Case presentation:
A 60-year-old lady, known to have multiple sclerosis, presented with
right-hand weakness a few hours after receiving the 1st dose of COVID-19
vaccine (Pfizer)
Her hand weakness was progressive; she was unable to hold or pick up
objects.
She had no other neurological deficits, no numbness or other limb
weakness, no visual loss or eye pain, No bladder or bowel dysfunction.
She was diagnosed with multiple sclerosis in 1996, was on interferon,
but stopped in 2015.
She was in remission for the past eight years without clinical
deterioration or new MRI changes.
On examination, the patient had normal vital signs
The neurological exam was remarkable for decreased handgrip and thumb
opposition strength. There was no muscle wasting or reduced sensation.
The rest of the neurological examination, cardiovascular, pulmonary, and
abdominal examinations were normal.
Labs showed leukopenia and mildly elevated CRP, otherwise normal Hgb,
platelets, urea, creatinine, and electrolytes (Table 1).
CT head was done, which showed Ill-defined focal hypodense lesions in
the bilateral parietal white matter, likely suggesting chronic
demyelinating lesions.
MRI head and MRI spinal cord with contrast were done, which showed old
demyelinating lesions with a newly described lesion measuring
approximately 10 x 9 mm size with restricted diffusion) Figure 1 and 2,
and enhancement on contrast study suggestive of activity figure 3.
She received a 3-days course of intravenous methylprednisolone 500 mg/
day. Her power improved through her hospital stay and was discharged
home.
Discussion:COVID 19 has resulted in a lot of morbidity and mortality all over the
world. As a new disease entity, the evidence on the pathogeneses,
potential complications, and treatment are growing daily. 7) COVID 19
vaccines were recently produced and given to the population after an
emergency approval from the FDA. New technology has been introduced,
which is mRNA-based vaccines. 8) They are associated with many variable
side effects, ranging from simple ones to potentially more severe or
life-threatening ones. They were described to cause myalgias, fever,
general fatigue. But not uncommonly, they were seen to cause covid
infection, with potential ARDS and death. 9) Vaccines, in general, have
been linked to various side effects, such as the development of GBS and
CNS Side effects. One other aspect that should be considered is that
vaccines can cause several side effects for patients with autoimmune
conditions. For example, the flu vaccine has been linked before to
causing a flare of multiple sclerosis. (10) COVID 19 vaccines are
continuously being studied, and more side effects will be identified as
more and more people receive the Vaccine. (11) They have been found to
cause several CNS side effects, such as weakness, numbness, ataxia, and
more drastic presentations such as encephalomyelitis and acute
demyelination syndrome with GBS. Moreover, it was described in recently
published studies that MS flare could be associated with COVID vaccines.
The frequency is not precise yet, and more and more studies are needed.
(12) Additionally, there is some evidence to suggest a temporal
relationship between MS flare and the receipt of various vaccines,
including those for rabies, hepatitis (Hep) A and B, polio, and
influenza [13]. Such cases are infrequent, and the establishment of
causality in most of these cases has proved controversial.
Multiple sclerosis is an autoimmune disease with unclear etiology. The
diagnosis is usually made as a combination of clinical and radiological
findings. Treatment is done with pulse steroids; high-dose IV steroids.
(14) The risk of relapses usually decreases with age and people who had
stable disease (include more on the relapse). Moreover, it is known that
MS flares decrease with age, and it is unlikely in patients who have had
stable diseases for many years. (15)
Our patient was diagnosed with MS more than 20 years ago and had stable
disease with no relapses. The most recent relapse was 18 years ago, and
she was kept off medications. Unfortunately, on the same day that she
received the COVID vaccine, she had a recurrence of symptoms. MRI Was
done, and it revealed an active lesion in the left periventricular
region. Her symptoms improved significantly after she started pulse
steroids with a resolution of her symptoms upon follow-up.