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This paper presents a case report of a child with Neonatal Brachial Plexus Palsy on the right arm, with C5, C6, and C7 nerve injuries. The symptoms presented at birth and at the time of diagnosis were absence of movement in the right arm but with mobility of the fingers; internal rotation of the injured limb with elbow extension; active flexion of the wrist and fingers; and ulnar deviation of the hand. The rehabilitation plan followed the conservative approach and included different intervention strategies (passive and active mobilisation, kinesio tape, use of splints, bimanual stimulation, etc.) carried out by the occupational therapist and the physical therapist. The rehabilitation allowed the child to have a functional limb for daily activities, with bimanual motor integration and coordination; passive and active range of motion in the different joints except for pronation, sensibility, and maintained strength. In conclusion, it can be said that this case report describes a set of rehabilitation strategies that were used in the conservative treatment of a child with NBPP and the functional gains they allowed. Early intervention, parental involvement in the rehabilitation process, and continuous follow-up of the child favoured the prognosis and allowed the prevention of functional sequelae of the limb.
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History: Transient and generalized adverse effects are common following COVID-19 vaccination;among other adverse effects, shoulder injuries related to vaccine administration (SIRVA) have been known to occur. In this case, a previously healthy right-hand dominant 62-year-old male presented with left shoulder pain and weakness 3 months after receiving a COVID-19 intramuscular vaccine in the left deltoid. Approximately 2 weeks after the injection, he started experiencing pain and numbness around the injection site along with ipsilateral shoulder weakness. Despite conservative management with Motrin, Medrol Dosepak, gabapentin and physical therapy (PT), the pain and weakness persisted. Physical Exam: Left Shoulder-No calor or erythema;significant atrophy of the anterior and middle deltoid muscle relative to right side;abduction 4/5;external rotation with shoulder adducted 4/5;range of motion for active forward flexion was 150 degrees and passive was 170 degrees;passive range of motion for external rotation was 70 degrees;internal rotation to the level of L5;sensation to light touch was intact. Right Shoulder-Range of motion, strength, and sensation were intact. Cervical Spine-Full ROM;no cervical paraspinal tenderness noted. Negative Spurling's and Lhermitte's tests. Differential Diagnosis: 161. Axillary Nerve Palsy 2/2 Chemical Neurotoxicity 162. Brachial Neuritis 163. Mechanical Axillary Nerve Palsy 2/2 Vaccination 164. Partial-Tear of Left Supraspinatus Tendon 165. Acromioclavicular Osteoarthritis Test Results: Left Shoulder-XR:Mild pseudo-subluxation;MRI w/o contrast: 8x9mmpartial-thickness articular surface tear of the distal supraspinatus tendon (<50%fiber thickness). Minimal subacromial bursitis. Mild acromioclavicular joint osteoarthritis. EMG/NCV: Left and Right Axillary Motor Nerves: prolonged distal onset latency;Left Deltoid: increased insertion activity, moderately increased spontaneous activity, reduced recruitment;Remaining LUE muscles without evidence of electrical instability Final Diagnosis: Axillary Nerve Palsy Secondary To Chemical Neurotoxicity from Intramuscular COVID-19 Vaccine. Discussion(s): We postulate that the neurologic deficits presented in our case may be attributed to chemical neurotoxicity to the axillary nerve following vaccination as the delayed onset of pain and weakness are most consistent with this differential. There are several cases of brachial neuritis following vaccination for the prevention of COVID- 19, however, EMG/NCV results in our patient were not consistent with brachial plexopathy. Additionally, while there have been a handful of reported cases of bursitis following COVID-19 vaccines falling under the SIRVA classification of injuries, this is the first case of reported axillary nerve neurapraxia. Outcome(s): The patient's left shoulder numbness and pain improved with PT and medical management. While mild improvement in strength was noted, weakness and atrophy persisted even on the third follow up visit 6 months after the initial appointment. He was counseled on his injury and was recommended to undergo repeat EMG testing to document recovery after his 6-month follow-up appointment. Follow-Up: The patient did not follow-up for a repeatEMG after his 6-month follow-up appointment. At that time, the patient was clinically stable, tolerating PT, and expecting recovery of his deltoid function.
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The mass vaccination against COVID-19 has saved millions of lives globally. The majority of people experience short-term mild side effects; however, in rare cases, some develop long-term severe adverse events. This case report illustrates the case of a middle-aged man with Parsonage-Turner syndrome, a rare adverse event following COVID-19 immunisation. The patient presented with pain and weakness of the right upper arm for 2 months, which developed 5 days after he received his mRNA COVID-19 booster vaccine. He sought medical attention after 9 weeks of experiencing weakness with obvious muscle wasting. He reported his condition only via a phone application, as he thought that his condition was self-limiting and will improve with time. Herein, we discuss the syndrome and highlight the importance of patient education and early recognition of serious adverse events related to vaccinations in the primary care setting.
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OBJECTIVE: The purpose of the study is to examine presentation, injury patterns, and clinical course, for COVID-19-related peripheral nerve injury following mechanical ventilation. METHODS: A multicenter retrospective study of patients with COVID-19 complicated by acute respiratory distress syndrome (ARDS) that required mechanical ventilation was undertaken. Patient records were reviewed for intensive care unit and intubation characteristics, prone or lateral decubitus positioning, and the onset of neuropathy diagnosis. RESULTS: Between September 2020 and January 2022, 11 patients were diagnosed with peripheral neuropathy, including 9 with brachial plexopathy following COVID-19 infection. Each patient developed ARDS requiring mechanical ventilation for a median of 39 days. Six patients (54.5%) underwent prone positioning and 1 lateral decubitus. Neuropathies involved 5 brachial pan-plexopathies, 2 incomplete brachial plexopathies, 2 lower trunk plexopathies, 1 radial neuropathy, and 1 bilateral ulnar neuropathy. At a mean follow-up of 10.2 months, patients with brachial pan-plexopathies demonstrated signs of reinnervation proximally, and 1 resolved to a radial mononeuropathy; however, the majority have demonstrated minimal clinical improvements. CONCLUSIONS: Our series demonstrates that peripheral neuropathies and especially brachial plexopathies have occurred following mechanical ventilation for ARDS-related COVID-19 infections. Contrary to prior COVID-19 studies, only 54.5% of these patients underwent prone positioning. Aside from a traumatic disturbance of prone positioning, the increased incidence of neuropathy may involve an atraumatic effect of COVID-19 via direct invasion of nerves, autoantibody targeting of nervous tissue, or hypercoagulation-induced microthrombotic angiopathy.
Subject(s)
Brachial Plexus Neuropathies , COVID-19 , Respiratory Distress Syndrome , Humans , COVID-19/complications , Retrospective Studies , Upper Extremity , Brachial Plexus Neuropathies/diagnosis , Respiratory Distress Syndrome/complications , Prone PositionABSTRACT
The medical field has undergone many changes since the start of the coronavirus disease 19 (COVID-19) pandemic. In small-and medium-sized hospitals that lack negative pressure facilities for operating rooms, it is impossible to operate on patients infected with COVID-19. As a result, many patients requiring emergency surgery experience serious complications or die. The authors performed intravenous regional anesthesia (IVRA) and emergency surgery in an isolation room on three patients who needed prompt surgical management for upper extremity arterial injuries but could not enter the operating room due to COVID-19 infection. Anesthesia was successful in all cases. A minor anesthetic complication occurred in one patient, who recovered spontaneously. IVRA is a relatively safe and easy method for anesthesia. More-over, since the tourniquet is inflated before anesthesia, it is well-suited for patients with arterial injury. The method is simple and therefore easy to perform in an isolation room where space and manpower are limited. IVRA can be a good option in emergency surgery for upper extremity artery injury. © 2023 Korean Wound Management Society.
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Parsonage-Turner syndrome (PTS) is a peripheral neuropathy involving the brachial plexus very rare in childhood. To date, no cases of PTS after COVID-19 vaccination have been reported in children. We report a case of a 15-year-old boy affected by PTS after the second dose of the BNT162b2 (Comirnaty, Pfizer-BioNTech) COVID-19 vaccine.Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.
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The proceedings contain 68 papers. The topics discussed include: post-transplant lymphoproliferative disorder (PTLD) in a patient with rheumatoid arthritis;cancer, covid and control of RA - a toxic combination?;continuation of golimumab (anti-TNF) in a patient with SpA and low-risk prostate cancer, what is the right decision?;orbital lymphoma in a 72-year-old lady with rheumatoid arthritis: an argument for rituximab;a case of cancer mimicking inflammatory arthritis;managing relapsing and refractory lupus nephritis in juvenile systemic lupus erythematosus: a case report;a case of juvenile systemic lupus erythematosus with pyrexia of unknown origin;recurring brachial plexopathy- the zebra among the horses;and Neisseria meningitidis as a cause of isolated bilateral polyarticular native knee joint septic arthritis.
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Parsonage-Turner Syndrome or neuralgic amyotrophy is a peripheral neuropathy typically characterized by an abrupt onset of pain, followed by progressive neurological deficits (e.g. weakness, atrophy, occasionally sensory abnormalities) that involve the upper limb, mainly the shoulder, encompassing an extensive spectrum of clinical manifestations, somehow difficult to recognize. This case report describes the proper management of a 35-year-old, bank employee and sports amateur who reported subtle and progressive upper limb disorder with previous history of neck pain. SARS-CoV-2 pandemic era made patient's access to the healthcare system more complicated. Nevertheless, proper management of knowledge, relevant aspects of telerehabilitation-based consultation for musculoskeletal pain, advanced skills, tools and technologies led the physiotherapist to suspect an atypical presentation of Parsonage-Turner Syndrome. Further, neurologist consultation and electromyography suggested signs of denervation in the serratus anterior and supraspinatus muscle. Therefore, an appropriate physiotherapist's screening for referral is conducted to correct diagnosis and thorough treatment.
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Parsonage-Turner syndrome is a neurological disease characterized by pain, muscle weakness, sensory deficits, and reflex abnormalities. Although its exact etiology is unknown, it can be observed after infection, surgery, trauma, and vaccination. This syndrome, which can occur after various vaccines, has been reported in a few cases worldwide after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. In this case report, Parsonage-Turner syndrome developed after the SARS-CoV-2 BioNTech vaccination in a 56-year-old male patient. To the best of our knowledge, this is the first case reported in Türkiye.
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PURPOSE/HYPOTHESIS: Coronavirus disease 2019 (COVID-19) may result in hypoxemic respiratory failure and death similar to acute respiratory distress syndrome (ARDS). Based on its known efficacy in ARDS, prone positioning (PP) was used to manage intubated patients with severe COVID-19 lung disease. Though less supported by evidence, awake prone positioning (APP) was also trialed in non-intubated patients with COVID-19 to preserve resources and optimize outcomes. The primary available evidence included in recent reviews on APP in COVID-19 were the resultant retrospective single group studies that showed mixed findings. While such designs expedite results, a risk of bias weakens their application. With emerging research, this focused review evaluated APP in COVID-19 based on prospective trials that included a comparison group. NUMBER OF SUBJECTS: Not applicable. MATERIALS AND METHODS: PubMed and CINAHL databases were searched through June 10, 2022 with the following strategy: [(SARS-COV-2) OR (COVID-19) OR (coronavirus)] AND [(prone) OR (proning) OR (prone positioning)]. Prospective studies investigating APP in non-intubated adults with COVID-19 compared to usual care were included. Quality of evidence was determined by the Cochrane Risk of Bias tool with recommendations made using the GRADE approach. RESULT(S): Seven articles evaluating APP in a combined total of 2604 participants (66% male, mean age: 59.8 yrs, BMI: 29.0) with mild to moderate hypoxemic respiratory failure were included. Participant characteristics were heterogeneous and the duration of proning ranged from 4 to 16 hrs/d. APP was associated with improved oxygenation;however, only one study reported a lower incidence of intubation. No effect was noted on mortality or length of stay (LOS). Adverse events were rare but APP was associated an initial worsening outcome in one instance. Lack of blinding and protocol heterogeneity were identified risks of bias. CONCLUSION(S): APP may improve oxygenation in non-intubated individuals with mild to moderate COVID-19 lung disease as compared to usual care;however, prospective controlled trials do not support a positive effect on intubation, LOS, or mortality. The lack of transference in contrast to PP in intubated patients suggests that the primary benefit of PP may be minimizing ventilator-induced lung injury. Alternatively, benefits of APP may be reserved in select individuals as patient characteristics and proning protocols may influence the response. Though serious adverse events were not reported, the potential for skin breakdown and brachial plexus injuries are noted in ventilated patients with the proning times necessary for benefit. Given these findings, the value of immobilizing awake patients in prone should be questioned and alternate active interventions investigated. CLINICAL RELEVANCE: The routine application of APP in COVID-19 lung disease to improve clinical outcomes is not supported by current literature. Based on the GRADE approach, a weak recommendation against using APP was determined. Future studies should investigate if optimal protocols matched to potential responders improve the value of APP in COVID-19.
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The proceedings contain 68 papers. The topics discussed include: post-transplant lymphoproliferative disorder (PTLD) in a patient with rheumatoid arthritis;cancer, covid and control of RA - a toxic combination?;continuation of golimumab (anti-TNF) in a patient with SpA and low-risk prostate cancer, what is the right decision?;orbital lymphoma in a 72-year-old lady with rheumatoid arthritis: an argument for rituximab;a case of cancer mimicking inflammatory arthritis;managing relapsing and refractory lupus nephritis in juvenile systemic lupus erythematosus: a case report;a case of juvenile systemic lupus erythematosus with pyrexia of unknown origin;recurring brachial plexopathy- the zebra among the horses;and Neisseria meningitidis as a cause of isolated bilateral polyarticular native knee joint septic arthritis.
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Introduction: Since the coronavirus disease 2019 (COVID-19) emerged in Wuhan, neurological complications affecting both the central and peripheral nervous systems have been reported. Multiple etiological mechanisms as immuno-mediation, direct nerve infection, prolonged intensive care units (ICU) hospitalization and prolonged positioning have been proposed as a cause of peripheral lesion. The aim of this study is to report an observational description of peripheral nervous system complications in patients with severe COVID-19. Method(s): We include patients with COVID-19 infections with weakness or sensory deficit, with one or more EMG tests carried out between April 2020 and December 2021. Standard neurophysiological techniques with motor and sensory nerve conductions, F responses and needle EMG exam in representative upper and lower limb muscles were performed. Result(s): A total of 89 patients were included, 66 males (74%) and 23 females (26%), with an average age of 55.7 years old (range from 11 to 90). Most of them (74%) were studied during hospitalization (16 of them during ICU admission). Nearly all patients (90%) had a prolonged ICU hospitalization (between 8 and 120 days). The reason for consultation was diffuse or focal weakness, difficulty in weaning, facial palsy or sensory deficits. The results of EMG tests showed myopathic findings in 61% of patients, focal peripheral nerve lesions in 64%, Guillain-Barre syndrome (GBS) in 5 (6%), and other types of peripheral polyneuropathy in 24%. From peripheral nerve injuries, peroneal neuropathy was the most frequent (58%), brachial plexopathy was found in 26%, median neuropathy in 25%, ulnar in 11%, lateral femoral cutaneous in 9%, axillary and spinal in 5%, radial and hypoglossal in 4% and musculocutaneous in 2%. Tapia's syndrome was diagnosed in two patients. Peripheral nerve injuries correlated with longer admissions in ICU and prone positioning. The follow-up studies showed a good recovery from myopathy but persistent motor sequelae in axonal GBS patients and in most peroneal nerve injuries. Neurophysiological findings are described. Conclusion(s): Peripheral nerve complications are frequent in patients affected by severe COVID-19 and prolonged hospitalization, mainly focal nerve injuries (61%), critical illness myopathy (64%) and peripheral polyneuropathy (30%) including GBS (5 patients). Prone and prolonged positioning in ICU may be associated with peripheral nerve injuries although other mechanisms cannot be excluded. Copyright © 2022
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Introduction: Since the beginning of the pandemic caused by SARS-Cov-2, we have observed an increase of patients referred for electroneuromyography (ENMG) studies complaining of neuropathic symptoms, and who share in common having suffered from the disease by coronavirus (Covid-19), in its different forms of presentation. Clinical, diagnostic, and epidemiological studies that identify possible risk factors of peripheral neuropathies are needed. Method(s): Retrospective and prospective multicenter study in which neurophysiologists from 10 Andalusian hospitals are currently participating. The risk factors analyzed are age, sex, date of infection, date of onset symptoms in relation to Covid infection, hospital admission, admission to intensive unit care (IUC), time of admission, prone position, if orotracheal intubation needed, body mass index (BMI), personal history of interest, if previously vaccinated and complications. The observed peripheral nervous system involvement, caused both directly and indirectly by the virus, has been taken into account. Result(s): A total of 73 patients with neuropathic involvement. Of this total, 39 polyneuropathies (11 Guillain-Barre syndrome, 1 small fiber and 27 other critical illness polyneuropathies associated with IUC patients, 1 of these with associated myopathy), 13 peroneal neuropathies (4 unilateral, 1 with suprascapular neuropathy concomitant and 7 bilateral), 7 brachial plexopathies, 5 neuropathies of the superior laryngeal nerve (3 with concomitant involvement of the inferior) in patients with a history of orotracheal intubation, 2 neuropathies of the femorocutaneous nerve, 2 mononeuritis multiplex, 2 phrenic neuropathies, 1 vagus nerve neuropathy with no history of orotracheal intubation, 2 axillary neuropathies (1 with associated spinal neuropathy). Conclusion(s): Covid-19 causes involvement of the peripheral nervous system. Possible risk factors include male gender, old age, longer hospital stay, IUC admission, orotracheal intubation, prone position, suffering from previous pathologies, and high BMI. The possible causes that we consider for neuropathic involvement are compressive and positional (more indirectly related to the disease) and inflammatory / immune-mediated as the most direct cause of involvement caused by the SARS-Cov-2 virus. Knowledge of the risk factors is important, for the prevention, early diagnosis, and the correct treatment of these neuropathies. Some patients are left with serious neurological sequelae, with the consequences that this entails (high social and economic costs). Copyright © 2022
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Introduction: European Medicines Agency (EMA) approved SARS-Cov-2 vaccines that are administered in Andalucia, south of Spain, have a very good clinical efficacy against Covid-19 and safety profile. Secondary effects (SE) associated with these vaccines are mainly mild (arthralgias myalgias), being SE related with the nervous system infrequent (>1/1000 to <1/100) tremor, paraesthesia, dizziness;rare (>=1/10.000 to < 1/1000) peripheral facial palsy, or very rare (<1/10.000) Guillain Barre syndrome (GBS). 85% of the Andalusian population have been already fully vaccinated, so our environment constitutes an ideal observatory for the real-life analysis of possible neuromuscular SE related to this vaccine. Result(s): Multicentric retrospective observational study of postvaccination against SARS-Cov-2 neuromuscular SE. We actively searched in 10 Andalusian hospitals for objective SE referred for electroneurography (ENG) and/or electromyography (EMG) after SARS-Cov-2 vaccination. We have registered 21 patients (12 males/9 females): 4 acute demyelinating polyneuropathies GBS;2 brachial plexopathies (Parsonage Turner type);1 ipsilateral of vaccine injection and one contralateral;1 inferior limb proximal myopathy in the context of a myocarditis;and 1 presented an acute neuromuscular postsynaptic defect Miastenia Gravis;the rest of the patients had distal paraesthesia with normal ENG-EMG. Conclusion(s): Neurophysiological studies in patients with peripheral neurological symptoms after SARS-Cov-2 vaccination are generally normal, but we should keep alert for possible serious and treatable complications that can be diagnosed with ENG-EMG tests. It would be advisable to extend this multicentric study the get a real idea of the performance of SARS-Cov-2 postvaccine ENG-EMG tests. Copyright © 2022
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An 18-year-old female with neurofibromatosis presented for enucleation biopsy of a slow-growing soft tissue mass on her right anteromedial arm during the COVID-19 pandemic. Ultrasonography was used in the mapping of the brachial plexus and the identification of possible neurofibroma along peripheral nerves. An interscalene brachial plexus nerve block was successfully and safely achieved with ultrasonographic and peripheral nerve stimulator guidance. Ultrasound-guided and nerve stimulator-guided peripheral nerve blocks are safe and viable anesthetic management options for patients with neurofibromatosis, especially in this time of the COVID-19 global pandemic. © 2022 University of the Philippines Manila. All rights reserved.
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Case Diagnosis: Parsonage Turner Syndrome Case Description or Program Description: A 34-year-old male presented with 1 month of suddenonset left neck pain radiating to the shoulder. Symptoms began upon waking from sleep without preceding triggers or infection. Pain was severe and rated 8/10. Nonsteroidal anti-inflammatories and muscle relaxants provided moderate relief, but he developed weakness weeks later manifested as difficulty with carrying his child, donning a coat, and overhead activities. Exam demonstrated decreased infraspinatus bulk and weakness with external rotation and abduction. Nerve conduction studies were normal but electromyography (EMG) demonstrated moderate supraspinatus membrane instability and severe infraspinatus instability without residual motor units or reinnervation signs. MRI of the shoulder confirmed intrinsic constriction of the suprascapular nerve consistent with Parsonage-Turner Syndrome (PTS). Subsequent autoimmune, hepatitis, Covid-19, and HIV studies were unremarkable. Setting(s): Outpatient Clinic Assessment/Results: The patient underwent several courses of physical therapy with slow progress but interval improvement in childcare and dressing capabilities. Discussion (relevance): PTS is a rare disorder that can present with a complex constellation of symptoms. PTS may mirror other pathologies including cervical spondylosis, rotator cuff tendinitis, adhesive capsulitis, or nerve compression by mass lesion. The typical pattern involves abrupt pain followed by weakness after pain has diminished. PTS is often attributed to prior viral infection, immunization, recent surgery, or heavy exercise but can also be idiopathic without identifiable triggers. EMG in conjunction with MRI can be crucial in grading severity of denervation and differentiating PTS from true compression which often requires more invasive interventions. While the majority of patients recover functionally by 3 years with conservative treatments, progress may be slow and physicians should consider long term follow-up with repeat electrodiagnostics to track recovery. Conclusion(s): In patients with abrupt shoulder or neck pain followed by progressive neurologic deficits, PTS needs to be considered. Electrodiagnostic studies can both aid in diagnosis and be used to track recovery over time.
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Case Diagnosis: A 59-year-old, previously healthy female. Case Description or Program Description: The patient presented with sudden-onset, severe left posterior shoulder pain. After two days, the pain resolved and she noticed numbness and tingling throughout the left upper extremity and weakness in her left hand. Three weeks prior to symptom onset, the patient experienced COVID-like symptoms but had a negative rapid antigen test. Two weeks prior, the patient received a third COVID-19 vaccination. Cervical spine MRI revealed severe foraminal stenosis at C4-5 and C6-7 and significant central canal stenosis at C6-7, measuring 8.3 mm. MRI imaging of the brain and brachial plexus, as well as upper extremity sonography, were noncontributory. EMG findings suggested a left C5-C6 radiculopathy and a left brachial plexopathy involving the lower trunk. A diagnosis of both cervical radiculopathy and Parsonage Turner Syndrome (PTS) was made, with viral infection followed by vaccination as the suspected etiology. Setting(s): Outpatient PMR Clinic Assessment/Results: A methylprednisone dose-pack, pregabalin 150 mg twice daily, and outpatient physical therapy were prescribed. She was referred to neurosurgery for further evaluation. The patient's symptoms have continued to slowly improve with steroids. Discussion (relevance): The patient's presentation includes a variety of overlying pathology. Posterior shoulder pain, upper extremity numbness and tingling, and hand weakness are common symptoms of radiculopathy and PTS. MRI and EMG confirmed C5-C6 cervical radiculopathy. Clinically, concurrent PTS was diagnosed due to the resolution of shoulder pain, occurring after a viral illness and COVID vaccination, and the improvement of strength without therapy. As COVID-19 vaccination efforts increase, PTS must be considered to maintain a comprehensive differential. Conclusion(s): PTS is a rare neurological condition that is underrecognized. Physiatrists play a critical role in identifying PTS through performing a detailed history, physical exam, and diagnostic studies. As COVIDrelated illness and vaccination rates increase, future studies are needed to explore the frequency of PTS in conjunction with other diagnoses.
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Case Diagnosis: A 78-year-old man with Parsonage- Turner Syndrome (PTS). Case Description or Program Description: The patient developed acute left-sided neck and shoulder pain upon awakening five days after receiving a Moderna COVID-19 vaccine booster shot. Clinical examination, electrodiagnostic studies, and magnetic resonance imaging were consistent with a diagnosis of PTS. Setting(s): Tertiary referral center. Assessment/Results: His physical exam revealed severe weakness in left shoulder abduction and external rotation without sensory deficits. An urgent MRI of his cervical spine demonstrated multilevel degenerative changes including severe bilateral C5-6 neural foraminal narrowing, and an MRI of the left shoulder showed mild degenerative changes. He was treated with a sixday course of an oral methylprednisolone dose pack and his pain and weakness significantly improved. He was referred for electrodiagnostic testing 24 days after the onset of his symptoms, and by the time of the study, his pain and weakness had improved by 50%. The test revealed no significant abnormalities in the sensory and motor nerve conduction studies. Needle electromyography showed abnormal spontaneous activity in both the left infraspinatus and left deltoid with decreased recruitment of polyphasic motor unit action potentials in the left deltoid. Notably, the left mid/low cervical paraspinals, and other left C5/C6 innervated muscles including the biceps, and brachioradialis were all normal, making a diagnosis of cervical radiculopathy unlikely. Discussion (relevance): There have been eight published reports of PTS related to COVID-19 vaccinations at the time of this publication, which are also reviewed. Reports have occurred in three separate vaccines with variable onset of symptoms and recovery patterns as detailed in the table provided. Conclusion(s): Our case report and review of the literature highlights the importance of recognizing PTS as a potential cause of severe shoulder/arm pain and weakness after administration of a COVID-19 vaccine.
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Case Diagnosis: A 46-year-old male with severe COVID-19 pneumonia. Case Description or Program Description: The patient underwent bilateral orthotopic lung transplant (BOLT) after being on extracorporeal membrane oxygenation (ECMO) and mechanical ventilation for 202 days. He had multiple complications due to prolonged prone positioning, intubation, immobility and steroid use which include tongue fissure, critical illness neuromyopathy, bilateral brachial plexopathy, bilateral upper extremity contractures, avascular necrosis (AVN) of bilateral humeral heads and bilateral femoral heads, left sciatic mononeuropathy and a stage IV sacral wound. The patient had severe weakness throughout all limbs, but was cognitively intact. He was admitted to IPR 3.5 weeks after his BOLT. The patient was independent for ADLs and mobility prior to his illness and was dependent for activities of daily living (ADLs) and mobility at time of admission to inpatient rehabilitation (IPR). Setting(s): Inpatient rehabilitation hospital Assessment/Results: Following 12 weeks of IPR he ambulated independently and was discharged to the community with family assist in an outpatient Day Rehabilitation program for continued functional recovery. Unfortunately, he still required maximum assistance for ADLs due to loss of function of his arms. Discussion (relevance): This is a unique case of a patient with severe COVID-19 pneumonia who was intubated and on ECMO for a very long amount of time with survival ultimately leading to numerable sequela involving all extremities but notable injuries presenting as a person in a barrel type syndrome. Conclusion(s): Person in a barrel syndrome is a rare syndrome described by severe bilateral upper extremity weakness with strength preserved in the bilateral lower extremities as well as head, neck, and face. This patient developed this syndrome as a sequela to prolonged prone positioning and immobility related to severe COVID-19 disease. Consultation of PM&R services while in the ICU to aid in identification of patients at risk and help to optimize patient positioning without compromising life-saving procedures.
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Case Diagnosis: Patient is a 63-year-old male with Guillain-Barre Syndrome and Parsonage-Turner Syndrome following COVID-19 Vaccination Case Description or Program Description: Eight days after receiving a viral vector COVID-19 vaccination, the patient developed low back and left thigh pain with severe right shoulder pain developing the following day. He denied recent viral illnesses, gastrointestinal symptoms, or prior right shoulder pain. Pain, weakness, and sensory changes gradually involved all four extremities. He was hospitalized and Guillain-Barre Syndrome (GBS) was confirmed by lumbar puncture. He tested negative for Campylobacter jejuni. Cervical and lumbar spine MRIs showed mild degenerative changes without stenosis or neuroforaminal impingement. Right shoulder MRI showed no abnormality. He responded to a 5-day course of IVIG. His extremity pain gradually resolved but right shoulder weakness remained. Electrodiagnostic testing six months after symptom onset showed evidence of GBS in recovery. Right shoulder girdle muscles were not tested during the first EMG. After stays at an LTAC and SNF, the patient was admitted to IPR. While at IPR, he reported debilitating right shoulder weakness and limited ROM. On exam, significant atrophy of the right deltoid, infraspinatus, and supraspinatus muscles was observed. A repeat electrodiagnostic study showed evidence of a right Parsonage-Turner syndrome (PTS) in addition to the GBS in recovery. Setting(s): Inpatient Rehabilitation (IPR) Assessment/Results: Patient's presentation and EMG findings pointed to a concurrent occurrence of PTS and GBS after his COVID-19 vaccination. A right shoulder ultrasound-guided glenohumeral joint corticosteroid injection improved his shoulder ROM. The patient was discharged home with outpatient therapy after four weeks of IPR. Discussion (relevance): Rare instances of GBS and Parsonage-Turner Syndrome have been reported after a COVID-19 vaccination. This appears to be the first reported case where GBS and PTS have both occurred in a patient soon after receiving a COVID-19 vaccination. Conclusion(s): Concurrent PTS and GBS can develop after COVID-19 vaccine administration.