Age: 35.0
Sex: F
Vaccine: COVID19
Symptoms: Blood arsenic increased, C-reactive protein, CSF culture, CSF glucose, CSF protein
Clinical narrative: Sequential bilateral bell's palsy; This literature-non-study case was reported in a literature article and describes the occurrence of BELL'S PALSY (Sequential bilateral bell's palsy) in a 35-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination.       Concurrent medical conditions included Migraine headache, Non-tobacco user and Abstains from recreational drugs.   On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date,  after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced BELL'S PALSY (Sequential bilateral bell's palsy) (seriousness criteria hospitalization and medically significant). The patient was treated with METHYLPREDNISOLONE (intravenous) for Adverse event, at a dose of 500 milligram twice a day; PREDNISONE ongoing since an unknown date for Adverse event, at an unspecified dose and frequency; ACYCLOVIR [ACICLOVIR] ongoing since an unknown date for Adverse event, at a dose of 400 milligram four times per day and ACYCLOVIR [ACICLOVIR] for Adverse event, at a dose of 400 milligram three times a day. At the time of the report, BELL'S PALSY (Sequential bilateral bell's palsy) was resolving. Related    DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Angiogram: unremarkable (normal) Computed tomography angiography(CTA) was unremarkable and negative for ischemic and hemorrhagic stroke.. On an unknown date, Angiotensin converting enzyme (Unknown-15): 3 u/l (normal) Angiotensin converting enzyme in cerebral spinal fluid was 3 U/L. On an unknown date, Antibody test (Unknown-<0.90): <0.90 (normal) Lyme Disease Antibody was <0.90 and <0.30  nmol/l (normal) Serum AcH receptor was <0.30  nmol/L.. On an unknown date, Antinuclear antibody: negative (Negative) Serum antinuclear antibody was negative.. On an unknown date, Blood arsenic increased (Unknown-<23): <3 mcg/l (normal) Serum arsenic was <3 mcg/L.. On an unknown date, C-reactive protein (0-0.99): <0.10 mg/dl (normal) Serum CRP was <0.10 mg/dL. On an unknown date, CSF culture: no growth (normal) CSF culture had revealed no growth.. On an unknown date, CSF glucose (40-70): 73 mg/dl (High) CSF Glucose was 73 mg/dL.. On an unknown date, CSF protein (15-45): 65 mg/dl (High) CSF total protein was 65 mg/dL... On an unknown date, CSF red blood cell count positive (0-2): 6 cells/ (High) Cerebral spinal fluid RBC was 6 cells/. On an unknown date, CSF test: clear (normal) Cerebral spinal fluid was clear. and colorless (normal) Cerebral spinal fluid was colorless.. On an unknown date, CSF white blood cell count (0-5): 0 cells/ (normal) Cerebral spinal fluid WBC 0 cells/. On an unknown date, Electromyogram: 70% axonal loss Nerve conduction and EMG studyrevealed profound but incomplete axonal loss of the left facial nerve with over 70% axonal loss when compared to the right facial nerve.. On an unknown date, Full blood count: unremarkable (normal) Complete blood count was unremarkable.. On an unknown date, International normalised ratio (0.9-1.2): 1.0 ratio (normal) Serum international normalized ratio was 1.0.. On an unknown date, Laboratory test: unremarkable (normal) Meningitis panel was unremarkable.. On an unknown date, Magnetic resonance imaging head: unremarkable (normal) Magnetic resonance imaging(MRI) of the brain was unremarkable.. On an unknown date, Metabolic function test: unremarkable (normal) Complete metabolic panel was unremarkable.. On an unknown date, Neurological examination: normal (normal) Cranial nerve testing was normal. The gross hearing was intact.. On an unknown date, Physical examination: normal gait and posture Physical exam revealed a normal gait and posture with negative Trendelenburg gait and Romberg sign., could not raiseeyebrows or close eyes Patient's pupils were equal, round, and reactive to light bilaterally. Patient could not raise eyebrows or close eyes bilaterally, and was unable to frown or smile. Nasolabial fold flattening was noted bilaterally. and strength testing was 5/5 Patient had mildly decreased right grip strength, but otherwise, strength testing in the upper and lower extremities was 5/5 on the medical research council for muscle strength. Touch and vibration sensations were intact. Deep tendon reflexes were 2+ in all extremities.. On an unknown date, Red blood cell sedimentation rate (0-20): 9 mm/hour (normal) Serum sedimentation rate was 9 mm/hour.. On an unknown date, SARS-CoV-2 antibody test: negative (Negative) COVID-19 test was negative..   The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown.   For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered BELL'S PALSY (Sequential bilateral bell's palsy) to be related.    No concomitant medications were reported.  Patient had presented with acute, spontaneous onset of right facial weakness and asymmetry with associated occipital headaches and mild right arm weakness. Patient had difficulty with speech, swallowing, and was unable to fully close right eye.   Patient had no prior history of COVID-19 infection. Patient had denied any family or surgical history and had denied home medication. Patient had reported consuming three standard drinks per week.   Four days later, patient had subsequently developed left sided facial weakness, asymmetry, and an inability to close left eye. Patient had reported a worsening of dysphagia and dysarthria. During this time, patient had denied numbness, paresthesias, balance or gait disturbances, vision changes, ptosis, bowel or bladder dysfunction, dizziness, substantial weakness in extremities, and sensory changes. Patient had also denied cough, shortness of breath, joint pain, new onset rashes, tick exposure, chest pain, and palpitations. Patient was discharged with a tapered prednisone course.  Company Comment: This literature non study case concerns a 35-year-old female patient with no relevant medical history reported, who experienced the expected serious (hospitalization, medically significant) AESI event of Bells palsy approximately 4 weeks after receiving a dose (dose number not specified) of mRNA-1273 vaccine. It is reported that patient presented with acute spontaneous onset of right facial weakness and asymmetry with associated occipital headache and mild right arm weakness, difficulty with speech and swallowing, unable to close her right eye, she reported no history of Covid-19 infection. She reported consuming three standard drinks per week. She was initially treated with 500 mg of intravenous (IV) methylprednisolone twice daily for three days and 400 mg of acyclovir four times daily. She was discharged with a tapered prednisone course and advised to complete a 10-day course of 400 mg of acyclovir three times daily for idiopathic Bells palsy. Four days later patient developed left side facial palsy and unable to close her left eye, she reported worsening of dysphagia and dysarthria. Physical exam revealed a normal gait and posture with negative Trendelenburg gait and Romberg sign. The patient's pupils were equal, round, and reactive to light bilaterally. She could not raise her eyebrows or close her eyes bilaterally, and she was unable to frown or smile. Nasolabial fold flattening was noted bilaterally. All other cranial nerve testing was normal. The gross hearing was intact. She had mildly decreased right grip strength, but otherwise, strength testing in the upper and lower extremities was 5/5. Touch and vibration sensations were intact globally, and her deep tendon reflexes were 2+ in all extremities. Nerve conduction and EMG study revealed profound but incomplete axonal loss of the left facial nerve with over 70% axonal loss when compared to the right facial nerve. Lumbar puncture was significant, only for a mildly elevated total protein count. Complete blood count, complete metabolic panel, and meningitis panel were unremarkable, as was the contrast MRI of the brain is normal,MRI brain and CTA is normal. The differential diagnosis for BBP includes sarcoidosis, Guillain-Barré, Lyme disease, trauma, tumor, and encephalitis; all of which were excluded with serological analyses, cerebral spinal fluid (CSF) analyses, imaging, history of present illness, and physical exam. The patient was continued on 500 mg of IV methylprednisolone twice daily and 400 mg of acyclovir four times daily and achieved significant improvement by day three of admission. The patient was subsequently discharged with neurology outpatient follow-up. Conclusion by author is idiopathic bilateral facial nerve palsy is very uncommon, patient developed bilateral bells palsy after following covid-19 vaccination and with negative work up. Correlation may exist between bilateral bells palsy and covid 19 vaccination. The benefit-risk relationship of mRNA-1273 Vaccine is not affected by this report.; Sender's Comments: This literature non study case concerns a 35-year-old female patient with no relevant medical history reported, who experienced the expected serious (hospitalization, medically significant) AESI event of Bells palsy approximately 4 weeks after receiving a dose (dose number not specified) of mRNA-1273 vaccine. It is reported that patient presented with acute spontaneous onset of right facial weakness and asymmetry with associated occipital headache and mild right arm weakness, difficulty with speech and swallowing, unable to close her right eye, she reported no history of Covid-19 infection. She reported consuming three standard drinks per week. She was initially treated with 500 mg of intravenous (IV) methylprednisolone twice daily for three days and 400 mg of acyclovir four times daily. She was discharged with a tapered prednisone course and advised to complete a 10-day course of 400 mg of acyclovir three times daily for idiopathic Bells palsy. Four days later patient developed left side facial palsy and unable to close her left eye, she reported worsening of dysphagia and dysarthria. Physical exam revealed a normal gait and posture with negative Trendelenburg gait and Romberg sign. The patient's pupils were equal, round, and reactive to light bilaterally. She could not raise her eyebrows or close her eyes bilaterally, and she was unable to frown or smile. Nasolabial fold flattening was noted bilaterally. All other cranial nerve testing was normal. The gross hearing was intact. She had mildly decreased right grip strength, but otherwise, strength testing in the upper and lower extremities was 5/5. Touch and vibration sensations were intact globally, and her deep tendon reflexes were 2+ in all extremities. Nerve conduction and EMG study revealed profound but incomplete axonal loss of the left facial nerve with over 70% axonal loss when compared to the right facial nerve. Lumbar puncture was significant, only for a mildly elevated total protein count. Complete blood count, complete metabolic panel, and meningitis panel were unremarkable, as was the contrast MRI of the brain is normal,MRI brain and CTA is normal. The differential diagnosis for BBP includes sarcoidosis, Guillain-Barré, Lyme disease, trauma, tumor, and encephalitis; all of which were excluded with serological analyses, cerebral spinal fluid (CSF) analyses, imaging, history of present illness, and physical exam. The patient was continued on 500 mg of IV methylprednisolone twice daily and 400 mg of acyclovir four times daily and achieved significant improvement by day three of admission. The patient was subsequently discharged with neurology outpatient follow-up. Conclusion by author is idiopathic bilateral facial nerve palsy is very uncommon, patient developed bilateral bells palsy after following covid-19 vaccination and with negative work up. Correlation may exist between bilateral bells palsy and covid 19 vaccination. The benefit-risk relationship of mRNA-1273 Vaccine is not affected by this report.