Guillain–Barré syndrome after COVID-19 vaccination with suspected concurrent cytomegalovirus reactivation

Background

Guillain–Barré syndrome (GBS) is an immune-mediated polyneuropathy most commonly associated with antecedent infections, such as Campylobacter jejuni or viral infections, but vaccination is also known as an antecedent event. In recent years, due to the worldwide pandemic, vaccination against coronavirus disease 2019 (COVID-19) has widely spread throughout the world. Although surveillance of vaccination-associated adverse effects is still ongoing, multiple cases of GBS after COVID-19 vaccination have been reported. However, the exact pathophysiology of COVID-19 vaccination causing GBS has not been clarified. Not only new-onset infection, but also reactivation of dormant viral agents, is known to trigger GBS. This reactivation might occur after COVID-19 vaccination; however, there are no reports of this phenomenon in association with post-vaccination GBS.

Case Presentation

A 44-year-old immunocompetent woman presented with acute onset weakness in all four limbs 6 days after COVID-19 vaccination. Neurological examination showed dysphagia, symmetrical weakness, absent tendon reflexes and distal dominant sensory disturbance in all four extremities. Nerve conduction studies were compatible with demyelinating neuropathy, and serum was positive for anti-GD1a-IgG antibody. A diagnosis of acute inflammatory demyelinating neuropathy was made. Serological examination on admission suggested concomitant cytomegalovirus reactivation. Plasma exchange rapidly improved her symptoms, including weakness and sensory disturbance, and she was discharged without residual symptoms.

Conclusions

The present case suggests that cytomegalovirus reactivation might play a role in the pathogenesis of GBS associated with COVID-19 vaccination. Accounting for cytomegalovirus reactivation might reveal unidentified pathophysiology of GBS after COVID-19 vaccination.