LETTERS
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Vaccination Mononeuropathy
Infectious Diseases and PML
Frances M. Dyro, M D
John Moossy, MD
In early 1977 a report was published concerning 2 patients who experienced prolonged discomfort of the upper extremity following New Jersey/76 (swine flu) influenza vaccination [ I]. Another report involved a patient in whom acute carpal tunnel syndrome developcd three weeks after vaccination [2]. W e studied with motor and sensory conduction velocities and electromyography a patient with similar signs and symptoms who complained of discomfort and also had mononeuropathy following vaccination.
T h e diverse infectious diseases associated with progressive multifocal leukoencephalopathy (PML) have been emphasized in the Annals by Drs Malas and Weiss [ 11. Such infections may precede, appear concurrent with, or occur late in the course of P M L In 1974, at rhc meerinfi of the American Academy of Neurology, wc reported and in 1976 published 2 cases of PML associated with multiple infections [2]. O u r Case 1 had herpes zoster radiculitis preceding the neurological signs of PML and a leptomeningitis due to Listeria monocytogenes late in his course. In our Case 2 , the diagnosis of cryptococcal meningitis was established during life but the PML was unsuspected clinically and was demonstrated only at autopsy. Both patients had impaired cellular immunity but normal immunoglobulins. That impaired cellular immunity is important seems obvious, but, as indicated by another report [3], it may be more complex than implied by the assertions of Drs Malas and Weiss.
The patient, a 45-year-old right-handed woman, was injected in the left deltoid muscle with Victoria N N e w Jersey/76 vaccine in October, 1976. Within hours of the injection she felt discomfort in the injection site. Over a two-month period, weakness of wrist extension and radiation of aching into the left shoulder developed. Electrodiagnostic testing was therefore performed. Conduction velocities in the radial nerves bilaterally were normal, although the left radial distal motor latency to the extensor indicis proprius was prolonged at 4.2 msec and a dispersed potential was seen o n stimulation in the spiral groove. Electromyography performed with monopolar needle electrodes showed increased insertional activity and increased complexity of motor units in the brachioradialis, extensor carpi radialis, and triceps muscles. Treatment with antiinflammatory agents gave little relief of symproms. T h e patient improved gradually over the next six months. Mononeuropathies of this type have been reported to occur following stings by hymenopterous insects and inoculations with other vaccines [3, 51. Because the clinical picture is very similar to that found in brachial plexus neuritis (Parsonage-Turnersyndrome [4]), a patient seen with complaints of pain and weakness following injection of the Victoria A/New Jerseyl76 vaccine may have a mononeuritis produced by the same mechanisms.
References
T W Jr: Neuropathy after influenza vaccinauon (letter). Lancet 1:253-254, 1977 Hasselbacher P: Neuropathy after influenza vaccination (letter). Lancet 1:551-552, 1977 Martin GI, Weintraub MI: Brachial neuritis and sevenrh nerve palsy: a rare hazard of DPT vaccination. Clin Pediatr 12~506507, 1973 Turner JWA, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis) with special reference to prognosis. Lancet 2:209-212. 1957 Wallace TW,Ludwig RN: Hornet sting neuritis. Cleveland Clin 37:117-118, 1970
1. Furlow
2. 3.
4.
5.
F~~~
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Vaccination Mononeuropathy
Infectious Diseases and PML
Frances M. Dyro, M D
John Moossy, MD
In early 1977 a report was published concerning 2 patients who experienced prolonged discomfort of the upper extremity following New Jersey/76 (swine flu) influenza vaccination [ I]. Another report involved a patient in whom acute carpal tunnel syndrome developcd three weeks after vaccination [2]. W e studied with motor and sensory conduction velocities and electromyography a patient with similar signs and symptoms who complained of discomfort and also had mononeuropathy following vaccination.
T h e diverse infectious diseases associated with progressive multifocal leukoencephalopathy (PML) have been emphasized in the Annals by Drs Malas and Weiss [ 11. Such infections may precede, appear concurrent with, or occur late in the course of P M L In 1974, at rhc meerinfi of the American Academy of Neurology, wc reported and in 1976 published 2 cases of PML associated with multiple infections [2]. O u r Case 1 had herpes zoster radiculitis preceding the neurological signs of PML and a leptomeningitis due to Listeria monocytogenes late in his course. In our Case 2 , the diagnosis of cryptococcal meningitis was established during life but the PML was unsuspected clinically and was demonstrated only at autopsy. Both patients had impaired cellular immunity but normal immunoglobulins. That impaired cellular immunity is important seems obvious, but, as indicated by another report [3], it may be more complex than implied by the assertions of Drs Malas and Weiss.
The patient, a 45-year-old right-handed woman, was injected in the left deltoid muscle with Victoria N N e w Jersey/76 vaccine in October, 1976. Within hours of the injection she felt discomfort in the injection site. Over a two-month period, weakness of wrist extension and radiation of aching into the left shoulder developed. Electrodiagnostic testing was therefore performed. Conduction velocities in the radial nerves bilaterally were normal, although the left radial distal motor latency to the extensor indicis proprius was prolonged at 4.2 msec and a dispersed potential was seen o n stimulation in the spiral groove. Electromyography performed with monopolar needle electrodes showed increased insertional activity and increased complexity of motor units in the brachioradialis, extensor carpi radialis, and triceps muscles. Treatment with antiinflammatory agents gave little relief of symproms. T h e patient improved gradually over the next six months. Mononeuropathies of this type have been reported to occur following stings by hymenopterous insects and inoculations with other vaccines [3, 51. Because the clinical picture is very similar to that found in brachial plexus neuritis (Parsonage-Turnersyndrome [4]), a patient seen with complaints of pain and weakness following injection of the Victoria A/New Jerseyl76 vaccine may have a mononeuritis produced by the same mechanisms.
References
T W Jr: Neuropathy after influenza vaccinauon (letter). Lancet 1:253-254, 1977 Hasselbacher P: Neuropathy after influenza vaccination (letter). Lancet 1:551-552, 1977 Martin GI, Weintraub MI: Brachial neuritis and sevenrh nerve palsy: a rare hazard of DPT vaccination. Clin Pediatr 12~506507, 1973 Turner JWA, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis) with special reference to prognosis. Lancet 2:209-212. 1957 Wallace TW,Ludwig RN: Hornet sting neuritis. Cleveland Clin 37:117-118, 1970
1. Furlow
2. 3.
4.
5.
F~~~
