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.