key: cord-0698542-9ykh769b authors: Queler, Sophie C.; Towbin, Alex J.; Milani, Carlo; Whang, Jeremy; Sneag, Darryl B. title: Parsonage-Turner Syndrome Following COVID-19 Vaccination: MR Neurography date: 2021-08-17 journal: Radiology DOI: 10.1148/radiol.2021211374 sha: c45b5ef956b6991abfe9d96cf6db9067cc9bc11b doc_id: 698542 cord_uid: 9ykh769b Vaccination is one of the several known triggers of Parsonage-Turner syndrome (PTS). This report describes 2 individuals with clinical presentations of PTS whose symptoms began 13 hours and 18 days following receipt of the Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273 COVID-19 vaccine, respectively. The diagnosis of PTS was confirmed using both electrodiagnostic testing and 3 Tesla magnetic resonance (MR) neurography. While research is needed to understand the association between PTS and COVID-19 vaccination, MR neurography may be used to confirm suspected cases of PTS as COVID-19 vaccines continue to be distributed worldwide. Abstract: Vaccination is one of the several known triggers of Parsonage-Turner syndrome (PTS). This report describes 2 individuals with clinical presentations of PTS whose symptoms began 13 hours and 18 days following receipt of the Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273 COVID-19 vaccine, respectively. The diagnosis of PTS was confirmed using both electrodiagnostic testing and 3 Tesla magnetic resonance (MR) neurography. While research is needed to understand the association between PTS and COVID-19 vaccination, MR neurography may be used to confirm suspected cases of PTS as COVID-19 vaccines continue to be distributed worldwide. Parsonage-Turner syndrome (PTS; neuralgic amyotrophy) is a rare peripheral neuropathy typically characterized by sudden onset, severe upper arm pain followed by muscle weakness. 1 Muscle weakness can be debilitating and up to two-thirds of patients experience long-term functional deficits. 1 Vaccination precedes PTS onset in an estimated 4.3-15.5% of cases. 1 but these provided only mild relief. Laboratory tests performed in the emergency room, including C-reactive protein, erythrocyte sedimentation rate, complete blood count and comprehensive metabolic panels were all normal. His past medical history was significant for Lyme disease manifesting with an erythema migrans lesion, fatigue and myalgias 2 months prior and treated with doxycycline, although Lyme IgM and IgG antibodies also obtained in the emergency room were negative. The patient was discharged and treated with an oral, 8-day prednisone taper, at the end of which his pain subsided. Electrodiagnostic testing performed 9 days post onset was normal; specifically, no median nerve abnormality was identified on the nerve conduction or electromyography portions of the exam. The patient developed weakness in wrist flexion and forearm pronation the day after electromyography, along with numbness along a 1-inch strip in the middle, volar forearm region. Cervical spine and brachial plexus MRI performed 9 days post onset of initial pain symptoms did not demonstrate any findings to account for the patient's symptoms. (Figure 2A) with accompanying denervation edema pattern of the supraspinatus and infraspinatus muscles (Figure 2B) . The patient was treated 3 weeks post onset with 300 mg of gabapentin 3 times a day for pain and began physical therapy 7 weeks after symptom onset. Three months post onset, his range of motion and strength subjectively improved but did not return to baseline levels. Post-vaccination PTS typically ensues within 28 days of immunization and has been reported as early as the same day as vaccination. 2 PTS is most frequently associated with tetanus vaccination, but has also been reported following human papilloma virus, influenza, shingles, and tick-borne encephalitis vaccines. [1] [2] [3] [11] [12] [13] To date, there are 3 published cases describing PTS post COVID-19 vaccination, 4-6 but none include imaging to substantiate the diagnosis. One of these cases involves the ulnar nerve, 4 which is rarely reported in PTS. 1, 14 Another describes painless onset of weakness localized to the upper trunk, 5 rather than more classic, individual nerve involvement. 1, 10, 14 Intrinsic, hourglass-like constrictions of affected nerves or nerve fascicles have been recognized in the acute (≤4 weeks) phase of PTS 10 and to date, they have not been observed in other spontaneous neuropathies. 10 n p r e s s randomized to either vaccine or placebo. In trials for BNT162b2 and mRNA-1273, Bell's Palsy occurred in 4 and 3 vaccinated subjects, respectively, compared to 0 and 1 subjects, respectively, in the placebo groups. [19] [20] A modest increase (29%) in peripheral neuropathies was also seen in the Ad26.COV2.S vaccine cohort (45) compared to placebo (35). 21 In all cases, evidence was insufficient to directly link the vaccines to these occurrences. Recently, however, regulatory agencies in the U.S. and Europe have revised the labels of Johnson & Johnson's Ad26.COV2.S and AstraZeneca's Vaxzevria vaccines, which are both viral-vectored vaccines, to reflect an observed, increased risk of Guillain-Barre syndrome following vaccination. 22 Post-authorization surveillance is therefore needed to monitor for rare adverse events that may have not been observed or observed only sparsely during clinical trials. 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