Case presentation:
A 60-year-old lady, known to have multiple sclerosis, presented with right-hand weakness a few hours after receiving the 1st dose of COVID-19 vaccine (Pfizer)
Her hand weakness was progressive; she was unable to hold or pick up objects.
She had no other neurological deficits, no numbness or other limb weakness, no visual loss or eye pain, No bladder or bowel dysfunction.
She was diagnosed with multiple sclerosis in 1996, was on interferon, but stopped in 2015.
She was in remission for the past eight years without clinical deterioration or new MRI changes.
On examination, the patient had normal vital signs
The neurological exam was remarkable for decreased handgrip and thumb opposition strength. There was no muscle wasting or reduced sensation. The rest of the neurological examination, cardiovascular, pulmonary, and abdominal examinations were normal.
Labs showed leukopenia and mildly elevated CRP, otherwise normal Hgb, platelets, urea, creatinine, and electrolytes (Table 1).
CT head was done, which showed Ill-defined focal hypodense lesions in the bilateral parietal white matter, likely suggesting chronic demyelinating lesions.
MRI head and MRI spinal cord with contrast were done, which showed old demyelinating lesions with a newly described lesion measuring approximately 10 x 9 mm size with restricted diffusion) Figure 1 and 2, and enhancement on contrast study suggestive of activity figure 3.
She received a 3-days course of intravenous methylprednisolone 500 mg/ day. Her power improved through her hospital stay and was discharged home.
Discussion:COVID 19 has resulted in a lot of morbidity and mortality all over the world. As a new disease entity, the evidence on the pathogeneses, potential complications, and treatment are growing daily. 7) COVID 19 vaccines were recently produced and given to the population after an emergency approval from the FDA. New technology has been introduced, which is mRNA-based vaccines. 8) They are associated with many variable side effects, ranging from simple ones to potentially more severe or life-threatening ones. They were described to cause myalgias, fever, general fatigue. But not uncommonly, they were seen to cause covid infection, with potential ARDS and death. 9) Vaccines, in general, have been linked to various side effects, such as the development of GBS and CNS Side effects. One other aspect that should be considered is that vaccines can cause several side effects for patients with autoimmune conditions. For example, the flu vaccine has been linked before to causing a flare of multiple sclerosis. (10) COVID 19 vaccines are continuously being studied, and more side effects will be identified as more and more people receive the Vaccine. (11) They have been found to cause several CNS side effects, such as weakness, numbness, ataxia, and more drastic presentations such as encephalomyelitis and acute demyelination syndrome with GBS. Moreover, it was described in recently published studies that MS flare could be associated with COVID vaccines. The frequency is not precise yet, and more and more studies are needed. (12) Additionally, there is some evidence to suggest a temporal relationship between MS flare and the receipt of various vaccines, including those for rabies, hepatitis (Hep) A and B, polio, and influenza [13]. Such cases are infrequent, and the establishment of causality in most of these cases has proved controversial.
Multiple sclerosis is an autoimmune disease with unclear etiology. The diagnosis is usually made as a combination of clinical and radiological findings. Treatment is done with pulse steroids; high-dose IV steroids. (14) The risk of relapses usually decreases with age and people who had stable disease (include more on the relapse). Moreover, it is known that MS flares decrease with age, and it is unlikely in patients who have had stable diseases for many years. (15)
Our patient was diagnosed with MS more than 20 years ago and had stable disease with no relapses. The most recent relapse was 18 years ago, and she was kept off medications. Unfortunately, on the same day that she received the COVID vaccine, she had a recurrence of symptoms. MRI Was done, and it revealed an active lesion in the left periventricular region. Her symptoms improved significantly after she started pulse steroids with a resolution of her symptoms upon follow-up.