BAMLANIVIMAB-INDUCED GUILLAIN-BARRÉ SYNDROME

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TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Guillain-Barre syndrome (GBS) is an autoimmune post-infectious neuropathy resulting in acute ascending flaccid paralysis 1. To the best of our knowledge and review of literature, this is the first reported case of GBS after receiving bamlanivimab a monoclonal antibody immunotherapy, now authorized for use in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. CASE PRESENTATION: A 61-year-old male presented with acute progressive ascending bilateral lower extremity weakness and fever. Previous medical history included Chronic obstructive pulmonary disease and a recent diagnosis of SARS-CoV-2 for which he received monoclonal antibody (Bamlanivimab) one week prior to admission. On admission, neurological exam was remarkable for decreased bilateral lower and upper extremity strength with poor hand grip strength. Patient was being monitored in the intensive care unit for respiratory failure using negative inspiratory force and vital capacity. Lumbar puncture results were remarkable for normal glucose (62 mg/dL), elevated protein (122.4 mg/dL) without an elevated white blood count. The patient was diagnosed with GBS and initially treated with Intravenous Immunoglobin (IVIG) for five days. However, he continued to be symptomatic and developed mild dysarthria and facial weakness. He was subsequently treated with plasmapheresis for five days. Neurological and respiratory function improved after plasmapheresis therapy. DISCUSSION: The case illustrates GBS presentation after treatment with monoclonal antibody therapy in the setting of SARS-CoV-2. Bamlanivimab is an IgG1κ monoclonal antibody that targets the spike protein of SARS-CoV-2 and prevents the attachment and entry of the virus into human cells. In mild-moderate cases, Bamlanivimab was authorized to treat mild-moderate SARS-CoV-2 in patients above 12 years old, weight more than 40 kg, and high risk of disease progression and/or hospitalization.2,3 In this case report, the patient developed GBS within a short time period after receiving Bamlanivimab. Other case studies have also reported subsequent development of GBS after treatment with monoclonal antibodies.4,5,6 Ipilimumab, an IgG1 monoclonal antibody that inhibits cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), was associated with GBS development after its use as an adjuvant therapy for patients with melanoma. 4,5 Adalimumab (a tumor necrosis factor alpha inhibitor) was also reported with GBS development when used as therapy for psoriasis and psoriatic arthritis. 6 These monoclonal antibodies have different mechanisms of action and were used in other disorders. CONCLUSIONS: This case report demonstrates that monoclonal antibodies may develop an autoimmune response. This case report is important in highlighting GBS as a potential side effect of Bamlanivimab given its potential for respiratory compromise and its current use in mild to moderate SARS-CoV-2.1,3 REFERENCE #1: Leonhard, S.E., Mandarakas, M.R., Gondim, F.A.A. et al. Diagnosis and management of Guillain–Barre syndrome in ten steps. Nat Rev Neurol 2019;15:671–683. REFERENCE #2: Chen, P., Nirula, A., Heller B. et al. SARS-CoV-2 Neutralizing Antibody LY-CoV555 in Outpatients with Covid-19. N Engl J Med 2021;384:229-237 REFERENCE #3: U.S. Food and Drug Administration. (2021, March 31). Coronavirus (COVID-19) Update: FDA Authorizes Monoclonal Antibody for Treatment of COVID-19. Retrieved from https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibody-treatment-covid-19 DISCLOSURES: no disclosure on file for Nia Jagroop;No relevant relationships by Visala Natarajan, source=Web Response No relevant relationships by Gladys Palaguachi, source=Web Response no disclosure on file for Benhoor Shamian;