Acute abducens nerve palsy following COVID-19 vaccination
We report the case of a healthy 59-year-old woman who presented with an acute abducens nerve palsy 2 days after receiving the Pfizer-BioNTech COVID-19 vaccine. In adults, such palsies are typically caused by microvascular disease or compressive tumors, although they have also been described after routine vaccinations. Given the temporal relationship between vaccination and the onset of symptoms, the lack of preexisting medical conditions, and unremarkable magnetic resonance imaging, the patient's abducens nerve palsy was felt to be related to her vaccination. This case highlights the importance of recognizing the potential of a COVID-19 vaccine to have neurologic sequelae similar to those that as have been reported with the virus itself as well as with other vaccines.
Case Report
Discussion
Our patient developed an acute right abducens nerve palsy following a febrile illness 2 days after receiving the Pfizer-BioNTech mRNA COVID-19 vaccine. Her lack of vascular risk factors, negative review of systems, normal optic nerves, and unremarkable MRI make microvascular or neoplastic etiologies unlikely. Given the patient's mild elevation in ESR and CRP, we hypothesize that this patient developed a viral-like inflammatory reaction to the vaccine, inciting an immune-mediated indirect insult along the abducens nerve. Although less likely in this patient, given the normal MRI, it is also important to consider vaccine-related thrombotic events as a possible etiology. The differential diagnosis incudes Duane syndrome, orbit fibrosis, myasthenia gravis, and even temporal arteritis, but all of these are unlikely, given the preexisting photographic evidence, lab findings, scan, and clinical course. Our finding has been reported to the CDC and FDA via the Vaccine Adverse Event Reporting System as well as to the manufacturer (Pfizer, New York, NY).
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Article info
Publication history
Published online: May 24, 2021
Accepted: May 19, 2021
Received: April 27, 2021
Identification
Copyright
© 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.
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Fig 1External photographs demonstrating an esotropia and limitation to abduction of the right eye consistent with an abducens nerve palsy.
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