REVIEW

Case Series of Guillain-Barré Syndrome After the

ChAdOx1 nCoV-19 (Oxford–AstraZeneca) Vaccine
Miranda Mengyuan Wan, MD, Angela Lee, MD, Ronak Kapadia, MD, FRCPC, and Christopher Hahn, MD, FRCPC Correspondence
Dr. Hahn
Neurology: Clinical Practice April 2022 vol. 12 no. 2 149-153 doi:10.1212/CPJ.0000000000001148 chahn@ucalgary.ca

Abstract
Purpose of Review
Vaccination has been associated with Guillain-Barre syndrome (GBS).
Amid a global vaccination campaign to stop the spread of COVID-19,
fears of GBS can contribute to vaccine hesitancy. We describe 3 cases
of GBS in Calgary, Canada, presenting within 2 weeks of receiving
the ChAdOx1 nCoV-19 (COVISHIELD) Oxford–AstraZeneca vac-
cination and review the available literature.

Recent Findings
All 3 patients presented to the hospital in Calgary, Alberta, Canada,
within a one-month time frame with GBS. Their clinical courses
ranged from mild to severe impairment, all requiring immunomodulatory treatment.

Summary
There is currently little evidence to support a causal relationship between vaccination and GBS. MORE ONLINE
Furthermore, there is limited evidence to support recurrent GBS in patients with GBS tem-
COVID-19 Resources
porally associated with vaccination. Neurologists should approach discussions with patients
For the latest articles,
regarding GBS after vaccination carefully so as not to misrepresent this relationship and to
invited commentaries, and
educate patients that the risk of COVID-19 infection outweighs the small individual risk of a
blogs from physicians
vaccine-associated adverse event. around the world
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Amid a global vaccination campaign against SARS-CoV-2 to control the COVID-19 pandemic,
vaccine safety is monitored through the reporting of potential adverse events following immu-
nization (AEFI) to public health authorities. One such event is Guillain-Barre syndrome (GBS), a
rare acute inflammatory disorder affecting the peripheral nervous system. Fears of GBS not only
halted the 1976-1977 Swine Flu vaccination campaign but have created harmful long-term as-
sociations between vaccinations and GBS and public caution regarding disease recurrence after
further vaccinations.1,2 However, a causal relationship remains equivocal because temporal as-
sociation or geographic clustering of events are to be expected if large populations are vacci-
nated.3 We report 3 cases of GBS who presented after ChAdOx1 nCoV-19 (COVISHIELD)
Oxford–AstraZeneca vaccination within a 1-month time frame. We discuss the relationship
between vaccinations and GBS, the role of subsequent vaccinations in this population, and the
importance of continued surveillance of AEFI and education surrounding vaccinations.

Case 1
A 40-year-old man with a history of nocturnal second-degree A-V block, but otherwise healthy,
presented to the emergency department with ascending paresthesias from his feet to fingertips

From the Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at
Neurology.org/cp.

Copyright © 2022 American Academy of Neurology 149

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 10 days after receiving dose 1 of the ChAdOx1 nCoV-19
vaccine. He was initially discharged home as neurologic ex-
amination was normal but returned the same day with pro-
gression to bilateral leg weakness and difficulty ambulating.
He was hypertensive at 154/95 mm Hg and had symmetric
4/5 Medical Research Council (MRC) grade weakness in
shoulder abduction, hip flexion, knee flexion, and ankle
dorsiflexion. Reflexes were decreased diffusely and absent in
the right arm and at the ankles. Pinprick sensation showed
patchy loss to the bilateral shins.
Investigations, including an MRI of the brain to support an
alternative diagnosis, were negative. His rapid COVID-19 na-
sopharyngeal PCR swab was negative. His lumbar puncture on
day 5 of symptoms showed normal white blood cell (WBC)
count and a protein level. Electromyography and nerve con-
duction studies on day 5 of symptoms showed absent F-waves
in the right ulnar and peroneal nerve despite normal compound
motor action potentials, as well as F-wave impersistence in the
tibial nerve, consistent with early acute inflammatory de-
myelinating polyradiculopathy.
He was diagnosed with GBS with autonomic dysfunction and
started on intravenous immunoglobulin (IVIg) with a dose of
2 g/kg divided over the first 5 days of admission. After
starting treatment, his clinical picture continued to evolve.
He had worsening autonomic dysfunction, consisting of
urinary retention and new-onset refractory hypertension
(systolic pressures 170–190 mm Hg). One episode of non-
sustained ventricular tachycardia was also captured on bed-
side telemetry. He developed severe headache thought to be
aseptic meningitis from IVIG that resolved spontaneously
after IVIG was completed. On day 5 of admission, he was
diffusely areflexic and had progressive weakness in his bi-
lateral upper and lower extremities requiring 2-person as-
sistance while using a 2-wheeled-walker to ambulate. He
developed a lower motor neuron left-sided facial weakness.
His neurologic symptoms began to improve around day 7 of
admission or 2 days post-IVIg. His urinary retention resolved,
and his blood pressure stabilized with 3 antihypertensive
agents. On day 15 of admission, he was able to walk in-
dependently with the assistance of a 2-wheeled walker. He
was discharged home on day 20 of admission with ongoing
outpatient neurorehabilitation.
Case 2
A 53-year-old woman with a history of migraines developed
bilateral paresthesias in her feet 12 days after her first dose of
the ChAdOx1 nCoV-19 vaccine. She awoke the next morning
with ascending paresthesias to her knees and bilateral lower
extremity weakness and presented to the emergency de-
partment. On initial examination, her slow vital capacity
(SVC) was 86% of predicted and motor power was 4/5 on
the MRC scale throughout with diffusely reduced deep
150 Neurology: Clinical Practice | Volume 12, Number 2 | April 2022
Copyright © 2022 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
tendon reflexes. Lumbar puncture was normal, including
WBC and protein. Rapid CoVID-19 nasopharyngeal PCR
swab was negative. All basic bloodwork was normal.
A preliminary diagnosis of GBS was made based on her
clinical presentation; she was promptly admitted to a general
medicine unit, and treatment with IVIg was initiated. Her
respiratory and motor status deteriorated rapidly, and less
than 12 hours after presentation, she was intubated for
neuromuscular respiratory failure.
After intubation, she was unable to trigger the ventilator.
Cranial nerve examination was normal, but she otherwise had
flaccid quadriplegia, except for muscle twitches to fingers and
toes. Reflexes were absent throughout.
MRI of the spine with gadolinium contrast showed mild
enhancement of the ventral roots in the cauda equina. Elec-
tromyography and nerve conduction studies showed evi-
dence of a demyelinating polyneuropathy with features of
temporal dispersion, conduction block, and F-wave pro-
longation consistent with a diagnosis of GBS.
On day 2 of admission, she was started on therapeutic plasma
exchange for a total of 5 cycles over 10 days. Despite apheresis,
her neurologic status continued to decline, and she had no gross
movements to her bilateral upper or lower extremities on day 4.
On day 9 of admission, she developed facial diplegia, and by day
13 of admission, she could only communicate with her eyes
using a communication board. Given her prolonged respiratory
failure, she underwent a percutaneous tracheostomy. Her
course in hospital was complicated by a Klebsiella pneumoniae
complex urinary tract infection, tracheitis, and conjunctivitis. At
the time of submission 4 weeks from onset, her neurologic
status remains unchanged in the intensive care unit, and repeat
EMG/nerve conduction study showed absent motor and sen-
sory responses in the arms and legs but no denervation po-
tentials on electromyography.
Case 3
A 59-year-old man with a history of hypertension presented
to the urgent neurology clinic 5 weeks after receiving the
ChAdOX1 nCoV-19 vaccine with sensory symptoms and
binocular diplopia. Two weeks after his vaccination, he de-
veloped symmetric numbness in the hands and lower ex-
tremities, up to his midthigh. Because of his symptoms, he
required assistance with bathing and would use a wheelchair
when outside of the house. One week later, he developed
binocular horizontal diplopia, worse with right gaze. He
presented to the emergency department and was referred for
outpatient urgent neurology assessment. He was seen 4 days
later in out-patient neurology clinic.
Neurologic examination at that time showed persistent sinus
tachycardia, right cranial nerve VI palsy, and predominantly
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large fiber sensory loss in the hands and lower extremities. He
was diffusely areflexic. He was subsequently admitted to the
neurology inpatient service for further monitoring, investigations,
and treatment. Lumbar puncture showed normal WBC with
elevated protein level of 1.46 g/L (normal 0.15–0.45 g/L),
consistent with albuminocytologic dissociation. Electrophysio-
logic studies were consistent with demyelinating poly-
neuropathy. They showed mild prolongation of right median
distal motor latency without median sensory peak latency pro-
longation, prolonged F-waves in 4 of 5 nerves studied, and de-
creased median sensory nerve action potential amplitudes with
sural sparing. Testing for antiganglioside antibodies was negative.
Correlating his clinical history and investigations, including
electrophysiologic studies, a diagnosis of variant GBS (distal
paresthesias and cranial nerve VI palsy) was made. Investi-
gations did not reveal an alternative cause for his symptoms.
He was treated with 2 g/kg of IVIg over 5 days, which was
well tolerated. He remained clinically stable and was dis-
charged home. At the time of discharge, he was independent
with mobility, although not back to his premorbid baseline.
At the time of writing, his vision has improved, and his am-
bulation continues to slowly improve.
An AEFI report was completed and sent to the local health
authority for all 3 cases.
Based on the clinical history, laboratory investigations, imaging,
and electrophysiologic studies, alternative diagnoses involving the
central or peripheral nervous system were considered unlikely.
There were no symptoms or signs to suggest preceding systemic
infection such as GI symptoms, chest infections, influenza-like
illness, or fever. COVID-19 testing was negative and therefore
thought to be unlikely as a possible trigger of GBS. The PCR test
used had 100% analytic specificity in the validation study of the
assay.4 Because there is no gold standard, the performance of this
test is not entirely known, but in a large retrospective cohort
study, the sensitivity of this assay was found to be 90.7%.5
Noninfectious triggers of GBS such as preceding surgery, auto-
immune disease, or immunosuppression were not identified.
Discussion
GBS remains the most common cause of acute flaccid pa-
ralysis worldwide. The underlying pathophysiology remains
unclear but is thought to be related to molecular mimicry of
antigenic agents triggering immune phenomena attacking
peripheral nerve myelin sheaths.6,7 This mechanism is also
thought to be the underlying pathophysiology in cases of
GBS associated with vaccination.2,8-10 However, despite the
association of GBS with multiple vaccines, there is no clear
evidence to suggest a causal relationship.11,12 We describe 3
cases of GBS following the first dose of the ChAdOx1 nCoV-
19 vaccine. These cases highlight the development of GBS in
a temporal relation to ChAdOx1 nCoV-19 vaccine in the
absence of previously described triggers of GBS.13-15
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Currently, there is no evidence to suggest a causal relationship
between vaccination against SARS-CoV-2 and GBS. Case re-
ports of GBS have been described after both adenovirus vectors
and synthetic messenger RNA COVID-19 vaccines, including
the ChAdOx1 nCoV-19 vaccine.16-18 The incidence of GBS
was equal in the placebo and vaccine arm of the Johnson &
Johnson COVID-19 vaccine trial, supporting that this re-
lationship was temporal and likely coincidental, rather than
causal.19 Our patients with GBS were geographically clustered
and temporally associated with receiving the ChAdOX1 nCoV-
19 vaccine, but this is not unexpected in mass vaccination
campaigns and does not imply causation.3,20-22 In a large
population-based study of GBS in North America and Europe,
the crude incidence of GBS was 0.81–1.89 cases per 100,000
person-years.23 At the time of writing, approximately 2 million
Albertans have received their first dose of a COVID-19 vaccine,
and therefore, we would expect 16–38 cases of GBS by chance
alone. There are fewer than 5 reports of GBS in Alberta as an
AEFI in the Alberta COVID-19 vaccination campaign.24 Our
case series illustrates 3 cases of GBS, temporally associated with
CoVID-19 vaccination; however, based on the current available
data, the incidence of GBS is not higher after initiation of the
CoVID-19 vaccination campaign compared with previously
reported rates. This supports the previous literature suggesting
that these cases may be coincidental events.20-22
Current guidelines outlined by the Centers for Disease
Control (CDC) and Prevention and Health Canada suggest
that in patients with a history of GBS that developed <6
weeks in a temporal relation to a vaccine, recurrent vacci-
nation must be approached with caution.25,26 However,
there is little evidence to support these recommendations. In
those with a history of GBS that developed in temporal
relation to a vaccination, there have been case reports of GBS
recurrence after receiving the same vaccination for tetanus
and influenza.27-29 One case report describes one patient
who, despite developing GBS after an influenza vaccine,
continued to receive the influenza vaccine for 15 consecutive
years without recurrence.30 In one study surveying the
British patient organization, the Guillain-Barré Syndrome
Support Group, 29 respondents received a vaccine <6 weeks
before developing GBS. Two of these 29 patients had a
recurrence of symptoms after a different vaccine was ad-
ministered.31 In a large case control study of 550 patients
with GBS in the Kaiser Permanente Northern California
database, 18 patients were confirmed to have GBS <6 weeks
after receiving the influenza vaccine. Of the 18 patients, 2
patients received subsequent influenza vaccination with no
recurrence of GBS. In addition, in all patients previously
diagnosed with GBS who subsequently received multiple
vaccines of various types, there was no recurrent case of GBS
that would be associated with the vaccine, after nearly 1000
subsequent vaccinations.32 A subsequent nested case-
control study over 3 cities in Jiangsu, China, including 1
056 patients with GBS, concluded there was no significant
association between GBS recurrence and vaccinations for a
number of different vaccines.12
Neurology: Clinical Practice | Volume 12, Number 2 | April 2022 151
 It remains unclear if patients such as those reported here should
receive subsequent SARS-CoV-2 vaccinations and which vac-
cine should be given. Preliminary studies are emerging assessing
the efficacy of combining different SARS-CoV-2 vaccines.33,34 A
shared decision must be made between the patient, health care
provider, and local health authorities, taking into account the
potential risks and benefits. After discussion, given the partial
protection achieved from a single dose of ChAdOx1 nCoV-19,
none of the patients in this case series have elected to obtain a
second dose of any SARS-CoV-2 vaccines. However, this de-
cision will need to be reconsidered in the future if booster doses
to address variants of concern become routine, similar to in-
fluenza vaccination campaigns.
TAKE-HOME POINTS
Currently, there is little evidence to support a causal
relationship between vaccination and GBS. Neurol-
ogists should educate patients that the risk of
COVID-19 infection outweighs a small individual risk
of a vaccine-associated adverse event.
Particularly amid a global vaccination campaign,
temporal association and geographic proximity of
GBS cases after ChAdOx1 nCoV-19 vaccination does
not imply causation.

The SARS-CoV-2 pandemic continues to devastate the Large, long-term epidemiologic studies will continue
to study vaccine safety, including the incidence of
world. The development of successful and safe vaccines
GBS after vaccination and the risk of GBS recurrence
and mass immunization campaigns will assist in ending the
in patients who developed GBS in temporal associ-
pandemic. It is crucial to avoid misinterpretation of AEFI
ation with their first dose of COVID-19 vaccine.
as causally associated with vaccines because doing so will
threaten the success of immunization campaigns, the de-
velopment of future vaccines, and harm public trust in
vaccines. It is important to continue ongoing vaccine safety Disclosure
surveillance programs, relying on population models to The authors report no disclosures relevant to the manuscript.
establish background incidence of adverse health out- Full disclosure form information provided by the authors is
comes and comparing them to observed rates.3 These available with the full text of this article at Neurology.org/cp.
programs and further large scale epidemiologic studies will
provide further insight. In the meantime, neurologists Publication History
must continue to provide ongoing patient education that Received by Neurology: Clinical Practice June 21, 2021. Accepted in final
the individual risk of developing GBS postvaccination is form November 24, 2021.
very small compared with the benefits of COVID-19
vaccination.
Appendix Authors
Limitations of this case series include the inability to
completely rule out an asymptomatic infectious trigger of Name Location Contribution
GBS, and there is limited follow-up of the cases. Continued Miranda Department of Clinical Drafting/revision of the
surveillance of COVID-19 vaccines and potential ad- Mengyuan Wan, Neurosciences, Cumming manuscript for content,
MD School of Medicine, including medical writing
verse events remain crucial to further understanding this University of Calgary, for content, major role in
relationship. Alberta, Canada the acquisition of data,
study concept or design,
and analysis or
interpretation of data
Conclusion Angela Lee, MD Department of Clinical Drafting/revision of the
We report 3 cases of GBS after the first doses of ChAdOx1 Neurosciences, Cumming
School of Medicine,
manuscript for content,
including medical writing
nCoV-19 vaccination. The geographic proximity and tem- University of Calgary, for content, major role in
poral association of these cases with vaccination do not Alberta, Canada the acquisition of data,
and study concept or
imply causality from SARS-CoV-2 vaccination. There are no design
causal associations between vaccinations and the de-
Ronak Kapadia, Department of Clinical Drafting/revision of the
velopment of GBS or in the recurrence of GBS in patients MD, FRCPC Neurosciences, Cumming manuscript for content,
who initially developed GBS <6 weeks from a vaccination. School of Medicine, including medical writing
University of Calgary, for content, study concept
Large, long-term epidemiologic studies will continue to Alberta, Canada or design, and analysis or
monitor vaccine safety. We must continue to emphasize that interpretation of data

the risk of SARS-CoV-2 infection is far greater than the Christopher Department of Clinical Drafting/revision of the
theoretical risks of GBS associated with SARS-CoV-2 Hahn, MD, FRCPC Neurosciences, Cumming manuscript for content,
School of Medicine, including medical writing
vaccination. University of Calgary, for content, major role in
Alberta, Canada the acquisition of data,
study concept or design,
Study Funding and analysis or
interpretation of data
The authors report no targeted funding.

152 Neurology: Clinical Practice | Volume 12, Number 2 | April 2022 Neurology.org/CP

Copyright © 2022 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
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