Case report: a systemic reaction with predominant neurological and skin manifestations after anti-SARS-CoV-2 vaccination

In this case report, the author from Austria presented a case of a systemic reaction, characterized by predominant neurological and skin manifestations, which appeared immediately following the third dose of the anti-SARS-CoV-2 mRNA vaccine and lasted for 11 months. 

About the case

A 39-year-old male received the first dose of the anti-SARS-CoV-2 mRNA-1273 (Moderna) vaccine in May 2021 without any major side effects. His medical history included chronic sinusitis for 15 years, neurodermatitis for two years, keratoconus, and mild tinnitus that deteriorated after vaccination. He didn’t take any medications regularly. Following the second dose in June 2021, he experienced a fever of up to 39.5° C, drowsiness, and a rash on his legs for five days. Following the third dose, he developed a systemic reaction with a fever of up to 38.8 °C on the day of the vaccination, and a severe headache the next day.

From the third day after the third vaccination, the patient experienced a variety of neurological symptoms, including drowsiness (brain fog), severe headaches, a sensation of pulling in the left part of the head, a feeling of pressure and heat in the forehead and left temporal region, insomnia, a pulsating sensation in his head at night, photophobia, sensitivity to noise, left-sided eyelid twitching, fasciculations and vertigo.

Symptoms of cognitive impairment included disorientation, derealization, a decline in memory, thinking and concentration, difficulties in abstract thinking, emotional disorders, palinopsia (visual perseverations), and aphantasia (he was unable to visualize images after closing his eyes).

After the second vaccination, he experienced a severe skin reaction between his legs, which lasted for 2–3 weeks. He also had fluctuations in his body temperature. The fourth day after the third vaccination, the patient got bilateral tinea inguinalis. The sixth day following the third vaccination, he noticed round inflamed patches with hair loss in his right occipital area, resembling tinea capitis (photo).

The patient also experienced other signs and symptoms, such as polyarthralgia, disturbed ejaculation, pain in the right armpit (vaccination arm), and a swelling of lymph nodes in the left armpit.

The antibodies against the spike protein were consistently elevated throughout the course of the disease, but they gradually declined. The antibodies against the nucleocapsid protein were normal, indicating that the patient was not infected with SARS-CoV-2.

The results of the laboratory analysis showed normal blood cell count, with occasional monocytosis. The characterization of lymphocytes showed normal number of total lymphocytes, CD16+56+ lymphocytes, CD4+T lymphocytes, CD8+ T lymphocytes and CD19+ B lymphocytes. The relative number of CD4+T cells and the CD4/CD8 ratio were both reduced, whereas the relative number of CD8+T cells was increased. The levels of electrolytes, parameters of kidney and liver function, and parameters of blood coagulation, were all within normal limits. Besides the low levels of vitamin B12 and vitamin C, the levels of other vitamins were within normal limits. The level of salivary cortisol was elevated at baseline, and after five and eight hours.

Parameters of connective tissue diseases, such as small nuclear ribonucleoprotein particle U1, autoantibodies against Sjögren’s syndrome-related antigen A and Sjögren’s syndrome antigen B, centromere protein B, topoisomerase 1, anti-double-stranded deoxyribonucleic acid antibodies, fibrillarin, antibodies against ribosomal P proteins, and anti-Mi-2 antibodies were not informative. The antibodies to cardiolipin, lupus anticoagulants, and beta-2 glycoproteins were within normal ranges. Antinuclear antibodies were not detected.

Six weeks after the third vaccination, electroencephalography showed only discrete theta waves over the left frontotemporal projections. T2-FLAIR brain magnetic resonance imaging revealed focal hyperintense white matter lesions in the frontotemporal distribution two months after the third vaccination. The patient refused consent for a lumbar puncture to obtain cerebrospinal fluid for laboratory testing. Electrocardiogram and transthoracic echocardiography were normal.

The administration of non-steroidal anti-inflammatory drugs (NSAIDs), antihistamines, angiotensin II receptor antagonists (sartans), and statins had a beneficial effect, but only temporarily. Nattokinase and quercetin occasionally provided some relief. Over a two-month period, different NSAIDs were used, including aspirin, naproxen, ibuprofen. Ibuprofen and single dose of methyl-prednisolone worsened his symptoms.

A significant improvement in photophobia and brain fog was achieved after four months of treatment with NSAIDs, whereas the full recovery of cognitive functions required another four months. Sartans and statins also improved cognitive dysfunction and led to symptom stability. Since then, the symptoms have occasionally resurfaced, for example, the discontinuation of statin therapy led to severe headaches in October 2022. The patient is still receiving long-term drug therapy.

In conclusion, this study reported a case of a systemic reaction, characterized by predominant neurological and skin manifestations, which appeared immediately following the third dose of the anti-SARS-CoV-2 mRNA vaccine and lasted for 11 months. 

This article was published in Cureus.

Journal Reference

Finsterer J (December 12, 2022) A Case Report: Long Post-COVID Vaccination Syndrome During the Eleven Months After the Third Moderna Dose. Cureus 14(12): e32433. (Open Access)