVIG treatment and trace right ankle reflex with continued absence of left patellar and ankle reflex. The patient finished 5 days of IVIG treatment with mild side-effects, including nausea and headache. It was reported the patient responded very well to IVIG treatment with improvement of his symptoms. He continued to be significantly ataxic and was intended to be placed in a rehabilitation facility. Patient followed in outpatient clinic had MRI imaging of brain showed incidental finding of colloid cyst, no facial nerve enhancement, no mass lesion, no abnormal leptomeningeal. Repeat MRI lumbar spine with contrast showed thickening of cauda equina nerve roots suggestive of inflammatory demyelinating neuropathy. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient recovered from arm soreness, chills, and mild fatigue, and the outcome of bifacial diplegia variant of guillian- barre syndrome was not reported. This report was serious (Other Medically Important Condition).; Sender's Comments: V0: This 41-year-old male patient having morbid obesity with no other significant medical history, with incidental finding of Colloid brain cyst on CT brain, about 15 days after prophylactic vaccination and also experienced bifacial diplegia variant of Guillian-Barre syndrome(GB syndrome) within 3 weeks of vaccination. Initial symptom of acute onset of urinary retention started about 12 days after vaccination which was treated with catheterization. Later patient presented with new onset of left-sided facial droop and initial diagnosis made as Bell's palsy and found to have colloid cyst in CT brain; treated with prednisone and valacyclovir. On day 21 post-vaccination, patient presented with weakness and paresthesias in all extremities, new onset of right facial weakness with neurological findings of bilateral lower motor neuron facial nerve palsy, more prominent on the left compared to right, deep tendon reflexes absent bilaterally at the patella and the Achilles with mute planter responses. Motor strength was 4+/5 in all four extremities. An MRI of cervical, thoracic and lumbar spine did not reveal any degenerative disease. CSF examination revealed albumin-cytological dissociation with CSF cell count of 50/uL and CSF protein of 562 mg/dL with negative CSF gram stain, CSF lyme polymerase chain reaction (PCR), and viral PCR testing on CSF, including herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus and Borrelia burgdorferi IgM and IgG; negative serum HIV test and chest X-ray unremarkable. Additional testing with EMG was supportive for demyelinating GB syndrome. Patient was treated with intravenous immunoglobulin over 5 days and responded well clinically. Considering the temporal relationship and lack of other reported potential etiologies, GB syndrome is assessed to have a plausible relationship with vaccination.