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.

Guillian-Barre Syndrome Post Covid-19 Vaccination

Case Report: This is a 50-year-old man that presented to the ED complaining of generalized weakness and acute loss of ability to ambulate which has been progressing for a month. Patient began having left arm and leg weakness, which started in his fingertips of his left upper extremity and soon moved proximally to upper left arm. Symptoms then progressed to right upper and lower arms. Symptoms further continued to progress making the patient bedridden. On presentation, CT head showed a C1/C2 subluxation possibly chronic without significant focal soft tissue swelling. CT cervical spine showed C1-C2 subluxation, possibly chronic. MRI of brain was unremarkable pre and postcontrast without focal findings or abnormal enhancement and showed redemonstration of the C1-C2 subluxation as described on CT scan. MRI of cervical spine showed at the level of C1 there is spinal canal stenosis. However, there is no direct pressure upon the cord/medulla. Upon evaluation, patient had significant motor weakness and required maximal assistance for movement. Patient was moreover noted to have flaccidity of muscles associated with weakness with no bulbar weakness. Patient had no difficulty in breathing or with speech. A lumbar tap was performed which showed elevated protein, WBC, and glucose. Upon further investigation, patient stated that he received his (3rd dose) of the Moderna Vaccine for Covid-19 about a month before the onset of symptoms and felt fine. Two weeks later, he began experiencing subjective fevers, diarrhea, abdominal pain, and fatigue that lasted for a week and then self-resolved. Approximately another two weeks later is when patient began noticing his neurological symptoms. Possible Guillain-Barre Syndrome post Campylobacter Jejuni (C. Jejuni) infection vs. post Covid-19 vaccine induced GBS was suspected at this point and patient was started on Intravenous Immunoglobulin (IVIG). Stool cultures were collected for C.Jejuni which came back negative. Gastrointestinal Pathogen Panel PCR Feces also came back negative. Patient was discharged to a rehab center and planned to receive another round of IVIG for 5 days. Conclusion(s): Guillain Barre Syndrome (GBS) is a rare immune-mediated neurological disorder affecting peripheral nerves and nerve roots, that presents as acute sensorimotor neuropathy starting with distal paresthesia that progresses to weakness of legs and arms, noteably, flaccid paralysis. GBS has several triggers namely infections such as C. jejuni, cytomegalovirus, M. pneumoniae, Epstien-Barr virus and Zika virus. There has also been several case reports and studies that have shown increased incidence of GBS vaccines such as influenza vaccine. Furthermore, there has been several studies that have linked GBS to COVID-19 vaccine. With COVID-19 cases continuing to persist, and increasing advocacy for vaccination against the disease, GBS should be considered as very rare but possible side effect of the vaccine.

Oro-Facial manifestations of COVID-19 infection in a sample of Iraqi people

Public health officials are gravely concerned about the harm that viral illnesses continue to pose to humanity, various viral outbreaks, including the Middle East Respiratory Syndrome Corona-Virus (MERS-CoV), H1N1 influenza, the severe acute respiratory syndrome coronavirus (SARS-CoV-2) and SARS CoV-2 or COVID-19 that struck the globe in December 2019. A wide range of COVID-19 oral symptoms, such as ulceration, blisters, enanthems, hemorrhagic sores and cheilitis. Aim(s): to investigate the prevalence of oral symptoms amongst COVID-19 patients due to the disease's aggressive nature and diverse symptomatology and to assess the impact of oral health conditions on COVID-19 disease severity in a sample of Iraqi people. Material(s) and Method(s): a cross-sectional study was conducted on (200) patients in total, (81) male and (119) female, who were identified as SARS-COV2 patients. Result(s): COVID confirmed patients were involved in the present study with mean age (36.69+/-17.22) years & age range of (16-78) years. at least one of the oral manifestations was present in 72.5% of the patients, while about 27.5% did not experience any oro-facial symptoms. The oral symptom with the highest prevalence was dry mouth 50% followed by gustatory dysfunction 37% then burning mouth sensation 22.5% after that the oral pain 17%;myofacial pain 15.5 %;stomatitis\mucositis 14.5%;the prevalence of aphthous lesions, fissural cheilitis and tongue depapillation were at the same percentage which was 9.5%;then candidiasis 7.5%;the least prevalent oral symptoms was gingival bleeding at percentage of 2.5%. Conclusion(s): COVID-19 has a noticeable effect on oral cavity, there was a correlations between some general and orofacial manifestations of COVID-19.Copyright © 2023, Codon Publications. All rights reserved.

Grisel's Syndrome and Covid Infection in Children: Report of Two Cases

Introduction: Grisel syndrome is a rare condition of rotator subluxation of the atlantoaxial joint that is not associated with trauma or bone lesion. It is characterized by acute and painful torticollis with fever, which is a consequence of complicated pharyngitis and tonsillitis. Material(s) and Method(s): We present two girls, aged 5 and 6 years, who developed atlantoaxial subluxation and torticollis during or after infection with COVID. As part of this, a pararetropharyngeal abscess developed. Based on clinical signs, radiological findings, and the course of the disease, Grisel's syndrome was confirmed. One patient had an asymptomatic COVID infection, before the development of Grisel's syndrome, and the other patient had an active COVID infection, during which Grisel's syndrome developed. Result(s): Both patients were treated multidisciplinary: conservatively with antibiotics and surgically, and then physical therapy was introduced along with the Philadelphia orthosis. Both were in constant clinical improvement and did not develop further complications. According to the literature, the Fielding-Hawkins classification describes 4 degrees of this subluxation, and our patients had type 3 at the time of diagnosis. Conclusion(s): Grisel's syndrome is a rare condition and should be suspected in children with painful torticollis after infections or head and neck surgery. The importance of this syndrome for maxillofacial surgeons is in early differential diagnosis, to avoid early and late consequences of undiagnosed pararetropharyngeal abscess and atlantoaxial subluxation and compression of vital structures. Grisel's syndrome needs to be treated multidisciplinary and immediately.

Remote Upper Limb group intervention post stroke increases intensity and improves wellbeing

Introduction: Increasing the intensity for upper limb rehabilitation post stroke has been emphasized in research and evidence. COVID-19 limitations with face-to-face therapy, have increased the opportunities to consider remote rehabilitation to provide the intensity needed. The aim of the group is to provide a goal based, structured exercise programme for upper limb among stroke survivors. Method(s): The Remote Upper Limb group has started to be part of the service that CST provides since 2020. The group consists of a warm-up, exercises using activity station, and functional exercises where we use items available at patients' home. The exercises are designed to address these areas: shoulder, elbow, forearm, wrist fingers, activities, and functional activities. The group also provides education session for the upper limb including pain, sensory deficits, specificity, subluxation, oedema and, learned non-use. Standardised outcome measures are taken at the beginning and the end of the group and used to measure progression and improvement. Result(s): The remote upper limb group intervention has emerged as a promising intervention to increase intensity and achieve patients' outcomes. The outcome measures have shown clinically significant improvement in patients' physical outcomes and their wellbeing. The patients report opportunities for peer support as their main benefit. Conclusion(s): The remote upper limb group is an intervention that increases patients' intensity and improves well-being in a costly effective way for both therapists and stroke survivors.