Life Threatening Guillain-Barre Syndrome Attributed to Infliximab After Ten Years of Therapy: A Case Report: 2084

Introduction: Tumor necrosis factor (TNF) alpha inhibitors have recently established a fundamental role in the treatment of inflammatory bowel disease (IBD). While TNF alpha inhibitors play an essential role in the treatment of many diseases, there have been reports of significant and sometimes life-threatening side effects. Although definitive causal evidence is lacking, some have reported temporal associations between the use of TNF alfa inhibitors and the development of neurological manifestations, including Guillain Barre syndrome (GBS). We report a case of a 76-year-old male with Crohn's disease who developed GBS after treatment with infliximab. CASE REPORT: A 76-year-old male patient with Crohn's disease presented with 10-day history of progressive bilateral symmetric lower extremity numbness, weakness, and ataxia. His Crohn's disease had been well controlled on infliximab for the last 10 years. He denied diarrhea, pneumonia, tick bites or recent immunization. Physical examination was prominent for motor weakness of lower extremities and absence of deep tendon reflexes. Extensive infectious and serologic workup was negative, and lumbar puncture showed albumin-cytologic dissociation. A diagnosis of GBS was made and patient was started on IVIG with gradual improvement of his symptoms. After complete multispecialty workup, the cause of GBS was attributed to infliximab as no alternative explanation was discovered. The patient eventually perished from complications of his prolonged hospitalization. DISCUSSION: GBS is an immune-mediated disease characterized by ascending paralysis with rapidly progressive, symmetrical limb weakness and areflexia. Although rare, there have been around 23 reported cases of GBS attributed to TNF alpha inhibitors. In most of these cases, GBS has been reported within the first year of TNF alpha inhibitor treatment. There are very few cases of patients developing GBS after almost 10 years of therapy. It is thought that the downregulation of the immune response with TNF alfa inhibitors could activate latent infections or make a person more susceptible to one, triggering an autoimmune response of cascading events. After a GBS event which may be attributed to TNF alpha inhibitor use, the choice of future management for IBD may be difficult. Clinicians should be aware of rare but potentially life-threatening side effects of TNF alpha inhibitor therapy.