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headache&#44; dizziness&#44; ageusia&#44; or cerebrovascular accidents &#40;ischaemia or haemorrhage&#41;&#44; among others&#46; Developing Guillain-Barr&#233; syndrome and Miller Fischer syndrome has also been reported within the context of SARS-CoV-2 infection<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the association between Guillain-Barr&#233; syndrome and vaccines such as the flu vaccine has been reported<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; only one instance has been described in current medical literature&#44; that of one case following vaccination with an mRNA vaccine<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and one following adenovirus<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the first two cases of Guillain-Barr&#233; syndrome described in the literature in which this syndrome&#44; vaccination&#44; and infection with SARS-CoV-2 coincide&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 1</span>&#46; A 77-year-old male with no history of note&#46; The patient was admitted on 13 March 2021 for COVID-19 pneumonia with mild involvement of the pulmonary parenchyma and evidence of hyperinflammation&#46; He was treated with dexamethasone with subsequent favourable progress and was referred for discharge six days later&#46; Two weeks later he received his first coronavirus vaccine dose &#40;BNT162b2&#41;&#46; He received it on 5 April 2021&#46; At 72&#160;h post-vaccination&#44; the patient started to experience symptoms of weakness in the lower limbs and progressive oedema of said limbs&#46; Days later neuropathic pain started in the left lower limb&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient went to the Emergency Department on 27 April 2021 due to worsening symptoms and the inability to walk&#46; Neurologically&#44; the patient presented absent bilateral reflexes in the lower limbs&#44; loss of epicritic and protopathic sensation&#44; as well as diminished strength in the flexion-extension of both feet and flexion of the leg &#40;2&#8211;3&#47;5&#41;&#46; He presented with pitting oedema up to the middle third of both legs&#46; The rest of the physical examination was unremarkable&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the initial additional tests&#44; elevated acute phase reactants stood out &#40;CRP 233&#160;mg&#47;dL&#41; and <span class="elsevierStyleSmallCaps">d</span>-dimer &#40;8&#46;09&#160;mg&#47;L&#41;&#46; A lumbar puncture was performed which showed clear fluid with no increased pressure and lymphocytic pleocytosis &#40;proteins 39&#160;mg&#47;dL and 1 cell&#41;&#46; The auto-immune study was negative&#44; including anti-ganglioside antibodies&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A neurophysiology study was performed which confirmed the initial suspicion of Guillain-Barr&#233; syndrome&#44; acute motor and sensory axonal neuropathy variant &#40;AMSAN&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Just hours later&#44; the patient&#8217;s respiratory situation worsened with desaturation and respiratory effort&#44; so treatment with intravenous immunoglobulins was started &#40;400&#160;mg&#47;kg&#47;day&#41; and&#44; subsequently&#44; plasmapheresis due to refractoriness&#44; with favourable subsequent progress&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 2&#46;</span> A 62-year-old patient with no personal history of note and vaccinated with the first dose of the ChAdOx1 vaccine&#46; At 72&#160;h&#44; the patient went to the Emergency Department due to symptoms of progressive fever and respiratory difficulty requiring orotracheal intubation for 8 days due to severe COVID-19 pneumonia confirmed via nasopharyngeal exudate PCR&#46; At 24&#160;h after being moved to the Internal Medicine ward&#44; onset of an acute episode of flaccid&#44; areflexic tetraparesis&#44; hypophonia&#44; and new respiratory failure that required reintubation&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A lumbar puncture was performed with clear CSF&#44; normal pressure with an albuminocytologic dissociation in the cytochemical analysis with proteins 48&#160;mg&#47;dL and 0 cells&#46; Treatment was started with IV immunoglobulins &#40;dose&#58; 400&#160;mg&#47;kg&#47;day for 5 days&#41; with rapid patient progress&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although many infectious agents have been associated with Guillain-Barr&#233; syndrome&#44; the most frequently associated agents are <span class="elsevierStyleItalic">Campylobacter jejuni</span>&#44; the Epstein Barr virus&#44; cytomegalovirus&#44; and Zika virus<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; The mechanism by which SARS-CoV-2 induces Guillain-Barr&#233; syndrome could be via viral stimulation of the inflammatory cells&#44; producing a cytokine release syndrome and&#44; subsequently&#44; the creation of immune-mediated processes that can be directed at the myelin or the axon of the peripheral nerve&#44; thus resulting in demyelinating and axonal variants&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Weakness can vary from slight difficulty to walk to almost complete paralysis of the limb&#44; facial&#44; respiratory&#44; and bulbar muscles&#44; as occurred in one of our cases&#44; though this is uncommon since motor muscle weakness that requires ventilatory support occurs in 10&#37;&#8211;30&#37; of cases&#44; oropharyngeal weakness in 50&#37;&#44; and oculomotor weakness in 15&#37; of cases<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There is some controversy surrounding the development of this syndrome and coronavirus vaccination&#44; despite two cases having been previously reported in the literature of individuals developing Guillain-Barr&#233; syndrome following coronavirus vaccination with different types of vaccines &#40;ChAdOx1-S and BNT162b2&#41;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Nevertheless&#44; some authors believe there is no causal relationship between the two situations<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There is currently very little information available regarding neurological manifestations following coronavirus vaccination&#44; or their incidence rates&#46; As such&#44; epidemiological studies and registries of future cases should elucidate the real incidence of neurological complications&#44; their pathogenic mechanisms&#44; and their therapeutic options&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Though a causal relationship between this syndrome and vaccination cannot be demonstrated with the current evidence&#44; we believe that neuromuscular complications could be due to said association&#44; and even more so in the presence of a concomitant&#44; undiagnosed infection of this kind&#44; or recent infection&#46; Both situations could be synergic and could stimulate development of the acute inflammatory demyelinating polyradiculoneuropathy&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Though scarcely reported&#44; it is possible that this complication is under-diagnosed&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Understanding and evaluating neurological manifestations following this vaccine is important as the initial symptoms are rarely assessed in a thorough manner and could interfere with prognosis&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">This manuscript did not receive any funding&#46;</p></span></span>"
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Vol. 221. Issue 9.
Pages 555-557 (November 2021)
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Vol. 221. Issue 9.
Pages 555-557 (November 2021)
Correspondence
COVID-19, Guillain-Barré syndrome, and the vaccine. A dangerous combination
COVID-19, Guillain-Barré y vacuna. Una mezcla peligrosa
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I.F. Aomar-Millána,
Corresponding author
iaomarmillan@hotmail.com

Corresponding author.
, J. Martínez de Victoria-Carazoa, J.A. Peregrina-Rivasa, I. Villegas-Rodríguezb
a Servicio de Medicina Interna, Hospital Universitario Clínico San Cecilio, Granada, Spain
b Servicio de Neurología, Hospital Universitario Clínico San Cecilio, Granada, Spain
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