Guillain-Barré syndrome associated with froin syndrome: case report

Abstract

Case report: A 31-year-old man was referred to our service after experiencing paresthesia, followed by distal weakness in both his feet and hands. These symptoms occurred 20 days after the administration of the fourth dose of the ChAdOx-1 COVID vaccine. A lumbar puncture was performed, which showed remarkably thick cerebrospinal fluid (CSF). Biochemical analysis of the CSF revealed 920 mg/dL of protein and a white cell count of 7.3/mm3 . An electromyography (EMG) was performed, which was compatible with the diagnosis of Guillain-Barré Syndrome (GBS). The patient was treated with intravenous immune globulin and showed clinical improvement. One month later, he experienced a recurrence of symptoms and underwent a new EMG, which again showed motor nerve conduction blocks. A new lumbar puncture was performed, and a thick fluid was obtained, with a protein concentration of 804 mg/dL. CSF flow blockage was suspected and the patient underwent a suboccipital puncture, which showed a more watery CSF, with a protein concentration of 227 mg/dL. A spinal magnetic resonance was performed, revealing an arachnoid web at the T3–T4 level. GBS relapse was presumed and the patient was treated with five sessions of therapeutic apheresis, which improved his strength and sensory symptoms. Discussion: Blockage of CSF circulation at the spinal level can produce fluid with abnormally high levels of protein, which in this case was a confounding factor during the clinical investigation. Conclusion: We report a case of concurrent GBS and spinal block, which led to abnormally high CSF protein levels during lumbar puncture, causing diagnostic ambiguity during the investigation.