Association Between Guillain-Barré Syndrome and COVID-19 Infection and Vaccination: A Population-Based Nested Case-Control Study

Guillain-Barré syndrome in patients with multiple myeloma: three cases report and literature review

BACKGROUND

Multiple myeloma (MM) with Guillain-Barré syndrome (GBS) is relatively rare, and the specific mechanism is still unclear. The previous infection, surgery, and medication use may have contributed to the occurrence of GBS. The use of bortezomib in patients with MM can easily lead to peripheral neuropathy, which is similar to the symptoms of GBS, making it challenging to diagnose GBS.

CASES PRESENTATION

Three patients with IgA type MM experienced lower limb weakness during treatment. Combined with lumbar puncture, nerve conduction studies, and other tests, the diagnosis was confirmed as GBS. All three patients had a history of spinal surgery before the onset of GBS, and had been treated with bortezomib which induced peripheral neuropathy. Two of the three patients had a clear history of upper respiratory tract infection before the onset of GBS. After treatment with intravenous immunoglobulin, one patient died and two patients showed improvement in GBS symptoms.

CONCLUSION

Patients with MM often have concurrent infections and spinal surgery, which may contribute to the occurrence of GBS. The symptoms of bortezomib-induce peripheral neuropathy overlap with those of GBS, which can easily lead to misdiagnosis or missed diagnosis of GBS. Timely lumbar puncture and nerve conduction studies may help to diagnose GBS and improve the prognosis.

Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a rare immune-mediated polyradiculoneuropathy. Patients typically develop rapidly progressive weakness and sensory deficits that can result in complete paralysis requiring mechanical ventilation. GBS is usually a monophasic disease in which an aberrant immune response to an infection or other trigger damages the peripheral nerves. For example, in patients with preceding Campylobacter jejuni infection, molecular mimicry causes a cross-reactive antibody response to nerve gangliosides. Diagnosis is based on clinical features, supported by cerebrospinal fluid analysis and nerve conduction studies. Effective treatments include plasma exchange and intravenous immunoglobulins. However, ~20% of patients who received treatment are unable to walk after 6 months and ~5% die as a consequence of GBS. Important knowledge gaps in GBS include its pathogenesis, especially after viral infections. In addition, there is a lack of specific biomarkers to improve the diagnosis, monitor the disease activity, and predict the clinical course and outcome of GBS. Major challenges for the future include finding more effective and personalized treatments, which are affordable in low-income and middle-income countries, and preparation for outbreaks of infections as potential triggers for GBS.

Global burden of vaccine-associated Guillain-Barré syndrome over 170 countries from 1967 to 2023

Research on Guillain-Barré syndrome (GBS) as a neurological adverse effect of vaccines on a global scale is scarce, highlighting the need for further investigation to evaluate its long-term impact and associated risk factors comprehensively. Hence, this study aims to assess the global burden of vaccine-associated GBS and its associated vaccines. This study utilized data from VigiBase, the World Health Organization global database of adverse event reports of medicines and vaccines, encompassing the period from 1967 to 2023 (total reports, n = 131,255,418) to investigate vaccine-associated GBS. Reported odds ratios (ROR) and information components (IC) were analyzed to assess the association between 19 vaccines and the occurrence of vaccine-associated GBS over 170 countries. We identified 15,377 (8072 males [52.49%]) reports of vaccine-associated GBS among 22,616 reports of all drugs-cause GBS from 1978 to 2023. Cumulative reports of vaccine-associated GBS have been increasing steadily over time, with a notable surge observed since the commencement of COVID-19 vaccines administration in 2020. Most vaccines showed significant associations with GBS such as Ad5-vectored COVID-19 vaccines (ROR, 14.88; IC, 3.66), COVID-19 mRNA vaccines (ROR, 9.66; IC, 2.84), and inactivated whole-virus COVID-19 vaccines (ROR, 3,29; IC 1.69). Influenza vaccines showed the highest association (ROR, 77.91; IC 5.98). Regarding age-and sex-specific risks, the association remained similar regardless of sex, with an increased association observed with advancing age. The mean time to onset was 5.5 days. Amid the COVID-19 pandemic, the reports of GBS surged in response to widespread COVID-19 vaccination. Nonetheless, COVID-19 vaccines exhibited the lowest association compared to other vaccines. Vigilance for at least one-week post-vaccination is crucial, particularly for older adults. Further research is warranted to elucidate the underlying mechanisms linking vaccines and GBS.

Guillain-Barre syndrome and link with COVID-19 infection and vaccination: a review of literature

Background

Guillain-Barré syndrome (GBS) is an autoimmune disease associated with significant morbidity. A wide variety of infectious and non-infectious triggers have been identified to be associated with GBS. COVID-19 has gained attention in recent years for its role in GBS pathogenesis. Our study aims to review the literature on GBS and its epidemiological and pathophysiological association with COVID-19.

Description

Recent literature on GBS associated with COVID-19 infections, such as case reports, case series, systematic reviews, and large-scale epidemiological studies, were reviewed. We also reviewed studies that included vaccines against COVID-19 in association with GBS. Studies that focused on understanding the pathobiology of GBS and its association with infectious agents including COVID-19 were reviewed.

Conclusion

Despite a lack of consensus, GBS is strongly associated with COVID-19 infection. The exact pathophysiological mechanism regarding COVID-19 as a causative agent of GBS is unknown. Mechanisms, such as the proinflammatory state, triggering of autoimmunity, and direct viral invasion, are postulated and remain to be investigated. Adenovirus vector vaccines are most likely associated with GBS, and the consensual reports clearly suggest mRNA vaccines are associated with low risk and may be protective against GBS by reducing the risk of COVID-19 infection.

The Impact of COVID-19 on the Guillain-Barré Syndrome Incidence

Despite the fact that the global COVID-19 pandemic has officially ended, we continue to feel its effects and discover new correlations between SARS-CoV-2 infection and changes in the organism that have occurred in patients. It has been shown that the disease can be associated with a variety of complications, including disorders of the nervous system such as a characteristic loss of smell and taste, as well as less commonly reported incidents such as cranial polyneuropathy or neuromuscular disorders. Nervous system diseases that are suspected to be related to COVID-19 include Guillain-Barré syndrome, which is frequently caused by viruses. During the course of the disease, autoimmunity destroys peripheral nerves, which despite its rare occurrence, can lead to serious consequences, such as symmetrical muscle weakness and deep reflexes, or even their complete abolition. Since the beginning of the pandemic, case reports suggesting a relationship between these two disease entities have been published, and in some countries, the increasing number of Guillain-Barré syndrome cases have also been reported. This suggests that previous contact with SARS-CoV-2 may have had an impact on their occurrence. This article is a review and summary of the literature that raises awareness of the neurological symptoms' prevalence, including Guillain-Barré syndrome, which may be impacted by the commonly occurring COVID-19 disease or vaccination against it. The aim of this review was to better understand the mechanisms of the virus's action on the nervous system, allowing for better detection and the prevention of its complications.

Improving Outcome in Severe Myasthenia Gravis and Guillain-Barré Syndrome

When progressive and severe, myasthenia gravis and Guillain-Barré syndrome may have the potential for fatal and unfavorable clinical outcomes. Regardless of important differences in their clinical course, the development of weakness of oropharyngeal muscles and respiratory failure with requirement of mechanical ventilation is the main driver of poor prognosis in both conditions. The need for prolonged mechanical ventilation is particularly relevant because it immobilizes the patient and care becomes extraordinarily complex due to daily risks of systemic complications. Additionally, patients with myasthenia gravis often require long-term immunosuppressive treatments with associated toxicity and infectious risks. Unlike myasthenia gravis, the recovery period is prolonged in Guillain-Barré syndrome, but often favorable, even in the more severely affected patients. Outcome, for a large part, is determined by expert neurocritical care.

Relative frequencies and clinical features of Guillain-Barré Syndrome before and during the COVID-19 pandemic in North China

OBJECTIVE

Most studies investigated the relationship between COVID-19 and Guillain-Barré syndrome (GBS) by comparing the incidence of GBS before and during the pandemic of COVID-19. However, the findings were inconsistent, probably owing to varying degrees of the lockdown policy. The quarantine requirements and travel restrictions in China were lifted around December 7, 2022. This study aimed to explore whether the relative frequency of GBS increased during the major outbreak in the absence of COVID-19-mandated social restrictions in China.

METHODS

GBS patients admitted to the First Hospital, Shanxi Medical University, from December 7, 2022 to February 20, 2023, and from June, 2017 to August, 2019 were included. The relative frequencies of GBS in hospitalized patients during different periods were compared. The patients with and without SARS-CoV-2 infection within six weeks prior to GBS onset formed the COVID-GBS group and non-COVID-GBS group, respectively.

RESULTS

The relative frequency of GBS among hospitalized patients during the major outbreak of COVID-19 (13/14,408) was significantly higher than that before the COVID-19 epidemic (29/160,669, P < 0.001). More COVID-GBS patients (11/13) presented AIDP subtype than non-COVID-GBS cases (10/27, P = 0.003). The mean interval between onset of infective symptoms and GBS was longer in COVID-GBS (21.54 ± 11.56 days) than in non-COVID-GBS (5.76 ± 3.18 days, P < 0.001).

CONCLUSIONS

COVID-19 significantly increased the incidence of GBS. Most COVID-GBS patients fell into the category of AIDP, responded well to IVIg, and had a favorable prognosis.

Guillain-Barré syndrome and COVID-19 vaccination: a systematic review and meta-analysis

BACKGROUND

Case-reports/series and cohorts of Guillain-Barré syndrome (GBS) associated with COVID-19 vaccination have been reported.

METHODS

A systematic review and meta-analysis of cohort studies of GBS after COVID-19 vaccination was carried out. Incidence and incidence rate ratio for a number of vaccine doses and risk of GBS, also considering the specific vaccine technology, were calculated in a random-effects model.

RESULTS

Of 554 citations retrieved, 518 were discarded as irrelevant. We finally included 15 studies. The random effect model yielded, regardless of the vaccine technology, 1.25 (95%CI 0.21; 2.83) GBS cases per million of COVID-19 vaccine doses, 3.93 (2.54; 5.54) cases per million doses for adenovirus-vectored vaccines and 0.69 (0.38; 1.06) cases per million doses for mRNA vaccines. The GBS risk was 2.6 times increased with the first dose. Regardless of the vaccine technology, the GBS risk was not increased but disaggregating the data it was 2.37 (1.67; 3.36) times increased for adenovirus-vectored vaccines and 0.32 (0.23; 0.47) for mRNA vaccines. Mortality for GBS after vaccination was 0.10 per million doses and 4.6 per GBS cases.

CONCLUSIONS

Adenovirus-vectored vaccines showed a 2.4 times increased risk of GBS that was about seven times higher compared with mRNA-based vaccines. The decreased GBS risk associated with mRNA vaccines was possibly due to an elicited reduction of infections, including SARS-CoV-2, associated with GBS during the vaccination period. How adenovirus-vectored COVID-19 vaccines may trigger GBS is unclear and further studies should investigate the relationship between vaccine technologies and GBS risk.