A unique case of Miller Fisher-Guillain-Barré overlap syndrome in a liver transplant recipient

Abstract

Guillain-Barré syndrome (GBS) is an ascending demyelinating polyneuropathy often associated with recent infection. Miller Fisher syndrome represents a variant with predominant facial and cranial nerve involvement, although Miller Fisher and Guillain-Barré overlap syndromes can occur. Guillain-Barré spectrum syndromes have been thought to be rare among solid organ transplant recipients. We describe an immunocompromised patient with a liver transplant who presented with ophthalmoplegia and bulbar deficits. His symptoms rapidly progressed to a state of descending paralysis involving the diaphragm; he then developed acute respiratory failure and eventually developed quadriparesis. Electromyography and a nerve conduction study demonstrated a severe sensorimotor axonal polyneuropathy consistent with Miller Fisher variant Guillain-Barré syndrome. Despite several negative nasopharyngeal swabs for COVID-19 polymerase chain reaction, a serology for SARS-CoV-2 IgG was positive. He was diagnosed with Miller Fisher-Guillain-Barré overlap syndrome with rapid recovery following treatment with plasma exchange. Although Guillain-Barré is a rare complication in solid organ transplant recipients, this case highlights the importance of rapid diagnosis and treatment of neurologic complications in transplant patients. Furthermore, it demonstrates a possible case of neurological complications from COVID-19 infection.

Occurrence of Guillain-Barré Syndrome in the Early Post-operative Period After an Urgent Liver Transplant

“…GBS is an acute onset inflammatory demyelinating polyneuropathy thought to be caused by an aberrant immune response to infections that results in damage to the peripheral nerves, although the pathogenesis is not fully understood [ 5 ]. Due to its inflammatory nature, it is not expected in immunocompromised patients, including solid organ transplant recipients, and as a result, there are only isolated case reports of GBS in heart [ 6 ], liver [ 7 - 9 ], and kidney transplant recipients [ 10 ]. Cytomegalovirus infection is the most commonly reported trigger for GBS in the post‐renal transplant setting [ 4 , 10 ], but vaccines have also been implicated [ 11 - 12 ], as well as calcineurin inhibitors [ 13 ], episodes of rejection, and Campylobacter and other infections [ 7 , 14 ].…”

Síndrome de Miller-Fisher durante el embarazo

“…Las polineuropatías desmielinizantes pueden ser desencadenadas por una respuesta inflamatoria aguda con evidencia de infiltrados inflamatorios y áreas de desmielinización segmentaria. En algunos casos estas han sido asociadas a infecciones respiratorias / gastrointestinales, infección aguda por citomegalovirus, vacunación por gripe, neurotoxicidad por inhibidores de la calcineurina y rechazo de aloinjertos (6) .…”