Sex: F
Vaccine: COVID19
Symptoms: Electromyogram, Neuralgic amyotrophy, Physical examination, X-ray
Clinical narrative: Parsonage-Turner Syndrome; This is a literature report. A 66-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19  VACCINE, Solution for injection; lot number and expiration date: not reported), via an unspecified route of administration, on right deltoid, on an unspecified date, as DOSE 2, SINGLE for covid-19 immunization. The patient was presented to the orthopaedic surgery clinic with persistent right shoulder dysfunction 1 month after receiving the second dose of the SARS-CoV-2 BNT162b2 in her right deltoid 3 fingerbreadths below the acromion. She reported initial shoulder pain and weakness after vaccination, which worsened and led her to visit the emergency department 2 weeks after the second dose. She noted soreness in her entire right arm down to her hand, particularly in the small fingers, including slight numbness in her fourth and fifth finger. Her physical examination in the emergency department consisted of rightmedialwinging of the scapula and weakness and pain with forward elevation of the shoulder. Xray performed of the shoulder showed no bony abnormalities. At her clinic visit 1 month after second dose, her pain had resolved, but scapular winging and decreased range of motion compared with contralateral persisted. At rest, her shoulders appeared normal. shows medial scapular winging of the right shoulder with forward elevation of the extremities and scapular protraction. Physical therapy was prescribed to focus on scapular stabilizing exercises and parascapular muscle strengthening. The patient was seen again for follow-up 2 months after second vaccine, during which she reported she had continued winging and dysfunction, but was back to her normal sports activities. Her (unspecified country) Shoulder and Elbow Surgeons score, which was used to indicate her difficulty of performing tasks of everyday living, showed only difficulty with lifting heavy objects and reaching objects overhead. At 3 months after immunization, she denied any pain, dysfunction, or disruption from activity, yet had continued winging of the scapula. Her electromyography (EMG) performed at that time revealed mild chronic neuropathic changes in the serratus anterior muscle, suggestive of mild right long thoracic nerve neuropathy. PTS or brachial neuritis is usually self-limiting, but recognition of the presentation is important in identifying specific limitations or needs a patient may have. Conditions associated with PTS are as varied as its presentation. Documented causes include recent bacterial, viral, or parasitic infections; recent surgery or anesthesia; autoimmune and connective tissue disorders; trauma; stressful exercises; immunizations including tetanus toxoid and antitoxin; diphtheria, pertussis, and tetanus vaccine; smallpox; and swine flu. It can also be associated with radiation therapy, lumbar puncture, radiologic dye administration, and allergy desensitization. The mechanism for PTS remains unknown at this time, but it seems to be triggered by autoimmune inflammatory event.  Vaccine administration is a known cause of this syndrome, but to the best of the authors knowledge at the time of submission, no cases have been reported from the novel SARSCoV 2 BNT162b2. Because of its difficulty to diagnose in the early stage, it is frequently missed, or an incorrect diagnosis is given. PTS is strictly a clinical diagnosis, but EMG can be used to better identify, isolate, and grade severity of denervation and, after a period of time, reinnervation of the involved muscles . PTS is believed to be an axonal process, and standard EMG protocols may be equivocal if particular attention is not made to each muscle group in and around the shoulder girdle. Other diagnostic modalities include magnetic resonance imaging of the cervical spine and shoulder, most often used to rule out mass lesions (e.g., ganglion cyst and discherniation), rotator cuff tears, or nonspecific inflammation in the brachial plexus. In this patient's case, advanced imaging was considered, but given her improved function and relatively limited functional deficits, it was not implemented. PTS is largely a clinical diagnosis; however, the authors concede that this lack of advanced testing is a limitation of the case presentation for which other differential diagnosis cannot be ruled out, including underlying malignancy or rheumatologic disorders. Since there is only 1 nerve involved, it remains possible that this is an isolated long thoracic nerve palsy of uncertain etiology rather than a brachial plexopathy. Her EMG findings were, however, consistent with her physical examination findings and consistent with PTS. Although symptoms usually resolve (89% at 3 years), treatment modalities consist in the early stage of nonsteroidal anti-inflammatory drugs, neuroleptics, and, in some cases, opiates. Acupuncture and oral steroids have also been reported, but evidence in the literature is lacking. Transcutaneous electrical nerve stimulation, in addition to range ofmotion and stabilizing exercises, has seen improved outcomes. Regarding vaccine safety, during the trials for the BNT162b2 vaccine, the most commonly reported systemic events were fatigue and headache (59% trial, 52% placebo), as well as fever after the second dose (11% in the young group, 16% in the older group). Adverse events were statistically higher in the trial group (27% and 12%). Serious adverse events included shoulder injury related to vaccine administration, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia. No deaths were reported attributed to the vaccine. It should be noted that the nature of the shoulder injury is not further characterized, so it is possible that this represents an additional case of PTS related to the BNT162b2 vaccine.  Findings from this case represent the first known documentation of PTS after SARS-CoV-2 BNT162b2 vaccination. The authors feel strongly that this should not be used to discourage vaccination. It should be used to further encourage and inform the public regarding the risks involved.; Sender's Comments: Based on the information available and a close temporal association a possible contributory role of the suspect BNT162B2 cannot be excluded for the reported event Parsonage-Turner syndrome.   The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate