Guillain‐Barre syndrome following COVID‐19 vaccines (GBSfCV19v) is a reported adverse effect that remains unclear. We present a structured review based on two case reports of GBSfCV19v, a systematic review, and Vaccine Adverse Event Reporting System (VAERS) analysis to estimate the risk and describe the clinical characteristics (CC) of these events. We've searched on MEDLINE and Embase, from the inception to May 20, 2021, using the keywords: “Guillain barre syndrome” and cross‐referenced with “covid‐19 vaccines.” We estimated the risk of GBSfCV19v, comparing it with the risk of GBS following the influenza vaccine (GBSfIv), considering the VAERS sensitivity. The clinical characteristics included: age, sex, comorbidities, type of vaccine, administered dose, clinical onset, deaths, cerebrospinal fluid (CSF), and electromyography (EMG) pattern. We found 43 cases, considering the risk of GBSfCV19v lower than GBSfIv (160–320 cases). The patients had a mean age of 54 years and 23 (56%) were male. The types of vaccines used: Pfizer (22), Moderna (9), AstraZeneca (3), Janssen (3), and Johnson & Johnson (1). 24 cases of GBS occurred after the first dose, with clinical onset of 7 days. CSF albuminocytological dissociation was reported in 7 patients, and EMG revealed a predominant demyelinating pattern. GBSfCV19v risk appears to be lower than what was expected from other respiratory virus vaccines. Most cases of GBS were middle‐aged males within a week following the first dose of the COVID‐19 vaccine, showing a typical demyelinating neuropathy with albuminocytological dissociation.

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Context: Trigeminal autonomic cephalalgias (TAC) are unilateral and recurrent headache with ipsilateral cranial autonomic symptoms such as lacrimation, conjunctival injection, ptosis and changes on pupillary diameter. Acute glaucoma is a rare etiology of headache in the emergency room and can be confused with TAC because it also presents with similar symptoms in the affected eyes. Case report: We present a case report of a 50-year-old insulin-dependent diabetic woman with severe headache that started the day before admission. The headache was left hemicranial, pulsatile and associated with ipsilateral lacrimation. On physical examination we observed mild conjunctival hyperemia, ptosis, visual loss of 20/800 and fixed mydriasis in left eye. Because of the visual loss the patient was referred for urgent ophthalmological evaluation that revealed high intraocular pressure (41 mmHg) and neovascularization of the iris, suggesting the diagnosis of acute glaucoma associated with the neovascularization related to diabetes mellitus. Conclusions: Acute glaucoma should be distinguished from TAC given the overlap of severe headache and ipsilateral eye symptom. However, the presence of fixed mydriasis and progressive visual loss suggested the diagnosis of acute glaucoma, since in TAC miosis is the usual pupillary alteration, as a consequence of parasympathetic overactivation, and visual loss is uncommon.

Context: Parkinsonian syndromes are routinely identified by neurologists. However, the differential diagnosis among probable etiologies can be challenging and complex. In Fahr’s syndrome, calcifications of the basal ganglia secondary to disorders of calcium metabolism are observed. A possible clinical presentation associated with this entity is the presence of a parkinsonian syndrome. Case report: A 54-years-old female patient presented with a progressive tremor in the right upper and lower limbs associated with bradykinesia. Seizures were observed during the course of the disease. After extensive clinical workup, primary hypoparathyroidism was diagnosticated along with the recognition of a mutation in the calcium activator gene. Computed tomography and magnetic resonance imaging of the head showed bilateral coarse calcifications in thalami and basal ganglia compatible with Fahr’s syndrome. We began treatment for control of the underlying disease, as well as for symptomatic control of parkinsonism. Conclusions: Different pathologies could justify the parkinsonian syndrome observed initially in the case described. Among them: Iidiopathic Parkinson’s Disease, Multiple System Atrophy, Progressive Supranuclear Palsy. In our patient, the atypical evolution in a young woman led to the research of possible secondary treatable causes. A diagnosis of Fahr’s syndrome related to hypoparathyroidism was unveiled. The differential diagnosis of Parkinson’s Syndrome is broad and difficult. We must be aware of the possible atypical presentations due to the possibility of a secondary condition whose etiology could be effectively treated.

Context: Central venous catheterization of the internal jugular vein is a common procedure that can be complicated with Horner`s Syndrome, caused by a direct lesion of cervical sympathetic pathways, pneumothorax compression, or carotid dissection. This entity should be considered when assessing new anisocoria in intensive care scenarios. Case Report: We report the case of a 64-year-old woman, who presented anisocoria during an intensive care unit hospitalization. She had been admitted with severe COVID-19 and need for mechanical ventilation. Her anisocoria was more evident in the dark, with right miosis, ipsilateral semi-ptosis, and preserved photoreaction reflexes. Before the anisocoria, she had a venous catheter inserted in her right jugular vein. Further evaluation showed a right pneumothorax, which was promptly drained after the mispuncture. The cervical arterial angiotomography showed no signs of carotid dissection. Conclusion: New anisocoria in critical patients is usually associated with impairment of the parasympathetic tonus, either by the use of topic or inhalatory anticholinergic drugs or cerebral herniation syndrome. However, in these situations, the anisocoria is more appreciable in light, with disruption of photoreaction in the greater pupil and ipsilateral ptosis. Therefore, we believe our patient developed an iatrogenic Horner`s Syndrome, secondary to a catheterization mispuncture, leading to a direct lesion of sympathetic pathways and their compression by the pneumothorax. Beyond parasympathetic pharmacologic blockade or cerebral herniation, Horner`s Syndrome constitutes a valuable differential diagnosis when evaluating patients with new anisocoria in the ICU.

Introduction: Up to 10% of strokes affect people under 45 years old. Syphilis is most common in adults. Fourteen percent of neurosyphilis cases have stroke its first manifestation. Objectives: To discuss neurosyphilis as an overlooked etiology for stroke. Design and setting: The case occurred in a public secondary care hospital located in São Paulo - Brazil. Methods: We present a case report of a 28-year-old woman brought to the emergency department due to acute ataxia. Previous history shows stroke at the age of 20 years old. Brain MRI showed ischemia in both cerebellar hemispheres, pons and midbrain. Arterial angiography showed segmental basilar artery stenosis. Serum laboratory tests showed Venereal Disease Research Laboratory (VDRL) of 1:128. Cerebrospinal fluid (CSF) analysis showed 117 cells (predominantly lymphomononuclear), protein 81 mg/ dl, normal glucose and VDRL of 1:8, confirming neurosyphilis. Treatment with intravenous penicillin led to partial improvement in ataxia before discharge. Discusion: A high percentage (up to 80%) of diagnostical errors is expected when stroke is caused by neurosyphilis. Misdiagnosis may compromise secondary prevention. It is possible that the first stroke was also caused by neurosyphilis in our patient. The involvement of the vertebrobasilar territory occurs in 25% of patients with meningovascular neurosyphilis. Basilar stenosis is typical for neurosyphilis. Conclusion: Stroke in young adults should include VDRL to screen for neurosyphilis. If positive, it should indicate a CSF exam.