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CLINICAL CASES IN MS – CASE 1: Neurological symptoms after COVID-19 vaccination

 

Watch Dr. Daniel Selchen as he shares his thoughts about this case.

Linda H., 48, is a partner at an accountancy firm, married with no children. She presents with paresthesiae following vaccination for COVID-19. She has no history of medical or neurological conditions and no pertinent family history.

Two weeks after receiving a first dose of the BNT162b2 (Pfizer-BioNTech) mRNA vaccine, Linda noticed a loss of sensation around her right breast, with subsequent paresthesiae of the right leg and left leg. Symptoms evolved over 1 week. There was no motor involvement. The patient was afebrile. She reported no bladder or systemic symptoms. Paresthesiae resolved after 5-6 weeks without treatment.

C-spine MRI revealed 1 lesion at C7-T1, right posterior; the lesion crossed the midline with some gadolinium enhancement. There was no longitudinal extension of the lesion. A subsequent brain MRI (without Gd) showed multiple deep hyperintense T2 lesions; 2 of the lesions abutted the corpus callosum.

The survey is now closed. We received 52 responses. See below for a summary of the answers you provided.

Question 1: Do you believe that COVID-19 vaccination…
A majority (51%) believed that vaccination may have unmasked a previously undiagnosed MS. Some believed that vaccination was unrelated to current neurological symptoms (19%), and some that vaccination may have triggered an autoimmune response (17%).

Question 2: Would you recommend that Linda not receive a second COVID-19 vaccination?
A majority (50%) would recommend delaying a second vaccination until a further work-up can be done, although many (35%) felt that a second dose should be advised since it would be unlikely to worsen neurological symptoms.

Question 3: What further investigations would you perform?
This question allowed for multiple investigations. The most common investigations selected were CSF for oligoclonal banding (67%); a broad autoimmune work-up (58%); MRI brain/C-spine in 3 months (56%); and MRI brain with Gd as soon as possible (52%).

Question 4: What is your diagnosis?
The most common diagnoses were CIS (48%) and RRMS (35%). A total of 8% believed the only diagnosis was COVID-19.

Question 5: What would be your preferred starting treatment for this patient?
A majority (57%) would not start treatment at this time. Some respondents would start with dimethyl fumarate (14%), teriflunomide (8%), glatiramer acetate (6%), an interferon-β (6%), ocrelizumab (4%) or ofatumumab (2%).

View the video commentary by Dr. Daniel Selchen:

 

How prognostic is NEDA?

 

A new study has found that a high proportion of MS patients with no evidence of disease activity (NEDA) in the first two years of treatment will experience relapse-associated worsening (RAW) and progression independent of relapse activity (PIRA) (Prosperini et al. Neurol Neuroimmunol Neuroinflamm 2021;8:e1059). Read More

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