key: cord-0702064-2ra1x7fi
authors: Matar, Elie; Manser, David; Spies, Judith M.; Worthington, John M.; Parratt, Kaitlyn L.
title: Acute Hemichorea‐Hemiballismus Following COVID‐19 (AZD1222) Vaccination
date: 2021-09-28
journal: Mov Disord
DOI: 10.1002/mds.28796
sha: 2918aefcc9404914a3ec30af672bb16e6be90599
doc_id: 702064
cord_uid: 2ra1x7fi

nan

Following COVID-19 (AZD1222) Vaccination

Achieving immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through vaccination is a key worldwide public health strategy for controlling the coronavirus disease 2019 (COVID-19) pandemic. The ChAdOx1 nCoV-19 (AZD1222; AstraZeneca) vaccine, consisting of an adenoviral vector containing the SARS-CoV-2 spike protein gene, has been shown to be efficacious against COVID-19 with an acceptable safety profile. 1 To date, AZD1222 has been licensed in more than 150 countries worldwide, and monitoring for potential adverse effects of COVID-19 vaccines is ongoing. Although de novo movement disorders have been reported in response to COVID-19 infection, 2 such complications after vaccination have yet to be formally reported (excluding videos on social media platforms 3 ). AZD1222 was licensed in Australia in early 2021 wherein rates of vaccination increased against a background of minimal community transmission of SARS-CoV-2, providing an opportunity to observe clusters of adverse reactions. We report two consecutive, strikingly similar presentations of acute hemichorea/ hemiballismus after AZD1222.

Case 1 (Supporting Information Video S1) is an 88-year-old man who presented 16 days after the first dose of AZD1222 having been awoken by involuntary movements of the left arm, leg, and face that worsened throughout the day. He had a medical history of treated dyslipidemia, hypertension, and gout.

Case 2 (Supporting Information Video S2) is an 84-year-old man who presented 40 days after the first dose of AZD1222 with acute onset of involuntary hyperkinetic movements of the left upper and lower limbs noted initially while watching television, worsening through the evening, and interfering with sleep. He had a history of asthma, allergic aspergillosis, and primary orthostatic hypertension and treated colorectal, esophageal, and prostate carcinomas in remission.

In both cases, there were no other neurological or systemic symptoms. There was no personal or family history of movement disorders. The neurological examination in both cases demonstrated continuous, nonpatterned, small-amplitude movements of the affected arm and leg, with superimposed proximal irregular large-amplitude movements consistent with hemichorea-hemiballismus. Mild parkinsonism affecting the contralateral side was noted in case 1. The remainder of the neurological and systemic examination was unremarkable.

An extensive panel of investigations (Table 1) including magnetic resonance imaging (see Supporting Information) did not reveal an alternative cause. An autoimmune postvaccination reaction was hypothesized, and both patients were given a short course of steroids (three daily doses of 1 g intravenous methylprednisolone), with case 1 demonstrating a prompt and significant resolution within 24 hours of the first dose. Case 2 had partial spontaneous improvement after the first day but had persistent symptoms that resolved after 3 days of corticosteroids.

We describe two cases of acute and reversible hemichoreahemiballismus after AZD1222 vaccination. Based on the steroid-responsiveness of our cases, an inflammatory mechanism was proposed. This is in line with a recent report of a patient with worsening levodopa-induced dyskinesias after receiving the BNT162b2 (Pfizer/BioNTech) mRNA vaccine, 4 and preclinical studies supporting a role of neuroinflammation in levodopa-induced dyskinesia generally. 5 The unilateral symptomatology in our cases is interesting; however, similarly focal presentations in the setting of systemic autoimmune disorders, such as Sydenham's chorea, have been reported. 6 Alternatively, subclinical Parkinsonism affecting the contralateral side (case 1) could also have masked a bilateral process. Extrapolating from the neuropathology of COVID-19-associated neurological dysfunction, 7 we speculate a focal immune-mediated endotheliopathy induced by the spike protein as a mechanism explaining the presentations reported in this letter.

Overall, COVID-19 vaccines have been demonstrated to be safe and effective, and idiosyncratic neurological reactions after vaccination are rare and tend to be monophasic. These cases highlight the need for careful clinical observation to aid pharmacovigilance efforts and the importance of large epidemiological studies to confirm potential neurological postvaccination reactions.

Additional Supporting Information may be found in the online version of this article at the publisher's web-site. 

Author Roles E.M. was responsible for the data collection, conception, and writing of the first draft. D.M. was responsible for the data collection, review, and critique of the manuscript. J.M.S. and J.M.W. contributed to the conception and participated in the review and critique of the manuscript. K.L.P. was responsible for organization, conception, and review and critique of the manuscript. 

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK

De novo movement disorders and COVID-19: exploring the Interface

Helping the public understand adverse events associated with COVID-19 vaccinations: lessons learned from functional neurological disorder

Severe dyskinesia after administration of SARS-CoV2 mRNA vaccine in Parkinson disease

Neuroinflammation: fanning the fire of l-dopa-induced dyskinesia

Restricted unilateral Sydenham's chorea: reversible contralateral striatal hypermetabolism demonstrated on single photon emission computed tomographic scanning

Endothelial cell infection and endotheliitis in COVID-19