(Kiosk 3) Ascending Small Fiber Neuropathy After covid-19 Vaccination - Sensory Variant of Guillain Barre Syndrome

Case Diagnosis: Subacute small fiber variant of Guillain Barre Syndrome status post COVID-19 vaccine

Case Description: Patient is a 62-year-old female without significant past medical history who presented for burning, stabbing pain, hyperesthesia, and sensation of “coldness” two weeks after receiving the first dose of COVID-19 vaccine. She denies any numbness or weakness of the extremities. The symptoms began in the bilateral feet and progressed to the calves, then thighs, thumbs, forearms, chest, and face over one month. Her exam showed a positive Romberg sign and decreased vibratory sensation, but otherwise normal sensation to pinprick, light touch and temperature, and normal strength, reflexes, and cranial nerves. Electrodiagnostic studies performed 10 days after symptom onset were normal. Skin biopsy of the proximal and distal right lower extremity showed reduced intraepidermal nerve fiber density, consistent with a small fiber neuropathy. Lumbar puncture showed an elevated CSF protein of 81 with normal cells count. Labs for related disorders and MRI of the brain were normal.

Discussion: There is conflicting literature regarding the risk of GBS status post-COVID vaccination, which has crucial implications regarding vaccine hesitancy and immunity against COVID-19. The only risk factor identified in the literature is a prior history of GBS.

Setting: outpatient neuromuscular clinic

Assessment/Results: Throughout her illness course, the patient attempted Gabapentin 600 mg three times daily with variable symptomatic relief. Patient also tried capsaicin cream which worsened symptoms. She found significant improvement after two rounds of IVIG but no change in symptoms after the third round. Residual symptoms continued until spontaneous resolution approximately a year and a half after initial onset.

Conclusion: There may be a small fiber variant of GBS associated with the COVID-19 vaccine. This presentation may differ from traditional GBS strains and must be considered, especially in patients without known risk factors.