Q:

8/16/2013
We have a patient who had the pneumovax vaccine and the shingles shot approximately two months ago. On 7/27/13, the patient had a stinging insect venom allergy injection. The patient called stating he was diagnosed with Guillain-Barre Syndrome last week. Our first question is can the venom shot or allergy injections have any relation to the Guillain-Barre diagnosis? Our second question is can the patient continue with his stinging insect immunotherapy? Thank you.

A:

Thank you for your inquiry.

There are two perspectives from which your question can be approached. The first perspective is the role of vaccines (immunizations) in the production of Guillain-Barré syndrome. As you can see from the abstract copied below and the reference from the CDC, clearly there is a putative relationship between immunizations (vaccinations) and the production of Guillain-Barré. The CDC recommends, for some vaccines, that if a patient developed Guillain-Barré within six weeks of the administration of a dose of the vaccine, a repeat dose should not be given.

The other perspective from which the question can be viewed is whether or not there has been an association between hymenoptera venom injection and the development of Guillain-Barré syndrome. Clearly there have been reports of Guillain-Barré occurring after field stings (see abstract and reference copied below). However, I am not aware of, nor could I find, any such reports related to venom immunotherapy per se.

Unfortunately, after analyzing these observations, one cannot give a definitive answer to your first question, and since the second hinges on the answer to the first, no reply, with confidence, can be given as to whether or not your patient should continue with venom immunotherapy.

However, I would be reluctant to pursue venom immunotherapy in your patient based upon the above observations. If, however, the patient experienced a life-threatening reaction to venom, then, in consultation with the patient as well as the neurologist offering care to the patient, a risk/benefit assessment can be made. If, however, the reaction was not life-threatening, in my opinion, the potential benefit would not outweigh the risk.

Thank you again for your inquiry and we hope this response is helpful to you.

Curr Opin Allergy Clin Immunol. 2005 Aug;5(4):355-8.
Unusual reactions to insect stings.
Reisman RE.
Source
School of Medicine, State University of New York at Buffalo, Buffalo, New York, USA.
Abstract
Purpose of Review: A variety of unusual or unexpected reactions have occurred in a temporal relationship to insect stings. This review will summarize these case history reports in recent years. As these reactions are very infrequent, the review will also include prior reported unusual reactions attributed to insect stings.
Recent Findings: Acute encephalopathy occurred 8 days after yellow jacket stings, without any other obvious cause. There have been prior reports of other neurological reactions, myasthenia gravis, peripheral neuritis and Guillain-Barré syndrome related to insect stings. Acute renal failure with tubular necrosis has occurred following massive numbers of stings from Africanized honeybees. Nephrotic syndrome has been reported in the past following single stings. Silent myocardial infarction has occurred, probably related to acute anaphylactic symptoms immediately following a sting. There are recent reports of other pathology, diffuse alveolar hemorrhage and rhabdomyolysis and prior reports of thrombocytopenic purpura and vasculitis. As the result of ocular stings, local reactions have occurred with corneal pathology leading to cataracts. Other prior reported reactions to ocular stings include conjunctivitis, corneal infiltration, lens subluxation, and optic neuropathy. There is scarce information regarding the pathogenesis of the majority of the unusual reactions and the subsequent allergic status or risk for sting anaphylaxis of people who have had these unusual reactions.
Summary: This review includes a variety of reactions, particularly involving neurological, renal and cardiovascular symptoms, related to insect stings. It is important that clinicians be aware of this relationship when assessing people with these reactions and address future prophylaxis.

Guillain-Barré syndrome following bee sting Cahide Yilmaz; Hüseyin Çaksen; Ömer Anlar; Dursun Odabas Journal of PediatricNeurology, Volume 3 (4) IOS Press - Jan 1, 2005.

The Turkish Journal of Pediatrics 2009; 51: 485-488 Case Report
Severe quadriparesis caused by wasp sting
Peter Bánovèin, Zuzana Havlíèeková, Miloš Jeseòák, Slavomír Nosá¾, Peter Ïurdík, Miriam Èiljaková, Ján Mikler.

Contraindications and Precautions to Commonly Used Vaccines in Adults1*†
United States, 2013.

J Clin Neuromuscul Dis. 2009 Sep;11(1):1-6. doi: 10.1097/CND.0b013e3181aaa968.
Guillain-Barré syndrome after vaccination in United States: data from the Centers for Disease Control and Prevention/Food and Drug Administration Vaccine Adverse Event Reporting System (1990-2005).
Souayah N, Nasar A, Suri MF, Qureshi AI.
Source
Epidemiological and Outcomes Research Division, Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA.
Abstract
Background: There are isolated reports of Guillain-Barré syndrome (GBS) after receiving vaccination.
Objective: To determine the rates and characteristics of GBS after administration of vaccination in United States
Methods: We used data for 1990 to 2005 from the Vaccine Adverse Event Reporting System, which is a cooperative program of the Centers for Disease Control and Prevention and the US Food and Drug Administration.
Results: There were 1000 cases (mean age, 47 years) of GBS reported after vaccination in the United States between 1990 and 2005. The onset of GBS was within 6 weeks in 774 cases, >6 weeks in 101, and unknown in 125. Death and disability after the event occurred in 32 (3.2%) and 167 (16.7%) subjects, respectively. The highest number (n = 632) of GBS cases was observed in subjects receiving influenza vaccine followed by hepatitis B vaccine (n = 94). Other vaccines or combinations of vaccines were associated with 274 cases of GBS. The incidence of GBS after influenza vaccination was marginally higher in subjects <65 years compared with those >or=65 years (P = 0.09); for hepatitis vaccine, the incidence was significantly higher (P < 0.0001) in the <65 group. Death was more frequent in subjects >or=65 years compared with those <65 years (P < 0.0001).
Conclusions: Our results suggest that vaccines other than influenza vaccine can be associated with GBS. Vaccination-related GBS results in death or disability in one fifth of affected individuals, which is comparable to the reported rates in the general GBS population.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology