Shoulder Weakness Following Intramuscular COVID- 19 Vaccine

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.

Parsonage-Turner Syndrome After COVID-19 Vaccination in a Child

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.

Adult and Paediatric Case-based Conference 2021

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.

Adult and Paediatric Case-based Conference 2021

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.

TH-146. Neuromuscular involvement in severe Covid-19 patients. Our experience in EMG unit of terciary hospital

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

TH-136. Peripheral neuropathies as complication of SARS-Cov-2: a multicenter study in the Andalusian population

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

TH-126. Preliminary results of an Andalucia-South of Spain multicentric registry of SARS-CoV-2 postvaccination neuromuscular pathology

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

Pain in the Neck: A Case Report of Suprascapular Neuropathy Due to Parsonage Turner Syndrome

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.

A Complex Clinical Presentation of Cervical Radiculopathy with Concurrent Parsonage Turner Syndrome: A Case Report

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.

Parsonage Turner Syndrome After COVID-19 Vaccine Booster: A Case Report and Review of the Literature

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.

Rehabilitation of Person in a Barrel Syndrome Due to Sequela of Prolonged Intubation After COVID-19: A Case Report

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.

Guillain-Barre Syndrome and Parsonage-Turner Syndrome Following COVID-19 Viral Vector Vaccination

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.

Parsonage-Turner Syndrome Resulting in Spinal Accessory Nerve Lesion After COVID-19 Vaccine: A Case Report

Case Diagnosis: A patient presenting with right shoulder pain and weakness after COVID-19 vaccination is found to have Parsonage-Turner syndrome (PTS) of the spinal accessory nerve. Case Description or Program Description: An 18-year-old male patient with no significant medical history presented to the Physiatry clinic for evaluation of right shoulder pain and protrusion of his right scapula. He denied any trauma or known inciting events. He received his two doses of the COVID-19 vaccine on the contralateral deltoid one month and one week prior. Two days after the 2nd dose, he woke up with 8/10 pain in his right shoulder and displayed right scapular protrusion. He also had self-limiting chills and myalgia. His pain improved, but the scapular protrusion persisted. On examination, there was right trapezius atrophy, right scapula lateral winging, and dyskinesis of right scapulothoracic motion. Right shoulder shrug strength was 4/5, but upper extremity strength otherwise remained 5/5 bilaterally. Electrodiagnostic studies approximately 1 month after symptom onset revealed an acute spinal accessory nerve lesion with ongoing denervation potentials in the superior portion of the mid trapezius muscle. Setting(s): Outpatient Physiatry clinic in Northeast health system. Assessment/Results: The patient's clinical presentation, history, and electrodiagnostic findings were consistent with Parsonage-Turner syndrome of the right spinal accessory nerve. One month after onset, his pain resolved, but he had residual right shoulder shrug weakness and right trapezius atrophy. He had not yet started physical therapy at the time of follow-up. Discussion (relevance): This is the first reported case, to our knowledge, of Parsonage-Turner syndrome resulting in spinal accessory nerve palsy from COVID- 19 vaccination. Conclusion(s): While the risk of complications, such as Parsonage-Turner syndrome, remains rare with COVID-19 vaccination, it is important to be mindful of vaccination history in patients with unexplained neurological injuries. However, data continues to show that the risk of complications of COVID-19 infection greatly exceed those of the vaccine.

More Than Just a Cold: A Case of Critical Illness Polyneuropathy with Mononeuritis Multiplex Following COVID-19 Infection

Case Diagnosis: Critical Illness Polyneuropathy following COVID-19 Infection Case Description or Program Description: A 58-yearold female presented to PM&R clinic following a prolonged hospitalization for COVID-19, after which she developed bilateral wrist and foot drop. Prior to her hospitalization, she ambulated independently. At the time of evaluation, she was wheelchair bound. Physical exam demonstrated bilateral wrist and foot drop, with bilateral foot numbness. EMG demonstrated bilateral common peroneal incomplete axonal neuropathy, with bilateral incomplete axonal brachial plexopathy affecting mainly the lower trunk on the left side and the middle cord on the right side. Setting(s): Tertiary-care teaching hospital Assessment/Results: Outpatient physical and occupational therapy were initiated and she was prescribed bilateral ankle foot orthoses. She was referred to neurology, with diagnosis of multifocal axonal neuropathy, with critical illness polyneuropathy, post viral (COVID) immune axonopathy with mononeuritis multiplex. Repeat EMG obtained 8 months later demonstrated mild improvement on the needle study with decreased denervation potentials of the muscles tested however, NCS remained unchanged. Over a 1-year span of therapy, her strength, function and numbness improved. She progressed to ambulate independently without an assistive device. Discussion (relevance): Critical illness polyneuropathy (CIP) is a neurologic manifestation of systemic inflammatory response syndrome, causing axonal injury by unclear mechanism. It is suspected that distal nerve microcirculation causes ischemia and axonal degeneration. There are increasing reports of polyneuropathy following COVID-19 infection. Diagnosis involves EMG, which demonstrates axonal loss without demyelinating features, with NCS showing decreased amplitude of SNAPs. CIP treatment includes reduction of dose and duration of steroids and neuromuscular blocking agents, rehabilitation programs, and careful extremity positioning. Conclusion(s): Our patient experienced functional improvement with conservative management, including outpatient physical and occupational therapy with bracing. As the COVID-19 pandemic continues, CIP must be considered in patients with weakness and a history of COVID-19 infection, particularly in those with severe infection and ICU stay.

More Than a Sore Shoulder Post COVID Shot: A Case of Parsonage Turner Syndrome Following COVID-19 Vaccination

Case Diagnosis: Parsonage Turner Syndrome following COVID-19 Vaccination Case Description or Program Description: A 35-year-old female, with history of left humerus osteosarcoma s/p resection with hemiarthroplasty at age 15, presented with left shoulder pain one day after receiving the first COVID-19 Moderna vaccine dose in her right deltoid. She initially presented to the emergency room, where radiographs showed no acute pathology. Two days later, she visited an outpatient orthopedist with persistent pain, and was prescribed a medrol dosepak, Percocet, and cyclobenzaprine, with left shoulder radiographs again unremarkable. She presented to our outpatient sports medicine clinic after failing prior treatments. Physical examination demonstrated tenderness to palpation throughout her left shoulder, with left upper extremity weakness. Bloodwork revealed mild leukocytosis (10.68) and thrombocytopenia (451). Left shoulder CT was unremarkable, and blood cultures were negative. Setting(s): Outpatient sports medicine clinic Assessment/Results: Parsonage-Turner syndrome (PTS) was suspected, and she was prescribed a Prednisone taper and Gabapentin. Her pain and weakness improved over a 1-month span. Discussion (relevance): PTS, commonly referred to as Neuralgic amyotrophy, is an inflammatory, non-traumatic, brachial plexus disorder. PTS is hypothesized to be an immune process, with patients describing events including infection, surgery, or vaccination preceding onset. PTS presents classically with upper extremity pain, followed by weakness throughout the unilateral upper/ middle brachial plexus. Diagnosis is primarily clinical, but can be supported by electrodiagnostic testing demonstrating denervation. Treatment often includes glucocorticoids, with most patients slowly regaining full function. Conclusion(s): There have thus far been a select few PTS cases following COVID-19 vaccination. It is unclear the role that our patient's prior left humeral hemiarthroplasty played in her PTS development, however its presence makes this case increasingly interesting. As patients continue to receive vaccine boosters in the fight against the COVID-19 pandemic, it is important to keep the diagnosis of PTS in mind for patients with pain and weakness following vaccination.

DIAPHRAGMATIC PARALYSIS FOLLOWING SECOND DOSE OF THE BNT162B2 MRNA COVID-19 VACCINE

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The vaccines against SARS-CoV-2 or COVID-19 have been shown to be safe and effective at preventing severe disease and death. In a phase 3 trial the BNT162b2 mRNA COVID-19 vaccine showed a 52% and 95% efficacy after the first and second doses, respectively (1). Side effects following vaccination are common but are typically mild and self limited (2). The most common side effects are headache, fever, fatigue, arthralgias and pain at the injection site (2). More severe and devastating side effects have been reported including cerebral venous thrombosis and myocarditis (3) (4). Here we report a case of unilateral diaphragmatic paralysis following the second dose of the BNT162b2 mRNA COVID-19 vaccine. CASE PRESENTATION: The patient was a 56 year old female with a past medical history of reactive airways disease and hypertension who was seen in the pulmonology clinic shortly after receiving her second dose of the BNT162b2 mRNA COVID-19 vaccine. After her second dose she developed burning shoulder pain, erythema and swelling that extended to the neck and axilla. She went to an urgent care and was advised to treat with ice and NSAIDs, she had a chest radiograph performed which was reported to be negative. Her symptoms persisted and she was sent to the emergency room, chest x-ray showed interval development of an elevated left hemidiaphragm. A CT Chest with inspiratory and expiratory films was performed and the left diaphragm was noted to be in the same location during inspiration and expiration consistent with diaphragmatic paralysis. PFT showed a reduction in her FVC, TLC and DLCO compared to 13 years prior. DISCUSSION: Diaphragmatic paralysis is a well described clinical entity that is most often associated with cardiothoracic surgery where hypothermia and local ice slush application are thought to induce phrenic nerve injury (5). It has also been described as a complication of viral infections, including a recent report of unilateral diaphragm paralysis in a patient with acute COVID-19 infection (6). In a case series of 246 patients with amyotrophic neuralgia which can include diaphragm paralysis, 5 patients received a vaccine in the week before developing symptoms (8) Additionally, Crespo Burrilio et al recently described a case of amyotrophic neuralgia and unilateral diaphragm paralysis following administration of the Vaxzevri (AstraZeneca) COVID-19 vaccine (7). This case highlights a potential side effect of the BNT162b2 mRNA COVID-19 vaccine that has not been previously reported CONCLUSIONS: Reference #1: Polack FP, Thomas SJ, Kitchin N. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N Engl J Med. 2020;383:2603–2615. Reference #2: Menni, C., Klaser, K., May, A., Polidori, L., Capdevila, J., Louca, P., Sudre, C. H., Nguyen, L. H., Drew, D. A., Merino, J., Hu, C., Selvachandran, S., Antonelli, M., Murray, B., Canas, L. S., Molteni, E., Graham, M. S., Modat, M., Joshi, A. D., Mangino, M., … Spector, T. D. (2021). Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. The Lancet. Infectious diseases, 21(7), 939–949. https://doi.org/10.1016/S1473-3099(21)00224-3 Reference #3: Jaiswal V, Nepal G, Dijamco P, et al. Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review. J Prim Care Community Health. 2022;13:21501319221074450. doi:10.1177/21501319221074450 DISCLOSURES: No relevant relationships by Jack Mann No relevant relationships by John Prudenti

Parsonage-Turner Syndrome after COVID-19 Vaccination

Parsonage-Turner syndrome (PTS) is an inflammatory disorder of the brachial plexus, which typically presents as severe neuropathic pain, followed by rapid multifocal weakness and amyotrophy of the upper limb. Triggering events such as infection, vaccination and trauma have been described. We present the case of a 53-year-old man who developed PTS twelve days after receiving a second dose of the AZD1222 vaccine against COVID19 (Oxford/AstraZeneca), as confirmed by electroneuromyography and MRI of the brachial plexus. As common triggering events were excluded, we consider the AZD1222 vaccine as possible trigger. Even though causality cannot be proven, we present this case of PTS following COVID-19 vaccination to raise awareness amongst caregivers to identify this underrecognized plexopathy timely. We will discuss PTS pathophysiology and the possible link between PTS and COVID19 vaccination.

Abstracts of the 12th Annual Meeting of the Italian Association for the study of the Peripheral Nervous System (ASNP)

The proceedings contain 69 papers. The topics discussed include: chemotherapy induced peripheral neurotoxicy: why should we care?;studying the caudal nerve anatomy and physiology to refine detection of peripheral nerve damage in rodent models;anxiety and depression in Charcot-Marie-tooth disease: data from the Italian CMT National Registry;fatigue in CMT: a web based survey from the Italian CMT National Registry;early molecular diagnosis of mutations on the transthyretin gene as a strategy to improve the prognosis of hereditary transthyretin-mediated amyloidosis - an update of the GENILAM project;THR124MET myelin protein zero mutation mimicking motor neuron disease;torsional neuropathy in parsonage turner syndrome following anti-COVID19 vaccination. how to detect and manage with it?;isolated musculocutaneous involvement in parsonage-turner syndrome associated with SARS-COV2 vaccination;neonatal FC receptor expression in patients with chronic dysimmune neuropathy. a feasibility study;and peripheral neuropathies after common organ transplantations. literature review and the use of electrophysiological tests and ultrasound.

Evaluation of Antibody Response to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Immunizations in Patients with B-Cell Malignancies

Background Multiple vaccines have been granted emergency use authorization by the Food and Drug Administration against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Of the currently available vaccines, none have been systematically studied for efficacy or toxicity in patients with immunodeficiency or with immunosuppressed states, such as B cell malignancy. The purpose of the study was to evaluate the immune response to currently available vaccines against COVID-19 in patients with hematologic and solid organ malignancies. Methods This prospective study enrolled 53 patients;12 with CLL, 10 with multiple myeloma (MM), 11 with non-Hodgkin's lymphoma (NHL) and 21 with a solid organ malignancy. Using a quantitative assay, IgG antibodies to SARS-CoV-2 Spike (S) protein, and nucleocapsid (N) protein by enzyme immunoassay were measured at baseline prior to vaccination and at 2 weeks after completion of vaccination. A fourfold increase in IgG was considered a positive response to vaccination. Through a predesigned survey, patients also self-reported side effects from each dose of vaccination. Results Seroconversion with vaccination was seen in 9/10 (90%) patients with MM, 5/12 (41.7%) patients with CLL, 6/11 (54.1%) patients with NHL, and 17/21 (80.9%) patients with solid organ malignancy. Per univariate analysis, CLL (OR 0.23, 95% CI 0.05-0.88;p= 0.033) was associated with lower odds of seroconversion while NHL (OR 0.48, 95% CI 0.12-1.8;p =0.291), MM (OR 5.33, 95% CI 0.61-46.08;p= 0.128) and solid organ malignancy (OR 2.90, 95% CI 0.79-10.64;p= 0.107) were not. Among patients with hematological malignancies, 5/13 (38.3%) patients treated with rituximab and 2/7 (28.5%) patients on immunoglobulin replacement (IgR) therapy responded to vaccination. This corresponded to reduced odds of seroconversion, 0.18 (95% CI 0.047-0.69;p = 0.013) in patients treated with rituximab and 0.14 (95% CI 0.024-0.826;p=0.030) in patients on IgR. Among patients with solid organ malignancies, treatment with chemotherapy (OR 2.05, 95% CI 0.48-8.61;p=0.320), immunotherapy (OR 4.57, 95% CI 0.52-39.9;p=0.169) or endocrine therapy (OR 1.0) did not lower odds of seroconversion with vaccination. Multivariate analysis revealed patients who received rituximab were less likely to respond to vaccination as compared to patients not previously treated with rituximab (OR 0.22, 95% CI 0.05-0.955;p=0.044). Injection site soreness was the most commonly reported side effect. The only severe side effect occurred in a patient with solid organ malignancy who developed Parsonage Turner syndrome. Conclusion Our study, to the best of our knowledge, is the first study comparing pre and post vaccination IgG titers against the SARS-CoV-2 S protein. Majority of patients with MM and solid organ malignancies, including those receiving active treatment, responded adequately to immunization. Patients with CLL appear less likely to respond to vaccination against COVID-19 as compared to patients with NHL, MM or solid organ malignancies. Previous treatment with rituximab was the most significant risk factor for suboptimal response to vaccination, regardless of underlying hematologic malignancy. These data highlight the importance of continuing risk mitigation strategies against COVID-19 in individuals with hematologic malignancy, particularly those with CLL or on treatment with rituximab. Future research is needed to investigate approaches to provide protective IgG against SARS-CoV-2 in this at-risk population. [Formula presented] Disclosures: Mustafa: Genentech: Speakers Bureau;GalaxoSmithKline: Speakers Bureau;CSL Behring: Speakers Bureau;Regeneron: Speakers Bureau;AstraZeneca: Speakers Bureau. Walsh: Janssen: Research Funding;Merck: Research Funding;Pfizer: Research Funding. Jamshed: Takeda: Honoraria.