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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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Intro: GBP510 contains the self-assembling recombinant nanoparticle displaying SARS-CoV-2 Spike protein receptor binding domain and is adjuvanted with AS03. We report interim Phase 3 study (NCT05007951) results up to 4 weeks post-dose 2 (Data-cut: March-18-2022), where immunogenicity to the D614G ancestral strain and safety of 25mug GBP510/AS03 candidate was compared to ChAdOx1-S (Vaxzevria). Method(s): This Phase 3 randomized, active-controlled, observer-blind, parallel- group study in adults was conducted in 6 countries. Cohort1: 1,895 subjects (naive to COVID-19 vaccination and infection) randomized at 2:1 ratio (GBP510/AS03:ChAdOx1-S) to assess immunogenicity and safety;Cohort 2: 2,141 subjects at 5:1 ratio, regardless of their serostatus at screening for safety assessment. Subjects were vaccinated twice at a 4-week interval with 0.5 mL of the test vaccine (GBP510/AS03) or active control (ChAdOx1-S) in deltoid muscle. The primary objective was to demonstrate the superiority of geometric mean titer (GMT) and non-inferiority in seroconversion rate (SCR: >=4-fold rise from baseline) of neutralizing antibodies over ChAdOx1-S by live-virus neutralization assay (FRNT). Finding(s): At 2 weeks post-dose 2, GMT ratio of the two groups (Test vaccine/Active control) was 2.93 [95% CI: 2.63, 3.27], satisfying the hypothesis of superiority (95% CI lower limit> 1). The SCR difference (Test vaccine - Active control) was 10.76% [95% CI: 7.68, 14.32], satisfying the hypothesis of non- inferiority (95% CI lower limit> -5%). Good cell-mediated immune responses for Th1 cytokines were also observed with the test vaccine (FluoroSpot). The AE incidence rate for the test vaccine was higher than the active control for solicited local AEs (56.69% vs 49.20%), and comparable for solicited systemic AEs (51.21% vs 53.51%) and unsolicited AEs (13.34% vs 14.66%) after any vaccination. Conclusion(s): Higher immune responses were observed with GBP510/AS03 compared to ChAdOx1-S against D614G strain after 2 weeks post-dose 2. GBP510/AS03 showed a clinically acceptable safety profile;no safety concerns were identified during the study period.Copyright © 2023
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Background: Covid-19 viral infection affects strongly the populations in the world by the level of morbidity, mortality and the economic impact. A worldwide vaccination program was developed since the end of 2020 to limit the propagation of the virus and the development of variants. In USA and Europe the risk of an allergic reaction is estimated to be 1.31 (95 % CI, 0.90-1.84) per million vaccine dose. The excipients are considered to be the most probable cause of IgE-mediated allergic reactions: PolyEthylene Glycol (PEG) for the Moderna and the Pfizer-BioNTech vaccines and Polysorbate 80 (P80) for the Astra Zeneca and the Johnson & Johnson. P80 presents clinical cross-reactivity with PEG. Patients with a history of severe allergic reaction to PEG or P80 should avoid the vaccination. However, some of them strongly wanted to be vaccinated because their accumulated risk factors for severe infection. Method(s): To 4 severely PEG/P80 allergic patients (grade 3 of anaphylaxis), we proposed a desensitization protocol (7 steps in 90 min + 60 min of observation) with the Pfizer-BioNTech vaccine. Each injection was performed alternately in the deltoid muscle (SC for 2 treated by apixaban) every 15 min. Two patient received all the injections in the same arm due to insufficient lymphatic drainage post mastectomy. The protocol was repeated 1 month and once again 6 months later for the second and the booster doses respectively. One patient didn't received the last one because she was meanwhile moved in palliative treatment. We followed the modification of their immunological status. All patients took a premedication with bilastine 20 mg and montelukast 10 mg (without PEG/P80) 24 h and 3 h before each protocol. Result(s): No patient developed adverse nor allergic reaction after the successive vaccinations. Conclusion(s): We c an p ropose adesensitization protocol to the COVID-19 Pfizer-BioNTech vaccine to patients with severe hypersensitivity to PEG/P80. The desensitization is well tolerated and followed by an increase of specific antibodies and an evolution of antibody level like patients who received the total dosis (0.3 ml) in one injection. (Figure Presented).
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BACKGROUND: Sotrovimab, a dual-action Fc-engineered human immunoglobulin G (IgG1) mAb, binds to a conserved epitope on the SARS-CoV- 2 receptor binding domain and was developed to treat mild to moderate COVID-19. A high concentration formulation is being evaluated to offer the potential for IM administration at lower volumes and at different injection sites. METHOD(S): COSMIC (NCT05280717) is a phase 1, open-label healthy volunteer study comprising three parts. Part A is an ongoing randomized, parallel group study investigating the relative bioavailability, safety, and tolerability of two concentrations of sotrovimab administered at different injection sites. A total of 215 subjects were randomized in a 2:2:1:1 ratio into 4 treatment arms: dorsogluteal injection (62.5 mg/mL), or 100 mg/mL administered as dorsogluteal, thigh, or deltoid injection(s). PK will be evaluated for 24 weeks post-dose. RESULT(S): Preliminary PK is available from 50 participants who received a 500 mg IM dose of sotrovimab of the higher concentration (100 mg/mL). Administration into thigh or deltoid resulted in higher geometric mean Cmax and AUCD1-15 and lower inter-subject variability compared to 100 mg/mL dorsogluteal. Following gluteal, thigh, or deltoid injections, the geometric mean (%CV) Cmax was 44.8 mug/mL (63.3), 70.9 mug/mL (35.5), and 65.1 mug/mL (27.1), respectively, and the geometric mean (%CV) AUCD1-15 was 534 day*mug/mL (67.5), 814 day*mug/mL (39.7), and 782 day*mug/mL (26.3), respectively. Median Tmax was earlier following thigh (4 days) and deltoid (5.5 days) injection than gluteal (7 days) injection. CONCLUSION(S): Administration of sotrovimab into thigh or deltoid muscles may improve exposure and reduce inter-subject variability compared to gluteal IM administration. These data may inform IM injection site selection for mAbs.
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Aim/Introduction: [18F]FDG PET/CT plays an important role in diagnosis, staging, response assessment and follow-up care for oncology patients. Since mass Coronavirus Disease 2019 (COVID-19) vaccination program in many countries, vaccineassociated hypermetabolic lymphadenopathy (VAHL) may cause misinterpretation, unnecessary lymph node biopsy and alteration of therapy. Prophylactic use of paracetamol has been shown to alleviate the vaccine side-effects;whether it can also reduce the incidence of VAHL is not well studied. In the present study, we aimed to evaluate whether paracetamol can also reduce the incidence of VAHL in suspected or confirmed lung cancer patients. Material(s) and Method(s): This was a single-centre retrospective study. All consecutive patients with suspected or confirmed cancers who underwent [18F]FDG PET/CT between 1 May 2021 and 30 September 2021 and received at least one dose of COVID-19 vaccine within 6 weeks before were investigated. Demographic and clinical history (including details of COVID-19 vaccination, use of oral paracetamol) were collected, and the occurrence of VAHL was measured. Result(s): Among 96 patients (M:F = 40:56, mean age 60 +/- 11 years), 43.8% (42/96) demonstrated VAHL with median SUVmax of 3.2 (range, 1.5-13.8), median size of 7 mm (range, 3-17 mm) and median number of 3 (range, 1-15). Patients with oral paracetamol (63 +/- 11 years) and those without oral paracetamol (60 +/- 11 years) showed no statistically significant difference in the incidence (p = 0.751), SUVmax (p = 0.174), size (p = 0.932) and number of VAHL (p = 0.208). In addition, positive uptake at vaccine injection site was seen in 38.5% (37/96) of patients;use of oral paracetamol or not did not result in statistically significant difference in the incidence of positive deltoid uptake (p>0.05). Conclusion(s): This study demonstrated that intake of oral paracetamol may not prevent the occurrence of VAHL on [18F]FDG PET/CT in suspected or confirmed cancer patients following COVID-19 vaccination. On the other hand, paracetamol seems not to affect patients' immune response to the vaccine, which is a desirable attribute for a medication commonly prescribed for mitigation of the adverse effects of the vaccine.
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Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was detected in Wuhan, China, in December 2019. The disease (Covid-19) is mainly associated with lung injury, although neuromuscular symptoms including muscle weakness and myalgia are encountered in up to 10.7% of hospitalized patients affected by Covid-19. Nevertheless, the extent of muscular involvement in infected subjects has never been assessed with neurophysiological investigations. Method(s): Over a 3-week period, from April 30 through May 20, 2020, a total of 70 patients were hospitalized in the Internal Medicine Ward of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico in Milan, Italy. After excluding patients who underwent invasive ventilation and steroid treatment, 12 patients were evaluated. The Covid-19 diagnosis was confirmed by 2 positive nasopharyngeal swabs performed before and after our evaluation. All patients were asymptomatic for muscular involvement. Result(s): A total of 12 patients were included in this study. None of the patients exhibited neuromuscular symptoms during the disease course. All patients showed mild to moderate respiratory symptoms and chest X rays were suggestive for pneumonia. Mean age was 69 (SD 12.80) years, and 5 patients were men. The main comorbidity was hypertension. Neurological examination was unremarkable, and all the subjects obtained an MRC sum score of 60. None of the patients showed an elevation of the serum creatine-kinase (CK) or serum lactate dehydrogenase (LDH) levels performed before the neurophysiological assessment. No NCS abnormalities were found except the absence of bilateral sural sensory action potential (SAP) in patient 12, which was already reported in a previous evaluation and likely due to diabetes. Needle electromyography showed a myopathic pattern in 6 out of 12 subjects. Such alterations were prominent in a patchy fashion, in particular in proximal muscles such as trapezius (6), iliopsoas (4) and deltoid (1). The levels of fibrinogen, CK, D-dimer, C reactive protein did not show relevant differences between the two groups. When compared to non-myopathic subjects, patients with skeletal muscle injury exhibited more severe respiratory conditions according to the need for non-invasive mechanic ventilation (NIMV) Conclusion(s): Our data show that in SARS-CoV-2 infection muscular involvement may occur despite the absence of clinical signs or symptoms and should be considered part of the disease spectrum. The application of muscle biopsy to unravel the mechanisms of myofiber damage on tissue specimen could help to clarify the pathogenesis and the treatment response of coronavirus-mediated injury. Copyright © 2022
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Introduction: Neurological complications of SARS-CoV-2 disease have received growing attention, but only few studies have described to date clinical and neurophysiological findings in COVID patients during their stay in intensive care units (ICUs). Here, we assessed the presence of either critical illness neuropathy (CIP) or myopathy (CIM) in ICU patients. Method(s): Patients underwent a neurophysiological assessment, including bilateral examination of the median, ulnar, deep peroneal and tibial motor nerves and of the median, ulnar, radial, and sural sensory nerves. Needle electromyography (EMG) was performed for both distal and proximal muscles of the lower and upper limbs. The technique of Direct Muscle Stimulation (DMS) was applied either to the deltoid or tibialis anterior muscles. Peak to peak amplitudes and onset latencies of the responses evoked by DMS (DMSamp, DMSlat) or by motor nerve stimulation (MNSamp, MNSlat) were compared. The ratio MNSamp to DMSamp (NMR) and the MNSlat to DMSlat difference (NMD: MNSlat-DMSlat) were also evaluated. Result(s): Nerve conduction studies showed a sensory-motor polyneuropathy with axonal neurogenic pattern, as confirmed by needle EMG. Both MNSamp and NMR were significantly reduced when compared to controls (p < 0.0001), whereas MNSlat and NMD were markedly increased (p = 0.0049). Conclusion(s): We have described COVID patients in the ICU with critical illness neuropathy (CIP). The predominance of CIP as compared to critical illness myopathy (CIM) has implications for the functional recovery and rehabilitation strategies in severe COVID-19. Copyright © 2022
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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.
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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.
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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.
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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: Vaccine-related lymphadenopathy (VRL) is a local reaction like pain and swelling and has been associated with mRNA Pfizer/Moderna COVID-19 vaccines more than other vaccines (1). VRL can lead to false positives on nuclear imaging studies and confound the evaluation of patients during cancer screenings or treatments. The first COVID-19 VRL seen on imaging was reported in January 2021 in two patients undergoing breast mammogram (1). Since then, more cases have been reported in other nuclear imaging studies (1). Here, we report a case of subclinical unilateral VRL by FDG-PET 3 days after the patient received the Moderna COVID-19 booster. CASE PRESENTATION: 73-year-old male smoker returned for a 6 month follow up low dose CT for a 7 mm left upper lobe (LUL) nodule. He received the Moderna COVID-19 booster in the left deltoid the same day. The LUL nodule was found to be slightly larger at 8 mm and ipsilateral axillary nodes were not enlarged (Figure 1). He returned 3 days later for FDG-PET which showed mild uptake in the LUL nodule (SUV 1.8) and hypermetabolic left axillary nodes (Figure 2). COVID booster date/laterality was documented, and the FDG-PET summary included a comment about a possible inflammatory response to the booster. A repeat low dose chest CT in 3 months was recommended. DISCUSSION: After the first reported cases of COVID-19 VRL, recommendations were published to aid providers in evaluating clinical and imaging abnormalities. The Society of Breast Imaging recommended the "wait and watch” approach for unilateral COVID-19 VRL within the preceding 4 weeks only if appropriate in the clinical context;repeat exam in 4-12 weeks and lymph node sampling if VRL persists (1). All other screening exams should be scheduled prior to the first dose of the COVID-19 vaccine or 4-6 weeks after the second dose (1). Radiology experts recommended: 1) imaging screening exam to be scheduled at least 6 weeks after the final vaccination, 2) administer the vaccine in the arm contralateral to any primary or suspected cancer, and 3) record the vaccine date, injection site, and type (1). Months later, they recommended that in patients with a known vaccination history, ipsilateral VRL can be managed conservatively without further imaging (1). CONCLUSIONS: The current recommended COVID-19 Pfizer/Moderna vaccination consists of a two-dose primary series and a booster dose 5 months later. In a recent single-center study in oncologic patients in Israel who had FDG-PET after the Pfizer booster, the duration of unilateral axillary VRL was found to be shorter than the first and second dose (2). Therefore it has been suggested that FDG-PET can be scheduled 2 weeks after the third dose (3). Whether there will be any changes in the guidelines to accommodate this finding remains to be seen. More studies are needed to best inform clinicians because COVID-19 vaccinations will continue for the foreseeable future. Reference #1: Lehman CD, D'Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties. J Am Coll Radiol. 2021;18(6):843-852. doi:10.1016/J.JACR.2021.03.001 Reference #2: Cohen D, Hazut Krauthammer S, Wolf I, Even-Sapir E. A sigh of relief: vaccine-associated hypermetabolic lymphadenopathy following the third COVID-19 vaccine dose is short in duration and uncommonly interferes with the interpretation of [18F]FDG PET-CT studies performed in oncologic patients. Eur J Nucl Med Mol Imaging. 2021. doi:10.1007/S00259-021-05579-7 Reference #3: Thaweerat W. Optimization of FDG PET study after mRNA COVID-19 vaccination to reduce the interference of vaccine-associated hypermetabolic lymphadenopathy. Ann Nucl Med 2021 363. 2022;36(3):327-328. doi:10.1007/S12149-021-01712-6 DISCLOSURES: No relevant relationships by Anh Nguyen No relevant relationships by Perry Nystrom
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Introduction: During the pediatric trials for Coronavirus disease 2019 (COVID-19) vaccine the patient population was limited, likely leading to an inappreciable amount of adverse events. As more of the healthy adolescent male population began receiving the COVID-19 vaccination, cases of myocarditis shortly after became more frequently seen. Case Description: A previously well 15-year-old obese male presented to a pediatric ER with 3 days of left arm pain and 1 day of acute left-sided chest pain three days after receiving his second Pfizer-BioNTech COVID-19 vaccine in his left anterior deltoid area. The patient felt unwell afterwards with myalgias, headache, numbness, tingling, emesis, and 1-day history of fever of 38.8°C. He denied feelings of dizziness, syncope, palpitations, change in pain with position or deep breaths. Motrin and Tums did not seem to provide any relief. He had no history of recent viral illness and no known COVID-19 exposure. Initial evaluation included a normal chest Xray and normal sinus rhythm on EKG. Laboratory work revealed elevated troponin-I at 3.18 ng/mL, elevated Total CK at 399 units/L, CK-MB at 19 ng/mL, and BNP <10 pg/mL. Cardiology was consulted and following a normal echocardiogram, the patient was sent for a stat cardiac MRI. The imaging revealed acute myopericarditis with a small pericardial effusion. Mild patchy delayed subepicardial enhancement was also noted in the mid cavity and basal posterolateral wall (suggestive of postinflammatory scarring related to localized myocarditis.) During this time, CK-MB and Troponin-I continued to trend upwards. The patient was then started on standard treatment with Ibuprofen 800 mg Q6H and pantoprazole for gastric protection. His CK-MB peaked at 174 and Troponin-I at 26 which both subsequently trended downwards and normalized prior to discharge. Discussion: Patients who present with chest pain require a broad differential to encompass other possible etiologies including Coxsackie virus, Echovirus, Mycoplasma, EBV, and even Syphilis. Infectious diseases also followed along with the patient throughout his hospital course. All work-up for other potential causes remained negative. 1 week after presentation, his cardiac markers returned to baseline normal values. Conclusion: The study included close to 3,000 adolescents with only 754 ranging in the 16-17 age group further emphasizing the limited power of the study. Myocarditis and pericarditis are known, however rare, side effect of vaccinations and is seen more commonly in males. As the time period between receiving the COVID-19 vaccination and presenting with cardiac symptoms is short it is crucial to provide rapid care and adequate treatment.
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CASE: A 23-year-old female presented to resident clinic for 7 months of right shoulder pain. She received her second COVID-19 mRNA vaccine just prior to onset of pain. She noted vaccine administration was “traumatic” with significant bleeding and bruising. She started noticing pain with overhead activities several days later. She is very active with cardiovascular exercises. She lifts weights but none requiring overhead motions. The pain was worst at the front of the shoulder but radiated to the lateral aspect. She had not tried, ice, heat, medications or physical therapy. Because of her injury, she was hesitant to receive her COVID-19 booster. BMI was low at 16.65. Exam showed thin build and overall low muscle bulk. Right shoulder showed no signs of muscle atrophy. There was tenderness of subacromial and coracoid areas. No pain along biceps tendon or AC joint. She had full ROM with shoulder abduction, internal and external rotation. She had full strength of supraspinatus, infraspinatus, teres minor, and subscapularis muscles. She noted pain with abduction, internal rotation and lift-off maneuver. Her Hawkins and Neer's maneuvers were positive. No pain with Yergason's and Speed's maneuvers. The patient was diagnosed with right shoulder subacromial bursitis and impingement syndrome. IMPACT/DISCUSSION: Mild shoulder pain is expected after vaccine administration and typically resolves in days. However, SIRVA is an increasingly recognized complication of improper vaccine administration particularly in the occupational setting. SIRVA results from vaccine being delivered inadvertently within the subdeltoid bursa or joint space. It is thought to result from an immune mediated reaction to the vaccine components as injury tends to be greater than expected from a needle injury. We were able to find 5 cases of reported SIRVA related to the COVID vaccine. All included some form of subacromial, subdeltoid, or subcoracoid bursitis. One case noted a supraspinatus tear. Ultrasound has demonstrated the subacromial bursa can extend distal to the acromion by up to 6 cm, so administration to bursa is possible in the superior deltoid. Appropriate injection technique can reduce the risk of injury;administrators should use landmarks of the acromion and distal insertion point of deltoid mid-humerus. Proper needle length is important. It has been suggested a smaller deltoid fat pat and smaller deltoid muscle bulk are risk factors for SIRVA. Women tend to have a higher incidence. CONCLUSION: We presented the case of a slender female who developed shoulder bursitis and impingement following administration of COVID-19 mRNA vaccine. She was referred to PT for rotator cuff strengthening, instructed to refrain from aggravating activities, and provided NSAIDs for pain relief. She reports pain relief. Another option for a more severe case would be a subacromial bursa steroid injection. It is important for providers to be aware of this pathology to provide appropriate treatment and decrease vaccine hesitancy.
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CASE: A 62-year-old woman presented with 4 months of sharp progressive left shoulder pain, radiating down her arm with associated weakness, numbness and tingling most pronounced at the 4th and 5th digit. Her symptoms began within hours of receiving the influenza vaccine to her left shoulder. She denied prior left shoulder or neck pain, headaches, changes in vision, other neurologic symptoms, or trauma. Exam: Left upper extremity without skin changes or deformity, normal muscle bulk, tone and DTRs, lateral upper arm tenderness to light and deep palpation, reduced sensation to light touch at the 4th and 5th left digit with loss of two-point discrimination, reduced active and passive ROM of the glenohumeral joint to flexion/extension/abduction, and restricted internal and external rotation. Cervical x-rays showed spondylosis at C5-6, C5-6 neural foramen narrowing. Normal left shoulder x-ray. Left shoulder MRI showed high grade bursal surface, full-thickness tear of the distal supraspinatus tendon at its insertion, mild subscapularis tendinosis, and small subacromial subdeltoid bursitis. She was treated with a topical NSAIDs, tramadol and cyclobenzaprine as needed and referred to physiotherapy and PM&R. Despite maximum therapy, there was only marginal improvement of left shoulder pain and function at 9 months, she is still unable to perform her ADLs or return to work, and currently receiving home care through her daughter as a caregiver. IMPACT/DISCUSSION: The MRI findings and the temporal relationship between vaccine administration and onset of symptoms, suggest Shoulder Injury Related to Vaccine Administration (SIRVA) as the most likely diagnosis. SIRVA is defined as shoulder pain with limited ROM that commences within 48 hours after vaccine receipt in individuals without prior history of pain, inflammation, or dysfunction of the affected shoulder. SIRVA occurs when a vaccine is delivered into the sub-deltoid bursa or joint space, leading to a robust inflammatory response. The single most important factor in SIRVA diagnosis is the temporal association between vaccine administration and symptom onset. Commonly reported symptoms include shoulder pain, decreased limb mobility, numbness/tingling and muscle tightness. SIRVA complications include bursitis, tendonitis, rotator cuff tear, and adhesive capsulitis. Approximately 65% of patients with SIRVA will have pain lasting more than 3 months. SIRVA is challenging to treat, but there has been some success with early corticosteroid injection within 5 days of symptom onset. Given the current increase in vaccine administration with COVID-19, this case highlights SIRVA as a diagnostic consideration for patients who present with shoulder pain post-vaccination. CONCLUSION: SIRVA should be considered in any patient with new-onset shoulder pain that began within 48 hours of vaccine administration. SIRVA is a post-vaccination complication resulting in shoulder injury that can be prevented with proper vaccine administration technique.
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CASE: A 60-year-old woman with past medical history including hypertension, nephrolithiasis, and Covid-19 4 months prior presented to the emergency department with 3 days of substernal chest pain radiating toward the back and shoulders 6 days after receiving her second dose of the BNT162b2 mRNA Covid-19 vaccine (Pfizer/BioNTech) in her left deltoid. The patient tested negative for Covid-19 and denied shortness of breath, cough, fever, or dyspnea on exertion. Her ECG was notable for more pronounced t-wave inversions in III and aVF, but further cardiac workup was unremarkable, and she was discharged the next day. The patient re-presented to care 6 days later with left arm pain, erythema, edema, and warmth. Her left bicep circumference was 31cm versus 28cm on the right. Upper extremity duplex ultrasound (US) was remarkable for deep venous thrombosis (DVT) of the left internal jugular, subclavian, axillary, and basilic veins. MRI angiogram was confirmatory. Other than her occupation as a hairdresser, the patient did not have known risk factors for DVT: no personal or family history of thromboembolism, no tobacco use, took no prescription medications, and had received all ageappropriate cancer screening. Her thrombophilia workup was negative. The patient was discharged on apixaban. Eleven days later, a venogram showed persistent clot burden in the left axillary, mid-subclavian, and brachiocephalic veins. Thrombectomy, overnight tPA infusion, and left subclavian vein stenting were performed and the patient was discharged on daily apixaban and aspirin. IMPACT/DISCUSSION: As of December 10th, 2021, the vaccine adverse event reporting system yielded 464 reports of “thrombosis” after the Pfizer/ BioNTech vaccine in individuals with no reported current illness, 32 of which occurred in the upper extremity. To our knowledge, our patient represents the first report of upper extremity deep venous thrombosis (UEDVT) shortly after receipt of the Pfizer vaccine in an otherwise healthy person. UEDVT is relatively rare: it occurs in about 0.4 to 1 per 10,000 people per year and less than 20% of incidents are idiopathic. Given the scarcity of potential causes, our case may simply reflect expected background incidence. Nevertheless, the literature includes multiple case reports of DVT after mRNA Covid-19 vaccination, including cases of lower extremity DVT and DVT with pulmonary embolism (PE) after the Pfizer vaccine, and cases of lower extremity DVT, PE, and UEDVT after the mRNA-1273 (Moderna) vaccine. Given the similar mechanism of action between the Moderna and Pfizer vaccines, it is possible that the same pathophysiology underlies the reports of DVT in these vaccine recipients. CONCLUSION: Upper extremity deep venous thrombosis after Covid-19 mRNA vaccination should remain on the differential as clinicians assess chest and arm pain following vaccination. There is a possible association between the BNT162b2 mRNA Covid-19 vaccine and upper extremity deep venous thrombosis that requires further research.
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BACKGROUND: The mRNA COVID vaccines are only licensed for intramuscular injection but it is unclear whether successful intramuscular administration is required for immunogenicity. METHODS: In this observational study, eligible adults receiving their first ComirnatyTM/BNT162b2 dose had their skin to deltoid muscle distance (SDMD) measured by ultrasound. The relationship between SDMD and height, weight, body mass index, and arm circumference was assessed. Three needle length groups were identified: 'clearly sufficient' (needle exceeding SDMD by >5 mm), 'probably sufficient' (needle exceeding SDMD by ≤ 5 mm), and 'insufficient' (needle length ≤ SDMD). Baseline and follow-up finger prick blood samples were collected and the primary outcome variable was mean spike antibody levels in the three needle length groups. RESULTS: Participants (n = 402) had a mean age of 34.7 years, BMI 29.1 kg/m2, arm circumference 37.5 cm, and SDMD 13.3 mm. The SDMD was >25 mm in 23/402 (5.7%) and >20 mm in 61/402 (15.2%) participants. Both arm circumference (≥40 cm) and BMI (≥33 kg/m2) were able to identify those with a SDMD of >25 mm, the length of a standard injection needle, with a sensitivity of 100% and specificities of 71.2 and 79.9%, respectively. Of 249/402 (62%) participants with paired blood samples, there was no significant difference in spike antibody titres between needle length groups. The mean (SD) spike BAU/mL was 464.5 (677.1) in 'clearly sufficient needle length' (n = 217) compared with 506.4 (265.1) in 'probably sufficient' (n = 21, p = 0.09), and 489.4 (452.3) in 'insufficient needle length' (n = 11, p = 0.65). CONCLUSIONS: A 25 mm needle length is likely to be inadequate to ensure vaccine deposition within the deltoid muscle in a small proportion of adults. Vaccine-induced spike antibody titres were comparable in those vaccinated with a needle of sufficient versus insufficient length suggesting deltoid muscle deposition may not be required for an adequate antibody response to mRNA vaccines.
Subject(s)
COVID-19 , Vaccines , Adult , Antibodies, Viral , BNT162 Vaccine , COVID-19 Vaccines , Deltoid Muscle , Humans , Immunogenicity, Vaccine , RNA, MessengerABSTRACT
Background-Aim: Vaccination is an established but uncommon cause of unilateral axillary lymphadenopathy. Early clinical experience with coronavirus disease (COVID-19) vaccination suggests that such vaccines cause a significantly higher incidence of lymphadenopathy detected on 18F-FDG PET/CT than other vaccines. Guidelines are needed to properly manage unilateral axillary lymphadenopathy in the era of COVID-19 vaccination and to avoid benign reactive node biopsies. The differential diagnosis for unilateral axillary lymphadenopathy is broad and includes benign and malignant etiologies: among the malignant causes, most cases are due to lymphoma or breast cancer. Methods: Shortly after the initiation of vaccination of frail cancer patients, a significant number of cases of unilateral axillary lymphadenopathy were incidentally detected in asymptomatic cancer patients who underwent 18F-FDG PET/CT for disease diagnosis or follow-up. Results: After deltoid vaccination, significant uptake of 18F-FDG can be observed in the axillary (level 1, 2 and 3), supraclavicular and cervical lymph nodes. The extent of FDG absorption varies with temporal proximity to vaccination, from intense immediately after administration to barely noticeable after a longer period of time (SUVmax range: 2.1-16.2). Also, after vaccination, lymph nodes may show variable morphology on CT, although they are usually normal or show only a slightly thickened cortex with retained fat hilum. In our department, we have added questions regarding the date and laterality of COVID-19 vaccine administration to our intake form prior to all PET/CT exams, to avoid misjudgment in cancer patients. Conclusions: We believe that isolated unilateral axillary lymphadenopathy detected on PET and associated with the ipsilateral vaccine arm is related to the COVID-19 vaccine, if within a few weeks of either dose. As data from clinical trials of the COVID-19 vaccine suggest that the first two FDA-approved vaccines are highly immunogenic, there is a higher percentage of patients who notice both local and systemic reactions than other vaccines. Careful management should avoid unnecessary biopsies of vaccine-related benign reactive lymphadenopathy. Vaccine ipsilateral axillary adenopathy of the arm should be considered as a potential reactive process that nuclear physicians should be familiar with. If a patient has known cancer with laterality, such as breast cancer, most melanomas, sarcoma of the extremities, lung cancer (particularly in the upper lobe), or head and neck cancer, the vaccine should be given in the arm. contralateral to avoid potentially confounding FDG uptake into lymph nodes on the cancer side. However, if active axillary lymph nodes are identified in the ipsilateral vaccinated arm, axillary ultrasound at 4 weeks is recommended.
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Background/Aims Vaccination against coronavirus is a cornerstone in the fight against the COVID-19 pandemic. Although the safety and efficacy of vaccines was established prior to roll out, long-term data and reports of rare adverse reactions remain inadequate. Literature reviews revealed two cases of PMR-like syndrome, left elbow arthritis and a case of rheumatoid arthritis (RA) flare following COVID-19 vaccination. Additionally, a case of new onset RA and case of reactive arthritis was reported with COVID infection. Methods We present four patients with polymyalgia rheumatica (PMR) following COVID-19 vaccination. The clinical details of the four patients are outlined in the table: Ultrasound (US) revealed typical finding of bilateral sub deltoid bursitis and biceps tendonitis in the first patient and there was severe right sub deltoid bursitis with biceps tendonitis in the second patient. None of the patients had features to suggest malignancy, giant cell arteritis, seronegative spondyloarthropathies or connective tissue disease. Results After exclusion of other inflammatory causes of shoulder pain, they were diagnosed with PMR based on clinical judgement and high inflammatory marker at time of presentations, ultrasound findings and significant improvement with prednisolone. Conclusion PMR following COVID-19 vaccination is exceptional and cannot be proven. In these patients post vaccination chronology of events favours this diagnosis. It is known that immunological illness may start after viral infection or vaccination (hapten or immune stimulation). The patients have responded well to the prednisolone similar to typical PMR cases. We need further studies to look at possible link between COVID-19 vaccination and PMR.
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PURPOSE: Reactive FDG uptake in the axillary lymph nodes (ALN) and deltoid muscle (DM) after COVID-19 mRNA vaccination has been recognized, although the actual situation in the Japanese population remains unknown. To determine the incidence of reactive FDG uptake and its contributing factors, we retrospectively studied a cohort of subjects who were vaccinated at our hospital. METHODS: Whole-body FDG-PET/CT examinations performed in 237 subjects out of 240 subjects with a definite history of COVID-19 vaccination (BNT162b2; BioNTech-Pfizer) were analyzed. Positivity and SUVmax of FDG uptake in the ALN and DM ipsilateral to vaccination, various subject characteristics, and the grade of the pathological FDG-PET/CT findings were evaluated using a multivariate analysis. RESULTS: FDG uptake in the ALN and DM ipsilateral to vaccination was seen in about 60% of the subjects even soon (0-4 days) after the first vaccination, with percentages reaching 87.5% and 75.0%, respectively, after the second vaccination. DM uptake had almost disappeared at around 2 weeks, while ALN uptake persisted for 3 weeks or longer. A multivariate analysis showed that a short duration since vaccination, a younger age, a female sex, and a low FDG-PET/CT grade (minimal pathological FDG uptake) contributed significantly to positive ALN uptake, while a short duration since vaccination and a female sex were the only significant contributors to positive DM uptake. This study is the first to identify factors contributing to positive FDG uptake in ALN and DM after COVID-19 vaccination. CONCLUSION: A high incidence of FDG uptake in ALN and DM was observed after vaccination. ALN uptake seemed to be associated with a younger age, a female sex, and minimal pathological FDG uptake. After vaccination, an acute inflammatory reaction in DM followed by immune reaction in ALN linked to humoral immunity may be speculated.