key: cord-0856705-ozgqki2c authors: Manea, Maria Mirabela; Dragoș, Dorin; Enache, Iulia; Sirbu, Adrian George; Tuta, Sorin title: Multiple cranial nerve palsies following COVID‐19 vaccination—Case report date: 2021-11-02 journal: Acta Neurol Scand DOI: 10.1111/ane.13548 sha: 231fd696ae83533523c08555af3e7ad467495dda doc_id: 856705 cord_uid: ozgqki2c BACKGROUND: The novel COVID‐19 vaccines have side effects that require efficient and close monitoring. AIMS OF THE STUDY: To examine whether the Pfizer‐BioNTech vaccine is associated with multiple cranial neuropathy. METHODS: We report the case of a 29‐year‐old male patient with no notable history who presented with left oculomotor, abducens, trigeminal and facial palsies 6 days after receiving the first dose of the Pfizer‐BioNTech COVID‐19 vaccine. RESULTS: Gadolinium‐enhanced MRI of the brain revealed enhancement in the left facial, trigeminal and oculomotor nerves, which persisted upon repeated examination. The cerebrospinal fluid analysis showed no sign of inflammation, both initially and after 1 month from the start of the patient's symptoms. Other causes were excluded by laboratory tests. The patient received high doses of corticosteroids, with improvement of symptoms. CONCLUSIONS: In our case, the most probable etiology of the patient's multiple cranial neuropathy is the Pfizer‐BioNTech vaccine, which highlights the need for prolonged surveillance of COVID‐19 vaccine neurological complications. meningeal irritation or increased intracranial pressure. Gadoliniumenhanced MRI of the brain revealed only diffuse gadolinium enhancement in the intracanalicular and labyrinthic portion of the left facial nerve ( Figure 1A ), as well as in the intracisternal course of the left trigeminal ( Figure 1B ) and oculomotor nerve. The MRI did not find any other meningeal or intracerebral involvement, apart from the intracranial nerve contrast. The involvement of multiple cranial nerves made other causes highly probable. Brain MRI excluded tumors, vascular causes or demyelinating diseases. There was no history of toxic exposures and the patient was immunocompetent. The screening for systemic inflammatory and systemic autoimmune diseases, and for granulomatosis were all negative. As for infectious causes, given that tuberculosis is endemic for our country, we have used Ziehl-Neelsen staining to rule out this etiology. Taking into account the CSF aspect on both lumbar punctures, together with the immunocytochemical study, the absence of the specific MRI enhancement, the lack of other signs and symptoms and the patient's response to corticosteroids, with no specific oncologic treatment for lymphomatous and carcinomatous meningitis, these etiologies were excluded. There is a high degree of probability that the cells with basophilic cytoplasm identified upon the first lumbar puncture were simply ependymal cells, a normal occurrence in the CSF. A highly improbable malignant nature of these cells was ruled out by the repeated lumbar puncture followed by detailed histopathological examination. 3 We did not have any reasons to suspect the patient might be suffering from fungal infection. The patient was immunocompetent. Furthermore, upon follow-up it became evident that the patient responded to corticosteroids, which again ruled out a fungal etiology. For these reasons, a fungal culture was not deemed necessary. However, as it is the first case of its kind (multiple cranial neuropathy after SARS-CoV2 vaccination), its inherent and unavoidable limitation is that it comprises a single case. Hence, it is necessary that other similar cases be reported to gain a progressively fuller understanding of the potential for neurological damage of these newly developed vaccines. While the efficacy and safety of these novel vaccines are important, the monitoring period for the appearance of post-vaccinal complications is presently limited to a few months, hence neurological side effects require close observation. None. The authors declare they have no conflicts of interests. All authors contributed equally to this work and should therefore be considered first authors. All authors read and approved the final manuscript. Was in accordance if ethical guidelines. The study was approved by the institutional review board. Written informed consent was obtained from the patient. The participant has consented to the submission of the case report to the journal. The peer review history for this article is available at https://publo ns.com/publo n/10.1111/ane.13548. n/a. Maria Mirabela Manea https://orcid.org/0000-0003-0484-2048 Fda. Vaccines and Related Biological Products Advisory Committee December 10, 2020 Meeting Briefing Document-FDA The CARE guidelines: consensus-based clinical case reporting guideline development Ependymal cells in cerebrospinal fluid: A traumatic occurrence Motor palsies of cranial nerves (excluding VII) after vaccination: reports to the US vaccine adverse event reporting system Sequential contralateral facial nerve palsies following COVID-19 vaccination first and second doses Bell's Palsy after second dose of Pfizer COVID-19 vaccination in a patient with history of recurrent Bell's palsy Acute abducens nerve palsy following COVID-19 vaccination A case of COVID-19 with multiple cranial neuropathies Multiple cranial nerve palsies following COVID-19 vaccination-Case report