A report describes a case of a 57-year-old man who, in April 2021, with a history of Bell′s palsy ten years earlier, presented to the Neurology Department with a 5-day–lasting moderate fever and arthromyalgia, followed by diplopia, right-side facial weakness, and gait instability. His Nasopharyngeal swab PCR and antigenic tests for SARS-CoV-2 were positive, and Chest CT imaging showed typical features of COVID-19 pneumonia.

He received Antiviral therapy with remdesivir (IV, 200 mg loading dose on day 1, followed by a 100-mg daily maintenance dose on days 2 through 10). Neurological examination showed right-side third and seventh cranial nerve palsy, distal weakness in four limbs, bilateral stocking hypoesthesia, gait ataxia, and global areflexia. Cerebrospinal fluid (CSF) analysis showed albuminocytological dissociation, a diagnostic hallmark of Guillain-Barré Syndrome (GBS). Electrophysiology studies confirmed the diagnosis with features indicating acute demyelinating sensory-motor polyneuropathy. Serum IgM to the ganglioside GD1b showed positivity to both immunoblot and ELISA. Immunoblots for serum IgG and IgM to GM1/2/3/4, GD1a/b (except for GD1b IgM), GD2/3, GT1a/b, GQ1b, and sulfatides and ELISA for GD1b IgG, GM1 and GQ1b IgG, and IgM were all negative.

The negative results for Cytomegalovirus IgM, Mycoplasma pneumoniae IgM, Campylobacter jejuni IgM/IgA, Epstein–Barr virus capsid antigen (VCA) IgM, and Haemophilus influenzae IgM ruled out recent infections. The patient began experiencing rapid worsening of breathing patterns and neurological conditions with asymmetrical flaccid tetraparesis and autonomic dysfunction, and profuse sweating. Thus, he received high-flow oxygen therapy. A course of IVIg (0.4 g/kg for five days) elicited gradual progressive functional recovery, which got completed after neurorehabilitation. 

In October 2021, the patient again presented to the Neurology Department with disequilibrium, difficulty climbing stairs, and foot hypoesthesia, which reportedly occurred five days after receiving the first dose of the BNT162b2 (Pfizer/BioNTech) mRNA vaccine.

Neurological examination showed areflexia, lower limb weakness, ataxic gait, and supported walking. CSF analysis showed Albuminocytological dissociation, and electrophysiology studies confirmed a demyelinating sensory-motor polyneuropathy. The extensive screening for recent infections by the most commonly GBS-associated infectious agents was negative. The immunoblot for ganglioside antibodies was positive for GM3/4, GD1a/b, and GT1b IgM (the latter confirmed on ELISA). 

After only five days from vaccination, the patient showed strong SARS-CoV-2 serological responses both to the vaccine and in terms of natural immunity. He received a new course of IVIg (0.4 g/kg for five days) which rendered complete recovery. A 4-month follow-up assessment showed only weak seropositivity for GT1b IgM. He experienced no adverse effects over the two IVIg courses.

2022 Jul 18;13:894872. doi: 10.3389/fimmu.2022.894872. PMID: 35924236; PMCID: PMC9339669.