First manifestation of multiple sclerosis after immunization with the Pfizer BioNTech COVID 19 vaccine
Vaccination against SARS CoV 2 is critical to control the pandemic. Although there are not yet sufficient data regarding the COVID 19 risk of patients with multiple sclerosis (MS) it is likely that especially older MS patients with higher levels of disability and relevant comorbidities have a higher risk of complications from COVID 19 infection [1] Therefore, vaccination against the SARS CoV 2 virus is generally recommended in MS, as is vaccination against other infectious agents [2] It is thought that vaccineinduced protection from infection by far outweighs the risk of autoimmune exacerbation. Regarding vaccination against SARS CoV 2 virus, three cases of reactivation or new onset demyelinating disease were reported after vaccination with Oxford AstraZeneca COVID 19 recombinant adenovirus (ChAdOx1 nCoV 19; AstraZeneca) [3] Professional societies and physicians are currently addressing vaccination concerns with an awareness campaign to promote high vaccination rates in the MS community who generally tends to be more skeptical about vaccination [4] The vaccination campaign is supported by initial safety data in MS: a very recently published study in approximately 500 MS patients showed that the relapse rate after vaccination with the PfizerBioNTech COVID 19 vaccine was similar (approximately 2% to the relapse rate in a comparative time period without vaccination [5] Here we report on a vaccinated patient who experienced the initial clinical manifestation of MS on a background of previously unknown, but likely pre existing subclinical inflammatory CNS disease. A 28 year old woman developed the first clinical manifestation of relapsing MS after vaccination with the PfizerBioNTech COVID 19 vaccine (BNT162b2, Comirnaty(c) BioNTech/Pfizer) Six days after the initially well tolerated first immunization, she began to develop left abdominal neuropathic pain, sensory impairment below the T6 level, with hypoesthesia of right abdominal wall and genital regions, and left leg paresis. Magnetic resonance imaging (MRI) of the spinal cord on day 18 after vaccination showed a contrast enhancing lesion at the T6 level, suggestive of myelitis, and cerebral MRI revealed multiple 20) partially confluent lesions with spatial dissemination but no Gadolinium enhancement. On cerebrospinal fluid (CSF) analysis mild pleocytosis (7 cells/ml) and oligoclonal bands were found. In line with a positive vaccine reaction, SARS CoV 2 S antibodies (abs, IgG; Roche) were detected in serum (50.8 U/ ml, 37 days after vaccination) SARS CoV 2 infection was excluded on the basis of a negative PCR and absence of antibodies against the SARS CoV 2 N protein (abs; Roche) The patient s history was unremarkable with respect to previous relapses. Family history was positive for MS in a paternal cousin. After relevant differential diagnoses were excluded we diagnosed relapsing MS according to the 2017 McDonald criteria and initiated high dose glucocorticoid therapy (1000 mg methylprednisolone i.v. for five days) Because complete remission of symptoms did not occur even after a second cycle of glucocorticoid therapy (2000 mg methylprednisolone i.v. for five days) we are currently escalating Joachim Havla joachim.havla@med.lmu.de
Journal of Neurology