Federal University of São Paulo Department of Neurology and NeurosurgeryHospital e Maternidade São Camilo Pompéia Department of NeurologyFederal University of São Paulo Medical StudentUNIFESP, Department of Neurology and NeurosurgeryUNIFESP, Medical StudentSciEL

Abrahão, Ayessandro

Barcelos, Lorena B.

Carvalho, Flavio A.

Dallalba, Cleber C.

Marin, Luis F.

Oliveira, Acary Souza Bulle

Santos, William A. C.

Silva, Gisele Sampaio

Arquivos de Neuro-Psiquiatria

Luis F. Marin

Ayessandro Abrahão

Flavio A. Carvalho

William A. C. Santos

Cleber C. Dallalba

Lorena B. Barcelos

Gisele S. Silva

Acary S.B. Oliveira

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Guillain-Barré syndrome associated with H1N1 vaccination

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Repositório Institucional UNIFESP

Arq Neuropsiquiatr 2010;68(6):974-975974LetterGuillain-Barré syndrome associated with H1N1 vaccinationLuis F. Marin1,2, Ayessandro Abrahão1, Flavio A. Carvalho1, William A. C. Santos1,2, Cleber C. Dallalba1, Lorena B. Barcelos3, Gisele S. Silva1, Acary S.B. Oliveira1CorrespondenceLuís Fabiano MarinRua Pedro de Toledo, 65004023-900 São Paulo SP - BrasilE-mail: luisfabianom@gmail.comReceived 7 October 2010Received in final form 14 October 2010Accepted 21 October 2010SÍNDROME DE GUILLAIN-BARRÉ ASSOCIADA À VACINA DO H1N11Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo SP, Brazil; 2Department of Neurology, Hospital e Maternidade São Camilo Pompéia, São Paulo SP, Brazil; 3Medical Student, Federal University of São Paulo, São Paulo SP, Brazil.Guillain-Barré syndrome (GBS) has been described as adverse event follow-ing different types of vaccines, such as in-fluenza, varicella, polio virus and hepatitis B1. Since 2009 with the emergence of the pandemic H1N1 influenza virus infection in humans, new vaccines have been devel-oped for influenza A (H1N1) as a preven-tive strategy to reduce transmission, pro-tect groups at increased risk of infection, and decrease complications and death2. In this context, we report two adults who de-veloped GBS after H1N1 immunization.CASESCase 1A previously healthy 33-year-old white man presented a 4-days history of progres-sive and ascending numbness and tingling in his feet and legs, followed by weakness of his lower limbs. There was no sugges-tive history of upper airway infection or diarrhea in the preceding weeks, but he had received H1N1 monovalent vaccine 15 days before symptoms onset. Neuro-logical examination disclosed superficial and profound sensibility diminished in the lower limbs, crural paraparesis (mus-cle strength grade 4) and absent tendon reflexes. Laboratory work-up including complete blood count, TSH, tests for re-nal and hepatic function, vitamin B12 and rheumatic screening were all normal. In-fectious diseases screening (HIV, syphi-lis, hepatitis, toxoplasmosis, cytomegalo-virus, Epstein-bar and Campylobacter je-juni) were negative. CSF analysis showed protein-cytological dissociation: 2 leuko-cytes/mm3, protein 51mg/dL and normal glucose. Electrophysiological investigation was suggestive of acute demyelinating sen-sory-motor polyneuropathy, more severe in the lower limbs. Case 2A 23-year-old white man received the H1N1 monovalent vaccine and developed nonspecific symptoms as nausea, vomit-ing, cramps and muscle pain. On seventh day, lower limb weakness was observed with mild distal sensory complaints. As-cending weakness also affecting the upper limbs and respiratory insufficiency devel-oped rapidly within 24 hours, requiring mechanical ventilation and he was trans-ferred to the intensive care unit. Neuro-logical examination showed flaccid tetra-paresis with absent tendon reflexes in the four limbs. Laboratory studies were nega-tive for infectious diseases and rheumat-ic screening. Complete blood count, cre-atinine, urea, glucose, TSH, B12 vitamin were all normal. A lumbar puncture was performed and CSF disclosed protein=69 mg/dL with 2 leukocytes/mm3 and normal glucose. Treatment with intravenous im-munoglobulin (0.4 g/kg per day, during 5 days) resulted in weaning from ventilator and progressive motor improvement. Elec-troneuromyography revealed absence of F waves and diffuse signs of demyelination, suggesting an acute inflammatory demy-elinating polyneuropathy. DISCUSSIONGBS is usually preceded by an upper Arq Neuropsiquiatr 2010;68(6) 975Guillain-Barré syndrome × H1N1 vaccinationMarin et al.airway respiratory or gastrointestinal infection. Although infrequent, it also may happen as a neurologic adverse event following immunization. The pathophysiology of vaccination-related GBS is not completely understood and probably an immune stimulation plays a role in its pathogenesis1,3.Recent studies showed no conclusive result proving a causal relationship between influenza A vaccine and GBS, nor a possible increased risk for GBS after H1N1 imunnization4,5. In this scenario, we cannot exclude that our patients had GBS as a coincidental finding, but the fact that no other secondary causes of GBS were found, and the symptoms of GBS developed very close to vacci-nation should be considered. To summarize, our findings suggest a probably rela-tionship between GBS and H1N1 monovalent vaccine. Further studies are necessary to unveil its real frequency and risk related to H1N1 immunization.REFERENCES1. Haber P, Sejvar J, Mikaeloff Y, DeStefano F. Vaccines and Guillain-Barre syn-drome. Drug Saf 2009;32:309-323.2. Valdespino-Gomez JL, Garcia-Garcia L, Leon-Rosales SP. Vaccines against Influenza A (H1N1) Pandemic. Arch Med Res 2009;40:693-704.3. Souayah N, Nasar A, Suri MFK, Qureshi AI. Guillain-Barré syndrome after vaccination in United States. A report from the CDC/FDA Vaccine Adverse Event Reporting System. Vaccine 2007;25:5253-5255.4. Evans D, Cauchemez S, Hayden FG. “Prepandemic” immunization for novel influenza viruses, “swine flu” vaccine, Guillain-Barré syndrome, and the de-tection of rare severe adverse events. J Infect Dis 2009;200:321-328.5. Centers for Disease Control and Prevention (CDC). Preliminary results: sur-veillance for Guillain-Barré syndrome after receipt of influenza A (H1N1) 2009 monovalent vaccine - United States, 2009-2010. MMWR Morb Mortal Wkly Rep 2010;59:657-661.