Case report
Case report of Guillain-Barré Syndrome after COVID BNT162b2 mRNA vaccine
Reporte de caso de Síndrome de Guillain-Barré posterior a vacuna COVID BNT162b2 mRNA
Oscar Sosa-Hernándeza,
, Sofía Sánchez-Cardozab
Corresponding author
dr.oscar.sh@gmail.com
Corresponding author at: Hospital General de Zona 50, Instituto Mexicano del Seguro Social, Av. Tangamanga No. 205 Prados San Vicente Primera Sección, San Luis Potosí CP. 78394, Mexico.
Corresponding author at: Hospital General de Zona 50, Instituto Mexicano del Seguro Social, Av. Tangamanga No. 205 Prados San Vicente Primera Sección, San Luis Potosí CP. 78394, Mexico.
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San Luis Potosí, Mexico" "etiqueta" => "a" "identificador" => "af0005" ] 1 => array:3 [ "entidad" => "Medicina de Rehabilitación, práctica privada, México" "etiqueta" => "b" "identificador" => "af0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cr0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Hospital General de Zona 50, Instituto Mexicano del Seguro Social, Av. Tangamanga No. 205 Prados San Vicente Primera Sección, San Luis Potosí CP. 78394, Mexico." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reporte de caso de Síndrome de Guillain-Barré posterior a vacuna COVID BNT162b2 mRNA" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Guillain-Barré syndrome (GBS) is a rare immunological condition affecting the peripheral nerves and the cause of which is not fully understood; however, it is associated with infections by viruses or bacteria, the main infectious agents being Campylobacter Jejuni, Epstein-Barr virus, cytomegalovirus, and Zika virus. Following the coronavirus 19 disease (COVID-19) pandemic, its infectious agent, SARS-CoV-2, has been identified as an additional cause.<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">In this global fight against the COVID-19 pandemic, one of the greatest achievements has been the development of vaccines from different laboratories that are currently being administered in most parts of the world, and that have proven to be effective and safe to use. Nevertheless, as with any vaccine, adverse events or events purportedly associated with the use of a vaccine can occur. The first association between GBS and vaccination was published in 1976 when an increase in incidence was reported following influenza vaccination.<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> Arce-Gálvez et al. published the first case of GBS related to COVID-19 vaccination in Latin America, which was associated with the Sinovac vaccine.<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">The objective of our work is to share the detection of a case of GBS, presumably associated with vaccination against COVID-19, with the aim of contributing to the knowledge of these events.</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Case report</span><p id="p0020" class="elsevierStylePara elsevierViewall">We report the case of a 23-year-old male, studying health care, with a significant history of renal disease secondary to glomerulopathy in a study by nephrology and in treatment with mycophenolic acid, allopurinol, and tacrolimus; hypothyroidism, being treated with levothyroxine; arterial hypertension, treated with spironolactone and losartan; surgery for atrial septal defect in childhood, and allergies to metamizole sodium and sulphonamides, as well as a minor outpatient surgical procedure months earlier. He reported not having had COVID-19, and had no history of gastrointestinal or respiratory disease of recent presentation at the onset of symptoms.</p><p id="p0025" class="elsevierStylePara elsevierViewall">After receiving the first dose of the COVID BNT162b2 mRNA vaccine (Pfizer-BioNTech), the patient reported only pain at the site of injection, with no further symptoms. After 22 days, he received the second dose of the vaccine. Twenty-four hours later, he developed proximal weakness in his upper right limb and later, in his left limb with descending, distal progression, affecting all four limbs and limiting his ability to perform the basic activities of daily living, as well as to walk independently. On manual muscle examination in accordance with the Medical Research Council (MRC) Grading System from 0 to 5, the upper and lower limbs exhibited grade 3, with generalised areflexia, with no apparent sensory abnormalities, or respiratory symptomatology. Three weeks after the onset of the clinical manifestations, an electroneuromyographic study was performed, which revealed symmetrical motor demyelinating polyradiculoneuropathy, for which treatment was initiated with intravenous immunoglobulin and steroids in hospital. The patient remained hospitalised for 10 days, without respiratory complications. At discharge, the patient exhibited improvement in the strength of all four limbs, with a manual muscle examination according to MRC in the proximal upper limbs grade 5, distal grade 3, with apparent hypotrophy in both hands, lower limbs grade 4 on the right and grade 5 on the left, persisting generalised areflexia, with no sensory alterations.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Discussion</span><p id="p0030" class="elsevierStylePara elsevierViewall">Garcia-Grimshaw et al., in a follow-up of neurological adverse events following the first doses of COVID BNT162b2 mRNA vaccine, estimated the incidence of GBS to be .43 per 100,000 doses administered, below the national reported incidence of 1.1-1.8 per 100,000 population per year.<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0035" class="elsevierStylePara elsevierViewall">In a 7-case series of GBS associated with the COVID BNT162b2 mRNA vaccine, all occurring in Mexico, the medical history included allergy in 3 of them, no history in 3 others, and hypertension associated with chronic kidney disease on haemodialysis in one. The average onset of symptoms was 6.18 days after the vaccine was administered. A diagnosis of acute demyelinating inflammatory polyradiculoneuropathy (ADIP) was confirmed in 4 cases and acute axonal motor neuropathy (AMAN) in 3 cases. Hospitalisation days ranged from 7 to 119 days, the mode being 10 days.<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> In general, the case we report has similar clinical features, history, and evolution as the patients presented in the aforementioned article.</p><p id="p0040" class="elsevierStylePara elsevierViewall">COVID-19 vaccine-related GBS cases have been published, the most common being the mRNA BNT162b2, and other cases have also been published following the AZD1222 (ChAdOx1) vaccine, which uses a non-replicating viral vector.<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a> This is linked to the number of doses administered worldwide and the number of countries that administer these two types of vaccines. Shao et al. conducted a systematic review in which they found that most of the cases received the AZD1222 (ChAdOx1) vaccine and in second place BNT162b2 with an incidence rate ranging from 1.8 to 53.2 cases per million doses administered.<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0045" class="elsevierStylePara elsevierViewall">An important point to highlight is the importance of timely case notification, as per the Standardised Procedure Manual for the Epidemiological Surveillance of Events Suspected to be Attributable to Vaccination or Immunisation (ESAVI), healthcare personnel are required to detect, notify, study, and classify ESAVIs, to study and classify ESAVIs according to the Mexican Official Standards (NOM-017-SSA2-2012 for epidemiological surveillance, NOM-220-SSA1-2016 on the installation and operation of pharmacovigilance, NOM-036-SSA2-2012 for the prevention and control of diseases, administration of vaccines, toxoids, faboterapics [sera], and immunoglobulins in humans), and to classify them according to the clinical data as non-severe or severe ESAVIs.<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a> We classified this case as severe ESAVI, given that, based on the operational definition, it meets 2 of the criteria, one that causes persistent or significant disability or incapacity, and another that requires hospitalisation or prolongs hospital stay, such as acute flaccid paralysis. This point highlights the need to reinforce epidemiological and clinical surveillance of patients with neurological symptoms after COVID-19 vaccination, to assess GBS causality.</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Conclusions</span><p id="p0050" class="elsevierStylePara elsevierViewall">It is important to mention that while GBS can occur following vaccination against COVID-19, this incidence is much lower than the one reported in Mexico in associated with other conditions, with cases related to gastrointestinal infectious diseases considered to be more common.</p><p id="p0055" class="elsevierStylePara elsevierViewall">At this point in the pandemic, and for the benefit of global public health, communication as to the efficacy and safety of COVID-19 vaccination must be bolstered, inasmuch as, just as in other vaccine-preventable diseases, the benefits far outweigh the adverse events.</p><p id="p0060" class="elsevierStylePara elsevierViewall">There is also a need to improve the reporting of cases suspected to be associated with vaccination and immunisation, as this contributes to the study and follow-up of such cases, generating scientific evidence on vaccination.</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Funding</span><p id="p0065" class="elsevierStylePara elsevierViewall">No funding was received for this work.</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Conflict of interest</span><p id="p0070" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2117940" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Presentación del caso" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Discusión" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusiones" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1804101" "titulo" => "Palabras clave" ] 2 => array:3 [ "identificador" => "xres2117941" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Case report" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusions" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1804100" "titulo" => "Keywords" ] 4 => array:2 [ "identificador" => "s0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "s0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "s0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "s0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "s0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "s0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1804101" "palabras" => array:3 [ 0 => "Síndrome de Guillain-Barré" 1 => "Vacunación" 2 => "COVID-19" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1804100" "palabras" => array:3 [ 0 => "Guillain-Barré Syndrome" 1 => "Vaccination" 2 => "COVID-19" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="as0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Introducción</span><p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">El síndrome de Guillain-Barré (SGB) es un padecimiento inmunológico poco común que afecta a los nervios periféricos, la causa no es del todo conocida, pero está asociada a infecciones por virus o bacterias.</p></span> <span id="as0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Presentación del caso</span><p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Reportamos el caso de un paciente masculino de 23 años de edad, estudiante del área de la salud, que 24 horas posteriores a recibir la segunda dosis de la vacuna COVID BNT162b2 mRNA (Pfizer-Biontech) presentó debilidad proximal de extremidad superior derecha, posteriormente en la izquierda con progresión descendente y distal.</p></span> <span id="as0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Discusión</span><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">En general se han publicado casos de SGB relacionados a las vacunas contra COVID-19 siendo la más común la BNT162b2 que es de mRNA, también hay casos publicados posteriores a la vacuna AZD1222 (ChAdOx1) que es de vector viral no replicante. Se calcula que la incidencia de SGB en 0.43 por cada 100,00 dosis aplicadas, por debajo de la incidencia nacional registrada de 1.1-1.8 por cada 100,000 habitantes al año.</p></span> <span id="as0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Conclusiones</span><p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Es importante mencionar que si bien se puede presentar SGB posterior a la vacunación contra COVID-19, esta incidencia es mucho menor a lo presentado en la comunidad en México asociado a otros padecimientos, considerándose más común la presencia de casos relacionados a padecimientos infecciosos gastrointestinales.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Presentación del caso" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Discusión" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusiones" ] ] ] "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="as0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Introduction</span><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Guillain-Barré syndrome (GBS) is a rare immune disorder that affects peripheral nerves and the cause is not known completely, but it is associated with infections by viruses or bacteria.</p></span> <span id="as0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Case report</span><p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 23-year-old male patient, a health student, who start 24 hours after received the second dose of COVID-19 vaccine, with proximal weakness of the right upper limb, later in the left side with descending and distal progression.</p></span> <span id="as0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Discussion</span><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">GBS cases related to COVID-19 vaccines have been published, the most common being BNT162b2, which is mRNA, there are also cases published after the AZD1222 (ChAdOx1) vaccine, which is a non-replicating viral vector. The incidence of GBS is estimated at 0.43 per 100.00 doses applied, under registered national incidence of 1.1-1.8 per 100,000 persons per year.</p></span> <span id="as0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Conclusions</span><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">It is important to mention that although GBS can occur after vaccination against COVID-19, this incidence is much lower than which occurs in the community in Mexico associated with other diseases, considering more common the presence of cases related to infectious gastrointestinal diseases.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Case report" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusions" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="np4005">Please cite this article as: Sosa-Hernández Oscar, Sánchez-Cardoza Sofía. Reporte de caso de Síndrome de Guillain-Barré posterior a vacuna COVID BNT162b2 mRNA. Vacunas. 2022. <span class="elsevierStyleInterRef" id="ir3005" href="https://doi.org/10.1016/j.vacun.2022.02.002">https://doi.org/10.1016/j.vacun.2022.02.002</span></p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bb0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case of Guillain-Barré syndrome following COVID-19 vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Hasan" 1 => "M. Khan" 2 => "F. Khan" 3 => "G. Hamza" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2021 Jun 29" "volumen" => "14" "numero" => "6" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bb0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guillain-Barré syndrome associated with SARS-CoV-2" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Toscano" 1 => "F. Palmerini" 2 => "S. Ravaglia" 3 => "L. Ruiz" 4 => "P Invernizzi" 5 => "M.G. Cuzzoni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMc2009191" "Revista" => array:7 [ "tituloSerie" => "N Engl J Med" "fecha" => "2020" "volumen" => "382" "numero" => "26" "paginaInicial" => "2574" "paginaFinal" => "2576" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32302082" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bb0015" "etiqueta" => "3." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guillain-Barré syndrome following BNT162b2 COVID-19 vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Trimboli" 1 => "P. Zoleo" 2 => "G. Arabia" 3 => "A. Gambardella" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Neurol Sci" "fecha" => "2021 Aug" "volumen" => "4" "paginaInicial" => "1" "paginaFinal" => "2" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bb0020" "etiqueta" => "4." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guillain-Barre syndrome after vaccination for Covid-19. The first report in Latin America" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Arce Gálvez" 1 => "L.A. Ramírez Abadía" 2 => "C.A. de los Reyes Guevara" 3 => "J.F. Hernández Orozco" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Neurology Perspectives" "fecha" => "2021" "volumen" => "1" "numero" => "4" "paginaInicial" => "236" "paginaFinal" => "238" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bb0025" "etiqueta" => "5." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurologic adverse events among 704,003 first-dose recipients of the BNT162b2 mRNA COVID-19 vaccine in Mexico: A nationwide descriptive study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. García-Grimshaw" 1 => "S.E. Ceballos-Liceaga" 2 => "L.E. Hernández-Vanegas" 3 => "I. Núñez" 4 => "N. Hernández-Valdivia" 5 => "D.A. Carrillo-García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Clin Immunol" "fecha" => "2021 Aug" "volumen" => "229" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bb0030" "etiqueta" => "6." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guillain-Barré syndrome is infrequent among recipients of the BNT162b2 mRNA COVID-19 vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. García-Grimshaw" 1 => "A. Michel-Chávez" 2 => "J.M. Vera-Zertuche" 3 => "J.A. Galnares-Olalde" 4 => "L.E. Hernández-Vanegas" 5 => "M. Figueroa-Cucurachi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Clin Immunol" "fecha" => "2021 Sep" "volumen" => "230" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bb0035" "etiqueta" => "7." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guillain-Barré Syndrome following ChAdOx1-S/nCoV-19 Vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.V. Maramattom" 1 => "P. Krishnan" 2 => "R. Paul" 3 => "S. Padmanabhan" 4 => "S. Cherukudal Vishnu Nampoothiri" 5 => "A.A. Syed" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ana.26143" "Revista" => array:7 [ "tituloSerie" => "Ann Neurol" "fecha" => "2021 Aug" "volumen" => "90" "numero" => "2" "paginaInicial" => "312" "paginaFinal" => "314" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34114256" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bb0040" "etiqueta" => "8." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case of Guillain-Barré syndrome following COVID-19 vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Hasan" 1 => "M. Khan" 2 => "F. Khan" 3 => "G. Hamza" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2021 Jun 29" "volumen" => "14" "numero" => "6" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bb0045" "etiqueta" => "9." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guillain-Barré Syndrome Associated with COVID-19 Vaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Shao" 1 => "C. Wang" 2 => "K. Chang" 3 => "M. Hung" 4 => "H. Chen" 5 => "S. Liao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid2712.211634" "Revista" => array:7 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2021" "volumen" => "27" "numero" => "12" "paginaInicial" => "3175" "paginaFinal" => "3178" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34648420" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bb0050" "etiqueta" => "10." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manual de procedimientos estandarizados para la vigilancia epidemiológica de eventos supuestamente atribuibles a la vacunación o inmunizacion (ESAVI)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Gobierno de México, Dirección General de Epidemiología" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:2 [ "link" => "https://epidemiologia.salud.gob.mx/gobmx/salud/documentos/manuales/42_Manual_ESAVI.pdf" "fecha" => "2021" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/24451460/00000023000000S1/v3_202404040648/S2445146022000280/v3_202404040648/en/main.assets" "Apartado" => array:4 [ "identificador" => "77038" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Clinical Note" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24451460/00000023000000S1/v3_202404040648/S2445146022000280/v3_202404040648/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445146022000280?idApp=UINPBA00004N" ]
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