Guillain–Barré Syndrome Post COVID-19 Vaccination with ChAdOx1 nCoV-19 Vaccine: A Colombian Case Report

Background Adverse events after vaccination against COVID-19 include rare events, such as Guillain–Barré syndrome. Study Aims. Documentation of clinical and temporary characteristics of the Guillain–Barré syndrome after using anti-COVID-19 ChAdOx1 nCoV-19 vaccine. Case Presentation. An adult, 29-year-old male, without relevant medical history, who developed neuromuscular symptoms nine days after administration of the first dose of anti-COVID-19 ChAdOx1 nCoV-19 vaccine. Results Symptoms appeared nine days after vaccination, with lower limbs paresthesia. Three days later, paresthesia of upper limbs occurred. The following day, distal weakness of limbs, with standing and gripping difficulties, occurred. The clinical evaluation demonstrated dysarthria, incomplete palpebral closure, bilateral facial, and tongue paresis. The electromyography was compatible with a motor demyelinating polyneuropathy, confirming the diagnosis of the Guillain–Barré syndrome. Management with five sessions of plasma exchange was prescribed, with favorable clinical results. Conclusions Clinical and laboratory tests confirmed the Guillain–Barré syndrome and the time elapsed from the date of the vaccine administration to the appearance of initial symptoms, added to the absence of other causes, and allowed to establish that the disease was caused by the vaccination.


Introduction
During the COVID-19 pandemic global emergency, diverse vaccines were authorized following manufacturing safety, efcacy, and quality standards demanded by the World Health Organization (WHO).As it is a new vaccine, rare adverse events are still being documented [1].
As anti-COVID-19 vaccination coverage increased with more timely and universal access, rare suspicious events were reported, such as Guillain-Barré syndrome (GBS) after vaccination, and more frequently, after nonreplicating viral vectors' vaccines.Terefore, the Pharmacovigilance Risk Assessment Committee of the European Medical Association recommended in its meeting of July, 2021, a change in the technical datasheet of AstraZeneca's vaccine against COVID-19 to include a warning so the health sector professionals and general public with access to that vaccine could be aware of the potential risk of acquiring the GBS [2], since some suspicious cases had been reported to the European Vigilance System, although they indicated that the available data did not confrm or discard a causal association [3].
Colombia made its frst case report of this event after the application of the Pfzer-BioNTech vaccine in March, 2021 [4], and at global level, cases were reported after administration of the AstraZeneca vaccine in Brazil [5], Korea [6], India [7], Iran [8], Italy [9], the United Kingdom [10][11][12][13][14], and Tanzania [15], mostly in adults older than 50 years of age.Since the beginning of vaccine Pharmacovigilance in Colombia, no cases of GBS were reported after administration of the ChAdOx1 nCoV-19 vaccine in the national public health vigilance system [16].
Based on the abovementioned, the objective of this study was to document the Guillain-Barré syndrome case in a male, young adult, who started having symptoms nine days after receiving the initial dose of anti-COVID ChAdOx1 nCoV-19 vaccine.

Case Presentation
Te case of a mestizo, 29-year-old male, who did not refer a medical history of interest or neurological family records before the vaccine administration, was reported.For this case report, the patient signed the informed consent, and the diagnosis was established according to Brighton collaboration criteria, based on the patient's clinical records.

Results
A mestizo, 29-year-old male, residing in the urban area of south-western Colombia (Tuluá, Valle del Cauca), without relevant medical records or infection history due to SAR-SCov2, except for childhood asthma, received the initial dose of ChAdOx1-S (Vaxzevria-AstraZeneca) on October 11, 2021.Nine days later, he showed clinical symptoms which initially included lower limbs paresthesia, followed by paresthesia of upper limbs after three days, accompanied by distal weakness in arms and legs, causing standing and gripping difculties.On the 11th day after the vaccine, the patient had difculty in remaining seated, associated to an occipital headache.Initially, the patient went to a local hospital, where vital signs were within normal ranges.Cardiopulmonary physical exam did not show any relevant fndings, and there was no deterioration of his superior mental functions shown in the neurological assessment.
Te patient had presence of dysarthria, incomplete palpebral closure due to eye orbicular muscle weakness, bilateral facial paresis with weakness of the buccinator and orbicularis muscle of the mouth, tongue with protrusion weakness on the left side, without afecting other cranial nerves, mainly proximal quadriparesis, osteotendinous refexes +/++++, and bilateral neutral plantar response, without sensitive compromise.Studies were carried out, including blood count, kidney function, and normal electrolytes (sodium, potassium, calcium, magnesium, and phosphorus), HIV negative magnetic test, nuclear magnetic resonance (NMR) of the cervical and dorsal spine, normal skull CT-scan without contrast, and normal lumbar puncture opening pressure, with albumin-cytologic dissociation and normal glucose results (Table 1).For that reason, the patient was referred to a higher complexity institution, with suspicion of the Guillain-Barré syndrome.Electromyography compatibility with motor demyelination polyneuropathy was obtained.Te neurology department's physicians evaluated the patient, who was considered to have an acute demyelinating polyneuropathy, Guillain-Barré syndrome-type.Prescription of management with fve sessions of plasma exchange therapy was obtained, obtaining a favorable clinical response, leaving only a discrete weakness in the lower limbs, but being able to gait.
During the 18 month follow-up after the presentation of the adverse event, satisfactory evolution was evidenced, without diuresis or stool problems, without motor sequelae, with transitory paresthesia, and sensory sequelae in the frst toe of the left foot.Te patient did not receive additional doses of vaccine against COVID-19 or other biologics.Given the good evolution, it was not necessary to perform a control electromyography.

Discussion
Until May 2022, the epidemiological behavior of COVID-19 had a total of 531 million cases, with 6.2 million global deaths.In Colombia, according to ofcial data from the National Health Institute, 6.1 million people were confrmed as infected with SARS-CoV-2 and 139,000 deaths, with a vaccination percentage of 70.31% [17,18].Te Oxford/AstraZeneca ChAdOx1 nCoV-19 vaccine (later denominated Vaxzevria) was approved for its manufacturing and distribution by WHO during the COVID-19 pandemic.Tis vaccine uses a viral vector (a chimpanzee recombinant adenoviral vaccine) which expresses S antigen of the peak protein of SARS-CoV-2, inducing immunization against it.Te most recent data from the Ministry of Health and Social Protection of Colombia indicate that as of May 2022, a total of 84,035,139 anti-COVID-19 vaccines had been administered, with 51,137 reports of serious and nonserious adverse events, for a rate of 61 postvaccine adverse events per 100,000 applied dosages.Out of the reported events, 8,019 corresponded to Vaxzveria secondary events, with a rate of serious adverse events estimated at 9.5 per 100,000 applied dosages [19].
Anti-COVID-19 vaccines have been related to a diversity of adverse efects, which include pain at the vaccine application site, general symptoms such as fatigue, edema, heart and liver disturbances, and neurological manifestations, such as seizures, impairment of consciousness, and GBS [14,20].Among the severe efects, polyneuropathies are the most reported conditions after the vaccine application.A systematic revision made in 2021 found within 17 evaluated articles, thirty-nine patients diagnosed with GBS, out of which 64.1% (25/39) correspond to events associated with the AstraZeneca vaccine, followed by BNT162b2 (Pfzer/ BioNTech), with 31% (12/39) [21].
In the case of Vaxzevria vaccine, considering that antigen S can be united to the sialic acid constituting the glycoproteins and gangliosides present in the cell membranes, the crossed antibody reaction is presumed to be associated to the appearance of GBS in this vaccine [22,23].GBS is an immune entity that compromises peripheral nerves, being the most frequent cause for acute faccid paralysis [24].GBS usually occurs as a consequence of recent infections caused by Campylobacter jejuni, Zika virus, and Mycoplasma pneumoniae, among others, which generate an autoimmune disorder that attacks the spinal roots and peripheral nervous system [25]; this condition has also been described after administration of vaccines since 1970, when the frst cases were documented, especially with vaccines against polio, hepatitis A and B, infuenza, rabies, and currently, anti-COVID-19 vaccines [14].In most cases, temporary associations between the initial symptoms and the vaccine administration were documented, without establishing their cause.
Te classical presentation of GBS initiates with paresthesia and distal weakness in upper and lower limbs, with proximal progression, as in the case of our patient, with a clinical condition like those described by Maramattom et al. in India, where seven cases of GBS were reported after the administration of the ChAdOx1 nCoV-19 (Vaxzevria) vaccine, with facial paresis, quadriparesis, and arefexia [7].Our patient also presented dysarthria, incomplete eyelid closing, and bilateral facial and tongue paresis.In our case, symptoms started nine days after vaccination, relating to fndings in international publications of anti-COVID-19 vaccines, which mention periods between seven and 22 days, including Vaxzevria [21].When the GBS was diagnosed, our patient was 29 years old, an age lower than that observed in other cases reported in Europe, the United States, and Asia, where the average patient's age was between 47 and 69 years of age [14,21,26].Te literature reports that the initial diagnose of SGB is clinical, and later it is supported by fndings in the lumbar puncture (spinal tap) and electrodiagnostic testing, where albumincytologic dissociation and abnormalities are consistent with GBS [27] in the same way that it was presented in our case.
Until this date in Colombia, only two cases of GBS have been documented after vaccination against COVID-19, both of which were secondary to CoronaVac ® [28, 29].In these cases, GBS presentation was the classic one, with initial quadriparesis.One of the patients had ventilatory failure, requiring orotracheal intubation, which was associated to the age (73 years old); this patient was older than those observed in other publications.Tese cases presented between nine and 21 days after the vaccine application, coinciding with our case report.
In conclusion, the clinical data and lab exams confrmed the GBS diagnosis and the time between administration of the vaccine and appearance of symptoms, as well as the absence of other causes, allowing the classifcation of this case as an adverse event following immunization (AEFI).the patient and provided the clinical records used in the preparation of this case report.

Table 1 :
Description of patient lab exams, October to November, 2021.