Guillain-Barre Syndrome in Ulcerative Colitis Following Treatment with Infliximab

Abstract

Purpose: Infliximab has been shown to be an effective, well-tolerated treatment for ulcerative colitis (UC). We report a case of Guillain-Barré Syndrome in a 35 year-old Caucasian male treated with infliximab for active UC. The patient was diagnosed with UC in November 2010 and started on mesalamine. Four weeks later he developed acute pancreatitis. The mesalamine was stopped, his pancreatitis resolved and he was started on a systemic steroid treatment while awaiting the results of his TPMT phenotype. An attempt to taper his steroids was unsuccessful, and he started Imuran® 150 mg po daily in March 2011. Infliximab was initiated in July 2011 (5 mg/kg, 0, 2, and 8 weeks) for ongoing active UC. After the second injection, his colitis went into clinical remission. Three days after the third injection, he developed progressive symmetric paresthesia to both hands and, within two weeks after, to both feet. He had no viral prodrome or diarrheal illness prior to symptom onset. A diagnosis of Guillain-Barré syndrome (GBS) was made through cerebrospinal fluid analysis and nerve conduction studies/EMG, and he was then treated with intravenous gammaglobulin for 4 days. The patient reported clinical improvement, with ongoing residual symptoms likely related to superimposed bilateral carpal tunnel syndrome. The development of GBS in this case appears to be related to the initiation of anti-TNF treatment. We can establish a temporal association, a lack of alternative explanations, a stabilization/improvement of the disorder when the drug-exposure was interrupted and it is consistent with other cases reported in the literature. To date, this is the first case reported of GBS after the initiation of anti-TNF for a patient with UC in the absence of extraintestinal manifestations of UC. A total of 19 cases of GBS following anti-TNF therapy have been described in the literature. Reports describe 2 cases for Crohn's, 3 for psoriatic arthritis, 11 for rheumatoid arthritis, 2 for UC in the setting of spondyloarthropathy and 1 case for which the indication was unclear. Symptoms of GBS typically occurred approximately 2 weeks after the initiation of therapy but were reported up to 2 years later. The clinical course of infliximab related GBS appears to be generally mild; however it may recur if infliximab is restarted and 1 patient did not have an improvement in his symptoms over time. GBS is a rare but potentially serious complication of infliximab therapy.