Neuralgic amyotrophy and COVID-19 infection: 2 cases of spinal accessory nerve palsy

Parsonage-Turner Syndrome and Hereditary Brachial Plexus Neuropathy

Parsonage-Turner syndrome and hereditary brachial plexus neuropathy (HBPN) present with indistinguishable attacks of rapid-onset severe shoulder and arm pain, disabling weakness, and early muscle atrophy. Their combined incidence ranges from 3 to 100 in 100,000 persons per year. Dominant mutations of SEPT9 are the only known mutations responsible for HBPN. Parsonage and Turner termed the disorder "brachial neuralgic amyotrophy," highlighting neuropathic pain and muscle atrophy. Modern electrodiagnostic and imaging testing assists the diagnosis in distinction from mimicking disorders. Shoulder and upper limb nerves outside the brachial plexus are commonly affected including the phrenic nerve where diaphragm ultrasound improves diagnosis. Magnetic resonance imaging can show multifocal T2 nerve and muscle hyperintensities with nerve hourglass swellings and constrictions identifiable also by ultrasound. An inflammatory immune component is suggested by nerve biopsies and associated infectious, immunization, trauma, surgery, and childbirth triggers. High-dose pulsed steroids assist initial pain control; however, weakness and subsequent pain are not clearly responsive to steroids and instead benefit from time, physical therapy, and non-narcotic pain medications. Recurrent attacks in HBPN are common and prophylactic steroids or intravenous immunoglobulin may reduce surgical- or childbirth-induced attacks. Rehabilitation focusing on restoring functional scapular mechanics, energy conservation, contracture prevention, and pain management are critical. Lifetime residual pain and weakness are rare with most making dramatic functional recovery. Tendon transfers can be used when recovery does not occur after 18 months. Early neurolysis and nerve grafts are controversial. This review provides an update including new diagnostic tools, new associations, and new interventions crossing multiple medical disciplines.

Association of Parsonage-Turner syndrome with COVID-19 infection and vaccination: a systematic review

OBJECTIVES

The exact etiology of Parsonage-Turner syndrome is unknown, but it is known to be preceded by infection, vaccination, or surgical intervention. In this review, we describe associations of Parsonage-Turner syndrome with COVID-19 infection and vaccination.

METHODS

A systematic literature search was conducted using PubMed/MEDLINE, ScienceDirect, and Google Scholar. Microsoft Excel was used for data extraction and statistical analysis. The quality of case reports and case series was assessed using the Joanna Briggs Institute Critical Appraisal Tool.

RESULTS

We selected 44 case reports and 10 case series, including 68 patients (32 post-vaccination and 36 with post-COVID-19 infection Parsonage-Turner syndrome). Middle-aged males were predominantly affected in both groups. The most frequently administered vaccine was Comirnaty (Pfizer) (53%). The mean latency was 11.7 days in the post-vaccination group and 20.3 days in the post-infection group. The most affected nerves in both groups were the axillary, suprascapular, and musculocutaneous nerves; and 78.1% and 38.9% of patients showed partial amelioration of their symptoms in the post-vaccination and post-infection groups, respectively.

CONCLUSION

Post-vaccination Parsonage-Turner syndrome presents earlier than post-infection disease. Pain and sensorimotor deficits of the upper limb are common in both situations. Complete or partial recovery occurs in most cases.

Parsonage-Turner Syndrome Following SARS-CoV-2 Infection: A Systematic Review

Parsonage-Turner syndrome (PTS) is an inflammatory disorder of the brachial plexus. Hypothesized underlying causes focus on immune-mediated processes, as more than half of patients present some antecedent event or possible predisposing condition, such as infection, vaccination, exercise, or surgery. Recently, PTS was reported following the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to investigate data on PTS triggered by SARS-CoV-2 infection to provide an extensive perspective on this pathology and to reveal what other, more specific, research questions can be further addressed. In addition, we aimed to highlight research gaps requiring further attention. We systematically reviewed two databases (LitCOVID and the World Health Organization database on COVID-19) to January 2023. We found 26 cases of PTS in patients with previous SARS-CoV-2 infection. The clinical and paraclinical spectrum was heterogeneous, ranging from classical PTS to pure sensory neuropathy, extended neuropathy, spinal accessory nerve involvement, and diaphragmatic palsy. Also, two familial cases were reported. Among them, 93.8% of patients had severe pain, 80.8% were reported to present a motor deficit, and 53.8% of patients presented muscle wasting. Paresthesia was noted in 46.2% of PTS individuals and a sensory loss was reported in 34.6% of patients. The present systematic review highlights the necessity of having a high index of suspicion of PTS in patients with previous SARS-CoV-2 infection, as the clinical manifestations can be variable. Also, there is a need for a standardized approach to investigation and reporting on PTS. Future studies should aim for a comprehensive assessment of patients. Factors including the baseline characteristics of the patients, evolution, and treatments should be consistently assessed across studies. In addition, a thorough differential diagnosis should be employed.

Parsonage-Turner Syndrome following COVID-19 infection: A Report of Three Cases

Introduction

Parsonage-Turner Syndrome (PTS), previously referred to as neuralgic amyotrophy or idiopathic brachial plexopathy, is a rare neurological syndrome characterized by an abrupt onset of shoulder pain followed by neurological deficits of motor weakness, numbness, and muscular atrophy. Although the pathophysiology and specific cause of PTS remain unclear, it has been reported following trauma, vaccination, surgical procedures and viral infection. Our practice has seen an increase in the incidence of PTS with the COVID-19 pandemic. We aim to describe three cases of patients found to have PTS shortly after proven infection with COVID-19 during the Omicron surge.

Case Description

Three patients developed symptoms of PTS within a few weeks of having COVID-19. All three cases had normal imaging and an EMG that diagnosed PTS. The first is a 23-year-old male who developed weakness and shoulder pain two weeks after his COVID-19 diagnosis. The second was a 58-year-old male who was intubated with COVID-19 pneumonia and woke up with extreme weakness and pain in his left arm. The final case was a 76-year-old male with a remote history of a left total shoulder arthroplasty who also developed acute pain and weakness soon after testing positive for COVID-19. All three patient's symptoms and clinical exam have been improving.

Discussion

In this report, we presented three patients who developed PTS soon after being diagnosed with COVID-19 during the omnicron surge. As we learn more about the COVID-19 virus and its effects on the musculoskeletal system, efficient diagnosis and multidisciplinary treatment of Parsonage-Turner Syndrome will become increasingly valuable to physicians and patients.

Neuromuscular Complications of SARS-CoV-2 and Other Viral Infections

In this article we review complications to the peripheral nervous system that occur as a consequence of viral infections, with a special focus on complications of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). We discuss neuromuscular complications in three broad categories; the direct consequences of viral infection, autoimmune neuromuscular disorders provoked by viral infections, and chronic neurodegenerative conditions which have been associated with viral infections. We also include discussion of neuromuscular disorders that are treated by immunomodulatory therapies, and how this affects patient susceptibility in the current context of the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is associated with direct consequences to the peripheral nervous system via presumed direct viral injury (dysgeusia/anosmia, myalgias/rhabdomyolysis, and potentially mononeuritis multiplex) and autoimmunity (Guillain Barré syndrome and variants). It has important implications for people receiving immunomodulatory therapies who may be at greater risk of severe outcomes from COVID-19. Thus far, chronic post-COVID syndromes (a.k.a: long COVID) also include possible involvement of the neuromuscular system. Whether we may observe neuromuscular degenerative conditions in the longer term will be an important question to monitor in future studies.

Shoulder palsy following SARS‐CoV2 infection: 2 cases of typical Parsonage‐Turner syndrome

Background and purpose

Coronavirus disease 2019 (COVID‐19) is now known to cause neurological complications in both the central and the peripheral nervous system. Two new cases of typical neuralgic amyotrophy or Parsonage–Turner (PT) syndrome following coronavirus 2 infection (SARS‐CoV‐2) are reported here with explicit electrophysiological and imaging pathological features, underlining the possible association between COVID‐19 and PT syndrome.

Case reports

Case 1 was a 45‐year‐old schoolteacher presenting with acute pain in the right shoulder a few days after SARS‐CoV‐2 infection, with shoulder abduction and elbow flexion weakness. Needle electromyography showed a decrease in motor unit recruitment in the biceps brachii, and plexus magnetic resonance imaging (MRI) revealed a hyperintense signal involving the right C6 root and the superior truncus of the brachial plexus. Case 2 was a 21‐year‐old man hospitalized for dyspnea secondary to SARS‐CoV‐2 infection. Ten days after symptom onset, he presented right shoulder pain with difficulty in raising his right arm, revealing an isolated deficit of the serratus major muscle with a right scapula winging. Electrophysiological evaluation exhibited an isolated involvement of the long thoracic nerve with a neurogenic recruitment pattern in the serratus major muscle. Plexus MRI displayed a thickening and hyperintense signal involving the right long thoracic nerve.

Discussion

Parsonage–Turner syndrome triggered by SARS‐CoV‐2 seems to present clinical, electrophysiological and MRI characteristics similar to classic para‐infectious PT syndrome, including the time frame between viral infection and neurological symptom onset.

Conclusion

SARS‐CoV‐2 might be a new infectious trigger of PT syndrome.

Parsonage-Turner syndrome following COVID-19 vaccination and review of the literature

Background

Parsonage-Turner syndrome (PTS) is a rare brachial plexopathy characterized by self-limiting shoulder girdle and upper arm pain followed by the upper extremity weakness and sensory changes. While the etiology is not well-understood, the most common cause of PTS is thought to be postviral. There are at least nine reports, to the best of our knowledge, of PTS associated with COVID-19 infection and nine reports associated with COVID-19 vaccination.

Case Description

Here, we present a case of PTS after COVID-19 vaccination in a 64-year-old male and a review of the current literature.

Conclusion

PTS can occur post-COVID-19 vaccination and should be on the differential diagnosis when patient continues to experience shoulder pain and develops weakness or sensory changes in the extremity.

Parsonage-Turner Syndrome After COVID-19 Vaccination: A Case Report

CASE

One week after receiving a COVID-19 vaccine in his left deltoid, a 34-year-old man developed severe right periscapular pain that lasted 2 weeks and was followed by profound right shoulder girdle atrophy and weakness. Both the pain and motor deficits resolved over the subsequent 4 months.

CONCLUSION

Parsonage-Turner syndrome (PTS) is an idiopathic brachial plexopathy that can develop in the setting of recent vaccination and lead to significant shoulder pain and weakness. Given the worldwide increase in newly vaccinated patients, orthopaedic surgeons should take detailed histories to identify potential triggers (recent vaccination or illness) that point toward PTS rather than musculoskeletal pathology.