Multiple cranial nerve palsies with small angle exotropia following COVID-19 mRNA vaccination in an adolescent: A case report

Abstract

Background: Several vaccines against the severe acute respiratory syndrome coronavirus 2 have been approved and widely distributed, raising public concerns regarding the side effects of immunization, as the incidence of ease. Although many adverse events following the coronavirus disease 2019 (COVID-19) vaccine have been reported, neurological complications are relatively uncommon. Herein, we report a rare case of multiple cranial palsies following COVID-19 vaccination in an adolescent patient.

Case summary: A previously healthy, 14-year-old Asian girl with facial palsy presented to the emergency department with inability to close the right eye or wrinkle right side of the forehead, and pain in the right cheek. She had received second dose of the COVID-19 mRNA vaccine (Pfizer-BioNTech) 18 days before onset of symptoms. She was diagnosed with Bell's palsy and prescribed a steroid (1 mg/kg/day methylprednisolone) based on symptoms and magnetic resonance imaging findings. However, the next day, all sense of taste was lost with inability to swallow solid food; the gag reflex was absent. Horizontal diplopia was also present. Due to worsening of her condition, she was given high-dose steroids (1 g/day methylprednisolone) for 3 days and then discharged with oral steroids. Improvement in the symptoms was noted 4 days post steroid treatment completion. At the most recent follow-up, her general condition was good with no symptoms except diplopia; ocular motility disturbances were noted. Hence, prism glasses were prescribed for diplopia relief.

Conclusion: Small-angle exotropia was observed in the facial, trigeminal, and glossopharyngeal nerve palsies, in our patient. The etiology of this adverse effect following vaccination was thought to be immunological.