2593 A case of glial fibrillary acidic protein (GFAP) astrocytopathy after novavax COVID-19 vaccination

Introduction Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy was first defined in 2016.¹ It usually presents as meningoencephalomyelitis associated with IgG binding to GFAP. The literature suggests an association with neoplasms and possibly viral infections.¹ Few case reports^{2 3} have shown GFAP astrocytopathy after COVID-19 infection, and one case report⁴ with the Moderna COVID-19 vaccination (mRNA-1273). We describe another GFAP astrocytopathy presenting as meningoencephalitis after the Novavax COVID-19 vaccination (NVX-CoV2373).

Case We describe a man in his 50s, previously well, with subacute meningoencephalitis. He presented initially with progressive worsening migrainous headache associated with anorexia, nausea, night sweats and malaise. Several days later, he developed cauda equina syndrome, unrelenting hiccups, encephalopathy and multiple cranial neuropathies. The symptoms were preceded by his 3^rd COVID-19 vaccination booster, Novavax COVID-19 vaccination (NVX-CoV2373), one week prior. Neuroimaging revealed diffuse leptomeningeal and perivascular enhancement involving the brain stem, spinal cord and cauda equina. The infective, vasculitic and paraneoplastic screening were negative. Both anti-MOG and AQ4 were also negative. Malignancy screening was negative. However, his CSF and serum anti-GFAP antibody levels were strongly positive. He was managed with IV methylprednisolone, plasmapheresis and rituximab over two months with marked improvement.

Conclusion GFAP astrocytopathy should be acknowledged as a rare potential neurological complication of COVID-19 vaccination, especially if meningoencephalitis is present.

References

1. Shan F, Long Y, Qiu W. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Review of the Literature. Front Immunol. 2018 Dec 5;9:2802.

2. Cheng F, Tang K. A case of COVID-19 encephalitis with anti-gfap antibody-positive meningoencephalomyelitis. J Neurol Sci. 2021 Oct;429:119908.

3. Cheng F, Tang K. A case of COVID-19 encephalitis with anti-gfap antibody-positive meningoencephalomyelitis. J Neurol Sci. 2021 Oct;429:119908.

4. Koh PX, Tay KY, Yeo T, et al. Glial fibrillary acidic protein astrocytopathy in a patient with recent mRNA SARS-CoV-2 vaccination: coversheet. Neuroimmunol Rep. 2022;2:100053.