Table 3.
Selected clinical findings of Guillain Barré Syndrome cases after pandemic influenza A (H1N1) 2009 monovalent vaccine, VAERS, 2009–2010.
| Case | Age (yr) Race Sex | Vaccines | Onset after vaccination (days) | PMH | Illness/other in 4 wks prior to onset of GBS Symptoms | Symptoms | CSF | EMG | Other | Neurologist’s Diagnosis/ Brighton level |
Treatment |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Civilian cases (n = 10) | |||||||||||
| 1 | 39 M | MIV (Sanofi Pasteur) | 2 | DM1 on insulin pump | Clostridium Difficile Infection (detected as inpatient) | Paresthesias (whole body) and cramps in legs | ND | Normal exam | Brain scan, MRI cervical spine | ‘‘Sensory GBS” (4) vs. small fiber neuropathy | Supportive |
| 2 | 39 M | MIV (UNK) | 0 (4 h) | Asthma | Viral URTI (onset 1 wk Before vaccination) | Ascending weakness, numbness, paresthesia in limbs | +ve albumin cytologic dissociation | ND | CBC normal | GBS (2) | IVIG |
| 3 | 24 M | MIV (Novartis) | 2 | Prader-Willi Syndrome, HTN, obesity, sleep apnea, leg cellulitis, anxiety/depression | ND | Lower leg weakness & numbness | Rare wbcs | +ve for acute progressive neuropathy | MRI cervical & lumbar spine normal, serology for HSV2 and EBV -ve | GBS (2) | Intubated, plasmapheresis |
| 4 | 35 M | MIV (Sanofi Pasteur) | 36 | Good health | Back injury after lifting 100 lb object, Herpes zoster left side of Back | Ascending numbness, and weakness all limbs, unable to walk | +ve albumin cytologic dissociation | Absent F waves c/w early GBS | CBC, CMP, CRP, ANA, MRI head, cervical and thoracic spine | ‘‘Atypical GBS” (2) | Plasmapheresis but suffered relapse on discharge, readmitted repeat plasmapheresis followed by course of IVIG with marked +ve clinical response |
| 5 | 32 M | MIV (Novartis) | Approx. 10 | ND | ND | Soreness legs & lower back, sweats, chest cramps, eye twitching | ND | ND | ND | Mild Miller Fisher variant of GBS (4) |
ND |
| 6 | 40 M | MIV (Sanofi Pasteur) | 3 | ND (MRI brain = showed no acute abnormality but frontal lobe encephalomalacia possibly remote trauma) | Weakness bilaterally arms and legs, numbness and paresthesias, metallic taste | +ve albumin cytologic dissociation | +ve for demyelination | CTs & MRIs brain, cervical & lumbar spine, USD abdomen, heavy metal screen, EBV serology-ve, CMV IgM/IgG +ve | GBS (1) ‘‘likely 2° to recent CMV infection with acute on chronic hepatitis, also monoclonal gammopathy of unknown significance | IVIG & SoluMedrol, Gangcyclovir for CMV | |
| 7 | 38 M | MIV (Novartis) | 7 | ND | URTI (symptoms began 7 days After vaccination) | Low back pain, fever cough, fatigue, ascending weakness, paresthesias numbness limbs face and tongue | +ve albumin cytologic dissociation | Abnormal supportive of AIDP | CBC, CMP, ESR, CRP, TFT, vitamin B-12, CXR, CT brain & abdomen | GBS (1) | IVIG |
| 8 | 44 M | MIV (Sanofi Pasteur) | 31 | Depression | URTI (onset 1 wk after vaccination) | Ascending paresthesias, numbness, weakness in all limbs | +ve albumin cytologic dissociation | ND | CBC, CMP, CRP, TFT, CXR, MRI lumbar spine |
GBS (2) | IVIG |
| 9 | 18 M | H1N1 (UNK) | 97 | Migraine, depression, PCN allergy | ND | Paresthesia & numbness in upper & lower limbs, areflexia, photophobia | +ve albumin cytologic dissociation | ND | ND | GBS (2) | Plasmapheresis IVIG |
| 10 | 41 M | MIV (Novartis) | 52 | ND | Febrile illness + mild Hepatomegaly 1–2 wk prior to symptom Onset | Ascending weakness all limbs, resp failure, transient delirium | +ve albumin cytologic dissociation | +ve for demyelination | Hep A, B, C serol -ve, monospot +ve = infectious mononucleosis | GBS (2) | Plasmapheresis intubated in ICU, antibiotics, prolonged Rehab |
| Military cases (n = 7) | |||||||||||
| 1 | 19 M | MIV (Sanofi Pasteur) Hep A/B (1wk earlier) | 9 | ND | Nausea (1 week) & cough, vomiting, Diarrhea (1 day) | Numbness, paresthesias | Protein normal, 0 wbcs | +ve for mild acute demyelination | MRI brain, cervical & thoracic spine, drug screen, CBC | GBS (2) | IVIG |
| 2 | 43 M | MIV (Sanofi Pasteur) | 10 | NHL (in remission 3.5 yr), allergic rhinitis | URTI | Paresthesias, numbness, L side facial droop, weakness in all limbs | ND | +ve for mild acute demyelination | CBC, CMP, Mg, Phosphorus, serum IgA, IgG, ESR, ANA | GBS (2) | Prednisolone & acyclovir (for presumed Bell’s palsy), IVIG |
| 3 | 28 M | MIV (Novartis), MCV4, LAIV3, Tdap, Hep A/B | 46 | ND | URTI | Headache, numbness in legs and face, blurred vision, areflexia and ataxia on exam, dysarthria | ND | +ve for mild acute demyelination | CBC, CMP | Miller Fisher variant of GBS (2) | IVIG |
| 4 | 40 M | H1N1 (UNK) | 36 | GERD, OSA, seasonal allergies | ND | Ascending weakness, paresthesias in all limbs | +ve albumin cytologic dissociation | ND | MRI cervical spine & brain | GBS (1) | IVIG |
| 5 | 18 M | MIV (Novartis) Hep A/B, MPS, PPV23 | 30 | ND | URTI/otitis media (3 days) | Ascending weakness in limbs | ND | +ve for mild acute demyelination | MRI cervical, thoracic, lumbar spine & brain | GBS (2) | IVIG |
| 6 | 21 M | MIV (Novartis), LAIV3, Tdap, IPV | 32 | ND | Pneumonia (1 week) (RBL infiltrate on CXR) | Ascending weakness all limbs | ND | +ve for mild acute demyelination | CBC, ESR, Blood cx | GBS (2) | IVIG, azithromycin, cefdinir |
| 7 | 26 M | MIV (Novartis), Hep A/B | 2 | Headaches & vertigo | Sinusitis (2 weeks) | Lightheaded, diplopia, numbness in limbs, areflexia on exam, ataxia, ophthalmoparesis | ND | ND | CT brain, Blood cx | Miller Fisher variant of GBS (3) | Azithromycin, Vitamin B12 |
MIV = monovalent H1N1 vaccine; DM1 = type 1 diabetes mellitus; ND = not documented; MRI = magnetic resonance imaging; GBS = Guillain Barré syndrome; URTI = upper respiratory tract infection; CBC = complete blood count; IVIG = intravenous immunoglobulin; HTN = systemic hypertension; wbcs = white blood cells; HSV2 = herpes simplex virus type 2; EBV = Epstein-barr virus; CMP = comprehensive metabolic panel; CRP = C-reactive protein; ANA = antinuclear antibody; USD = ultrasound exam; CMV = cytomeglaovirus; IgM = immunoglobulin M; IgG = immunoglobulin G; AIDP = acute inflammatory demyelinating polyradiculopathy; TFT = thyroid funtion tests; CT = computerized tomographic scan; H1N1 (UNK) = H1N1 vaccine unknown type; PCN = penicillin; Hep A, B, C serol = hepatitis A, B, C serology; NHL = Non-Hodgkins lymphoma; IgA = immunoglobulin A; IgG = immunoglobulin G; ESR = erythrocyte sedimentation rate; MCV4 = meningococcal conjugate vaccine; LAIV = live attenuated influenza vaccine; Tdap = tetanus diphtheria acellular pertussis vaccine; Hep A/B = hepatitis A & B vaccine; GERD = gastroesophageal reflux disease; OSA = obstructive sleep apnea; MPS = meningococcal polysaccharide vaccine; PPV23 = pneumococcal polysaccharide vaccine; IPV = inactivated polio vaccine; RBL = right basal lobe; CXR = chest X-ray; CT = computerized tomographic scan; Blood cx = blood culture.
To calculate the rate of post-MIV GBS we excluded civilian Case #9 and military Case #4 as the vaccine they received was reported as ‘‘H1N1 unknown”.