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Two reports detailed cases of an unusual variant of Guillain-Barré syndrome (GBS) associated with the AstraZeneca adenovirus vector COVID-19 vaccine.

One paper reviewed ; the other discussed , India. Both were published in Annals of Neurology.

All cases occurred in people who had received the vaccine 10 to 22 days earlier.

GBS in these cases was characterized by "a disproportionately frequent and severe bilateral facial paresis," observed Seward Rutkove, MD, of Beth Israel Deaconess Medical Center in Boston, and Rebecca Betensky, PhD, of New York University School of Global Public Health in New York City, in an .

Given these reports, plus cases of GBS with prominent bilateral facial weakness in the (VAERS) after the Johnson & Johnson vaccine, "the relationship between this illness and these two adenovirus vector vaccines should be investigated further," Rutkove and Betensky wrote.

GBS is an acquired demyelinating polyneuropathy often beginning in the lower extremities and ascending over time with loss of reflexes. Some cases start a few days or weeks after respiratory or gastrointestinal viral infection. Facial weakness is not atypical, but usually is not a predominant finding compared with severe appendicular weakness and respiratory dysfunction.

"Coincidentally, shortly before our editorial office received these two manuscripts, our neurology service at Beth Israel Deaconess Medical Center in Boston admitted a 58-year-old man without significant past medical history who presented with marked bilateral facial weakness and modest appendicular weakness approximately 2 weeks after receiving the J&J/Janssen COVID-19 vaccine, which like the AstraZeneca vaccine, is also adenovirus based with embedded spike proteins," the editorialists noted.

A recent paper also outlined a case report of a woman who developed GBS 10 days after receiving the Johnson & Johnson vaccine in a clinical trial in Boston.

"As the authors of the [J&J case report] warn, we have to be careful of simply assuming that these cases of GBS are due to the vaccine," Rutkove and Betensky wrote.

VAERS reports data on people in the U.S. only who received vaccines; events related to the AstraZeneca shot are not included. "Nevertheless, we identified 279 (59 J&J, 97 Moderna, 121 Pfizer, 2 unknown) reports that explicitly specified GBS in the symptom field of the VAERS submission following COVID vaccination," Rutkove and Betensky noted.

Eight of these cases had prominent bilateral facial weakness, paresis, or paralysis. Five of the eight cases were linked to the Johnson & Johnson vaccine. There also were 24 reports of isolated bilateral facial weakness, paresis, or paralysis; 12 of these were associated with the J&J vaccine.

"This is many more than expected given that, to date, Janssen vaccine comprises 8% of total U.S. full vaccinations and 3.7% of total U.S. vaccinations (P<0.0001, exact binomial test)," the editorialists wrote.

"The validity of this test relies on (1) differences between populations taking the different vaccines not being related to the adverse events and (2) the adverse events occurring soon after vaccination and (3) no differential reporting of these adverse events by different manufacturers to VAERS," they continued. VAERS reports are voluntary and often cases are underreported, they noted.

In the India report of AstraZeneca vaccinations, six of seven GBS cases involved women. All patients progressed to areflexic quadriplegia. Six patients required mechanical ventilation for respiratory failure.

"All seven cases had bilateral facial paresis, which usually occurs in fewer than 20% of unselected GBS cases," wrote Boby V. Maramattom, MD, DM, of Aster Medcity in Kerala, and co-authors. "Four patients (57%) also developed other cranial neuropathies such as abducens palsy and trigeminal sensory nerve involvement, which are rare (<5%) in reports of GBS from India."

All four cases in the British report involved men. "In our cases, there was an interval of 11-22 days between vaccination and symptom onset," wrote Jonathan Rhys Evans, consulting neurologist at Nottingham University Hospitals NHS Trust, and colleagues. "This would coincide with the period that the maximal immune response to the vaccine would be anticipated."

The frequency of GBS in these areas of India and England was estimated to be 1.4 to 10 times greater than expected.

"Although these patients had neurological symptoms temporally associated with vaccination, causality cannot be assumed," the British authors wrote. But if the link is causal, "it could be due to a cross-reactive immune response to the SARS-CoV-2 spike protein and components of the peripheral immune system," they suggested.

"Even if ultimately proven true, this slightly increased risk of atypical GBS, a generally reversible, non-fatal condition, seems like a small price to pay to prevent infection and ultimately to help to bring this pandemic to an end," the editorialists concluded. "Nevertheless, we believe that knowledge of this potential but rare complication is important for physicians to know, but should not diminish the widespread use of the AstraZeneca or J&J vaccines as many millions more receive them in the coming months and years."

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