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|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 4 | Page : 1722-1723
Tumefactive Lesions Following a SARS-CoV-2 Vaccination Require Diagnostic Assignment
Department of Neurology Peartment, Neurology and Neurophysiology Center, Vienna, Austria
|Date of Submission||01-Apr-2022|
|Date of Decision||31-Mar-2022|
|Date of Acceptance||09-Jun-2022|
|Date of Web Publication||30-Aug-2022|
Postfach 20, 1180 Vienna
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Finsterer J. Tumefactive Lesions Following a SARS-CoV-2 Vaccination Require Diagnostic Assignment. Neurol India 2022;70:1722-3
We read with interest the article by Garg et al. about a 58-year-old female patient who developed right-sided hemiparesis 2 days after receiving the first dose of the vector-based Astra Zeneca vaccine (AZV). Cerebral magnetic resonance imaging (MRI) showed a tumefactive T2-, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI) hyperintense lesion in the left parietal lobe white matter extending to the corpus callosum. The patient benefited significantly from steroids to almost complete recovery at the 3 months follow-up. The study is attractive but raises concerns that need to be discussed.
The main shortcoming of the study is that the patient did not undergo a cerebrospinal fluid (CSF) investigation. Given that diseases of the central nervous system (CNS) or peripheral nervous system (PNS) are increasingly recognized as complications of SARS-CoV-2 vaccinations, it is of crucial importance that infectious and immune encephalitis, multiple sclerosis, neuromyelitis optica, lymphoma, and acute disseminated encephalomyelitis (ADEM), are adequately ruled out by CSF studies. In addition to the standard parameters, the CSF should be examined for cytokines (e.g., interleukin [IL]-6, IL-8, IL-1a, tumor necrosis factor (TNF)-alpha) or chemokines that were shown upregulated in SARS-CoV-2 associated CNS/PNS disease.
The tumefactive lesion should also have been investigated using magnetic resonance spectroscopy (MRS)and fluor-deoxy-glucose (FDG) positron emission tomography (PET) to assess the metabolic conditions within this lesion.
Another shortcoming is that the patient was not tested for SARS-CoV-2. Because SARS-CoV-2 infection can be complicated by a wide range of CNS disorders, including encephalitis, ADEM, multiple sclerosis, neuromyelitis optica, transverse myelitis, hypophysitis, and acute hemorrhagic necrotizing encephalitis (AHNE), the exclusion of COVID-19 is crucial in the index case.
SARS-CoV-2 infection and vaccination can be complicated by a multisystem inflammatory syndrome (MIS-V). Therefore, we should know if the patient presented with features other than the tumefactive lesion, such as fever, hypotension, elevated inflammatory parameters, hypercoagulation, thyroiditis, diarrhea, or abdominal pain.
The report lacks the MRI-modality apparent diffusion coefficient (ADC) to assess if the lesion represents ischemia or vasogenic edema, and perfusion-weighted images (PWIs) to assess if hypo- or hyper-perfusion was present.
Establishing a neurological diagnosis is crucial, as acute treatment, disease course, long-term disease management, and the outcome can be highly dependent on the underlying cause of the lesion described.
Overall, the interesting study has limitations and inconsistencies that call the results and their interpretation into question. Clarifying these weaknesses would strengthen the conclusions and could add value to the study.
The study was in accordance with ethical guidelines. The study was approved by the Institutional Review Board.
Financial support and sponsorship
Conflicts of interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
| » References|| |
Garg RK, Malhotra HS, Kumar N, Pandey S, Patil MR, Uniyal R, et al
. Tumefactive demyelinating brain lesion developing after administration of adenovector-based COVID-19 vaccine: A case report. Neurol India 2022;70:409-11.
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Finsterer J. Neurological side effects of SARS-CoV-2 vaccinations. Acta Neurol Scand 2022;145:5-9.
Gigli GL, Vogrig A, Nilo A, Fabris M, Biasotto A, Curcio F, et al
. HLA and immunological features of SARS-CoV-2-induced Guillain-Barré syndrome. Neurol Sci 2020;41:3391-4.
Nune A, Iyengar KP, Goddard C, Ahmed AE. Multisystem inflammatory syndrome in an adult following the SARS-CoV-2 vaccine (MIS-V). BMJ Case Rep 2021;14:e243888.