Botulinum toxin injections during the COVID-19 epidemic: A retrospective chart review

BACKGROUND AND AIM: Clinical services were severely affected globally during the COVID-19 pandemic. This study aimed to characterize the clinical experience of using botulinum toxin (BTX) injections during the COVID-19 pandemic. Method(s): This is a retrospective chart review of patients who received BTX injections from April 2019 to January 2022. Result(s): A total of 105 patients received an BTX injections, out of which 76 (72.4%) were men. The mean age of the patients was 47.9 +/- 15.1 years. The most common indication for receiving BTX injections was dystonia (n = 79;75.2%), followed by hemifacial spasm (n = 22;21%) and miscellaneous movement disorders (n = 4;3.8%). Focal dystonia (n = 45;57%) was the most frequent form of dystonia, followed by segmental dystonia (n = 24;30%). The percentage of generalized dystonia and hemidystonia was 12% and 1%, respectively. Cervical dystonia (44.4%), blepharospasm (17.8%), and writer's cramp (15.6%) were the most frequent forms of focal dystonia. The miscellaneous group included four patients (3.8%) with trigeminal neuralgia, Holmes tremor, dystonic tics, and hemimasticatory spasm. The mean ages of patients in the dystonia, hemifacial spasm, and the miscellaneous groups were 47.7 +/- 14.9 years, 49.2 +/- 14.0 years, and 44.2 +/- 26.0 years, respectively. The mean BTX dose was 131.6 +/- 104.1 U. The mean BTX doses for the dystonia group, hemifacial spasm, and the miscellaneous group were 158.7 +/- 105.3 U, 40.1 +/- 11.3 U, and 100.0 +/- 70.7 U, respectively. Conclusion(s): Most patients in our cohort had dystonia, followed by hemifacial spasm. Among the patients with dystonia, most had focal dystonia, with cervical dystonia being the most common movement disorder. The data obtained in our study is important to increase awareness of the effectiveness of BTX injections in patients with chronic disorders.Copyright © 2023 Annals of Movement Disorders.

SEVERE HYPONATREMIA AS A MANIFESTATION OF A NEUROLOGIC DISORDER ASSOCIATED WITH THE COVID-19 VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: More reports are indicating a temporal association between Bell's palsy and the mRNA vaccine for coronavirus disease 2019 (COVID-19). Therefore, collecting vaccine history is becoming important in post-marketing surveillance to monitor the safety of vaccines in real-world settings. We report the case of concomitant occurrence of Bell's palsy and glossopharyngeal neuralgia leading to severe symptomatic hyponatremia in a previously healthy patient. CASE PRESENTATION: A 60 year-old-female without significant medical history presented to the hospital with odynophagia, and generalized weakness for two weeks. She decreased her oral intake due to stabbing pain in the back of her throat triggered by swallowing. She reported hyperacusis and frequent shooting pain in the left cheek managed with non-steroidal anti-inflammatory drugs. The symptoms occurred several days after the first dose of the mRNA vaccine for COVID-19. She denied previous COVID-19 infection and herpes zoster. Examination revealed dry mucosa, left facial muscle weakness, inability to raise the left eyebrow or lift the labial commissure, effacement of the nasolabial fold, and left-sided frontal wrinkles. Laboratory investigation revealed sodium of 110. Computerized Tomography of the brain revealed negative findings for intracranial abnormalities. Severe symptomatic hyponatremia was managed with hypertonic saline. The neurologist made the diagnosis of Bell's palsy and glossopharyngeal trigeminal neuralgia leading to poor oral intake. We initiated acyclovir, prednisone, and gabapentin. The patient recovered from hyponatremia and experienced improvement of neurological symptoms with initiated medications. DISCUSSION: High morbidity and mortality of patients with COVID-19 accelerated the development and production of the vaccines. During the pandemic, mRNA COVID-19 vaccines reduced asymptomatic and prevented severe symptomatic COVID-19 infection and its complications. Although the benefits and protective effects of the COVID-19 vaccines outweighed the risks associated with them, we have reports of associations between vaccines and certain disorders such as Bell's palsy. Glossopharyngeal neuralgia is defined as sudden severe brief pain in the distribution of the glossopharyngeal nerve. It can be described as transient stabbing pain experienced in the ear, tonsillar fossa, and base of the tongue. Unusual presentation is fear to eat as this can be a precipitating cause of the pain. It overlaps with trigeminal neuralgia and can create a diagnostic dilemma. CONCLUSIONS: In summary, it is unknown what causal relationship exists between the mRNA COVID-19 vaccine and neurological diseases such as Bell's palsy and glossopharyngeal neuralgia. Glossopharyngeal neuralgia is frequently overlooked as a diagnosis. This is a unique case of concomitant glossopharyngeal neuralgia and Bell's palsy that is coincidental with a history of COVID-19 vaccine. Reference #1: El Sahly HM, Baden LR, Essink B, et al. Efficacy of the mRNA-1273 SARS-CoV-2 Vaccine at Completion of Blinded Phase. New England Journal of Medicine. 2021;385(19):1774-1785. doi:10.1056/NEJMoa2113017 Reference #2: Singh PM, Kaur M, Trikha A. An uncommonly common: Is glossopharyngeal neuralgia. Ann Indian Acad Neurol. 2013;16(1):1-8. doi:10.4103/0972-2327.107662 Reference #3: Cellina M, D'Arrigo A, Floridi C, Oliva G, Carrafiello G. Left Bell's palsy following the first dose of mRNA-1273 SARS-CoV-2 vaccine: A case report. Clin Imaging. 2022;82:1-4. doi:10.1016/j.clinimag.2021.10.010 DISCLOSURES: No relevant relationships by Nemanja Draguljevic No relevant relationships by Katherine Hodgin No relevant relationships by Kristina Menchaca No relevant relationships by Catherine Ostos Perez

COVID-19 vaccine-associated trigeminal neuralgia: Analysis of the WHO safety database

Introduction: To contain the COVID-19 pandemic, vaccination is deemed as a promising approach. A French pharmacovigilance survey identified five cases of trigeminal neuralgia (TN) following vaccination with AZD1222 (Vaxzevria®, AstraZeneca) [1]. Furthermore, a case report mentioned such an adverse reaction with tozinameran (Comirnaty®, Pfizer-BioNTech) [2]. TN is characterized by recurrent, unilateral, and brief electric shock-like pain in one or more trigeminal divisions [3]. TN is triggered by innocuous stimuli. We aimed to investigate the potential signal of TN related to COVID-19 vaccines. Material and methods: We queried VigiBase® (World Health Organization pharmacovigilance database) for all reports of "Trigeminal Neuralgia" (MedDRA Preferred Term) associated with "COVID-19 vaccine" (Active Ingredient), from 1967 to December 29, 2021 [4]. Disproportionality analysis relied on the Reporting Odds Ratio (ROR) with its 95% Confidence Interval (CI), and the Information Component (IC). A positive IC025 is statistically needed to confirm the detection of a signal [5]. Results: In VigiBase®, we gathered 1,283 cases of COVID-19 vaccine-related TN. Most reports involved women (998, 77.8%), with a median age of 52 years, and 510 (39.8%) were deemed serious. Tozinameran was mostly reported with 782 (61.0%) cases, followed by AZD1222 (264, 20.6%), elasomeran (Spikevax® Moderna, 185, 14.4%), and JNJ-78436735 (Janssen® Johnson & Johnson, 37, 2.9%). The association of COVID-19 vaccines and TN revealed significant disproportionality, with an IC025>0 and a ROR of 3.1 (95% CI 2.9-3.3). Tozinameran showed the strongest ROR (3.6;95% CI 3.3-3.8), followed by AZD1222 (2.3;95% CI 2.0-2.6), elasomeran (2.0;95% CI 1.7-2.3), and JNJ-78436735 (1.8 95% CI 1.3-2.5), each with IC025>0. Discussion/Conclusion: COVID-19 vaccines and TN showed relevant disproportionality. Albeit this reaction may rely on an immune-mediated inflammation, causality can only remain hypothetical in this pharmacovigilance study. Nonetheless, this finding may suggest a signal, strengthening reports mentioned by literature and French pharmacovigilance. A TN occurring after COVID-19 vaccination should alert the clinician.

Neuromuscular Manifestations of COVID-19

Objective: Determine neuromuscular manifestation incidence in COVID-19 patients from the longitudinal electronic health record database Optum. Background: Both central and peripheral nervous system (PNS) manifestations of COVID-19 have been reported. A Chinese retrospective case series, on 214 hospitalized COVID-19 patients, found that 8.9% presented with peripheral nerve disease and 7% had muscular injuries. Other studies looking at the prevalence of PNS manifestations are limited and have significantly lower numbers. Design/Methods: The COVID-19 data is sourced from more than 700 hospitals and 7000 clinics in the US. Patients with numerous neuromuscular diagnoses were identified based on ICD-10 coding. Examples include carpal tunnel syndrome, radial nerve lesion, sciatic nerve lesion, myasthenia gravis, acute transverse myelitis, Bell's palsy, and trigeminal neuralgia. Results: We reviewed a total of 598,847 patients with positive COVID-19 PCR and/or diagnosis coding. Neuromuscular complications must have been within 45 days of diagnosis to be included. Incidence of similar neuromuscular complaints was evaluated in 3,001,153 controls without COVID-19. Critical illness neuropathy was found in 35,782 COVID-positive patients and 6,281 of those without. Retrospective study limitations include temporal relationship to COVID-19 does not necessarily indicate causality and inability to confirm the coding by record review or EMG/NCS. Conclusions: Incidence of neuromuscular disorders is generally lower or equivalent in COVID19 patients than in the general population, except for critical illness neuropathy and myopathy. This finding may be explained by more COVID-19 patients being in the intensive care unit and bedbound for longer periods. It is worth noting that a small case series of COVID-related critical illness neuropathy and myopathy patients showed no histopathological or clinical differences compared to non-COVID patients. To our knowledge, this report includes an analysis of neuromuscular manifestations in one of the largest cohorts of COVID-19 patients. This can assist with risk-benefit discussions regarding treatment initiation, etiology of diagnoses, and counseling for COVID-19 questions.