Letter to the Editor,
With interest we read the article by Prado et al. about a 35 years-old male who developed facial diplegia 10 days after the second dose of an anti-SARS-CoV-2 vaccination with an inactivated strain. 1 The patient was diagnosed with Guillain-Barre syndrome (GBS), subtype cranial nerve affection, and profited from steroids. 1 The study is promising but raises concerns that should be discussed.
We disagree with the statement that the patient had isolated facial palsy. 1 The patient is described with tongue numbness, why it is conceivable that the sensory portion of the trigeminal nerve was additionally affected. Furthermore, the patient was described with dysphagia why it cannot be ruled out that the glossopharyngeal and the vagal nerves were affected as well. Furthermore, the pectoralis reflex, the bicpes tendon reflex and the brachioradialis reflex were hyporeflexic, 1 suggesting that peripheral nerve roots were additionally affected.
We also disagree with the statement that a brainstem lesion was ruled out because it would lead to multiple cranial nerve lesions and limb weakness in addition to abnormal cranial imaging 1 . First, a cerebral CT-scan is not sufficient to rule out brainstem encephalitis. Cerebral MRI with contrast medium is obligatory to rule out encephalitis. Second, dissociation cyto-albuminique may be also seen in brainstem Bickerstaff encephalitis (BBE). Third, it cannot be excluded that the Vth, IXth and Xth cranial nerves and radices of the median and the pectoralis nerves were also affected. Fourth, the initial symptoms included severe, throbbing headache, photophobia, and lumbar pain, 1 suggesting meningitis/encephalitis. Cerebrospinal fluid (CSF) cell count can be normal in viral and immune encephalitis.
Furthermore, we disagree with the statement that no similar case reports about facial diplegia as the sole manifestation of post-COVID-vaccination GBS have been published 1 . In a recent study of nine patients with facial diplegia and paresthesias following a SARS-CoV-2 vaccination, five presented with facial nerve involvement exclusively. 2 A similar case of facial diplegia with paresthesias and dysphagia following SARS-CoV-2 vaccination was reported from the US. 3 Exclusive affection of facial nerves bilaterally was reported in a 65 years-old female 15 days after vaccination with the Johnson & Johnson vaccine. 4
Affection of cranial nerves in GBS can be documented by enhancement of cranial nerve roots on contrast-enhanced MRI. 5 We should be informed about the results of cerebral MRI with contrast medium to know if any of the cranial nerves but particularly the facial nerves showed enhancing nerve roots.
The patient developed facial diplegia 10 days after application of the second dose of an inactivated anti-SARS-CoV-2 vaccine. 1 However, it is not specified which brand was used. We should be informed if the SARS-CoV-2 WIV04 (5 µg/dose) or the HB02 (4 µg/dose) strains were applied.
Guillain-Barre syndrome may manifest with autonomic involvement. We should know if there were indications for urinary retention, orthostatic hypotension, syncope/pre-syncope, or newly developing constipation.
Overall, the interesting study has several limitations that call the results and their interpretation into question. Clarifying these weaknesses would strengthen the conclusions and could enhance the study.
Footnotes
Author Contribution: JF: design, literature search, discussion, first draft, critical comments, final approval,
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval: Was in accordance with ethical guidelines. The study was approved by the institutional review board
Consent to Participate: Was obtained from the patient
Availability of Data: All data are available from the corresponding author
ORCID iD
Josef Finsterer https://orcid.org/0000-0003-2839-7305
References
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