Case description
We represent the case of a 50-year-old right-handed male patient,
admitted to the neurology department of the military hospital of
Tunis-Tunisia. He has no medical history of chronic diseases or
medication use. He had a mild covid-19 infection confirmed by RT-PCR on
April 2021. He had a complete immunization schedule with no history of
vaccine reaction. He received the first dose of Covid-19 BNT162b2 mRNA
vaccine on the 8th August 2021 followed by the second
dose on the 4th December 2021, both in his right
deltoid muscle. There was no recent trauma, surgery or infectious
disease. Fifteen days after the second dose of the vaccine, he presented
with pain on the injection site, resistant to pain relievers, radiating
to the right shoulder and the neck. Two weeks later, he presented
numbness, heaviness and muscle weakness of the upper right limb. There
were no sensory disturbances or other symptoms. General physical
examination was normal. Neurological examination revealed hypoesthesia
and monoparesis of the right upper limb with muscle weakness in shoulder
abduction and extension and right deltoid amyotrophy. No motor deficits
were found in other parts of the body. All deep tendon reflexes were
normoactive and symmetrical. Superficial and deep sensation was normal.
His laboratory results were all normal, as well as the lumbar puncture
results. Electroneuromyography (ENMG) performed 30 days from symptoms’
onset showed signs of brachial plexus neuritis (neurogenic tracing of
the right deltoid muscle). Computed tomography (CT)-scan imaging of the
brain was normal. Magnetic resonance imaging (MRI) of the right
shoulder, performed two weeks after symptoms’ onset, revealed no
abnormal results.
Considering all these findings the patient was diagnosed with subacute
PTS post-Covid-19 BNT162b2mRNA vaccine. He was treated with
corticosteroids grade 2 and analgesics with initiation of physical
rehabilitation. During the follow-up period, the patient’s medical
condition improved; with a partial recovery in motor functions.