Bell’s palsy following COVID-19 vaccination

Authors: Giuseppe Colella,1Massimiliano Orlandi,2 and Nicola Cirillo1,3

Currently two Coronavirus Disease 2019 (COVID-19) vaccines have been granted emergency use and marketing authorization by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) [12]. Initial efficacy and safety data for both BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) vaccines have been published [34]. To the best of our knowledge, there is no mention of facial paralysis in the article describing safety and efficacy of the BNT162b2 vaccine [3], however, four such adverse events were eventually highlighted in product monographs published by the relevant regulatory bodies [15]. Although FDA vaccine review memoranda do mention the occurrence of facial paralysis in the test group for both vaccines [12], consumer/patient information sheets of neither of the vaccines distributed in North America warn about Bell’s palsy as a possible adverse effect [6].

Here, we report a case of an otherwise healthy 37-year-old white Caucasian male who developed facial palsy within days after COVID-19 vaccination. We were given written, explicit informed consent to disclose the information reported in this letter. The patient received the first injection of the mRNA Vaccine BNT162b2 on 8th January, 2021, and the following day he developed symptoms including malaise, fatigue, and headache, but not hyperpyrexia. From the 11th, he complained of ingravescent left-sided latero-cervical pain irradiating ipsilaterally to the mastoid, ear, and retro-maxillary region. On 13th January upon awakening, he noticed a marked monolateral muscle weakness and attended the Maxillofacial Unit at our University Hospital. He presented with a left-sided facial droop accompanied by reduced mobility (paresis), with flattening of forehead’s skin and marionette line (labial-buccal sulcus) ipsilaterally as well as mild flattening of the nasolabial fold (Fig. 1). Lagophthalmos and mild labial hypomobility was also recorded. This clinical presentation was accompanied by a moderate Bell’s sign (failure to close the eye on the affected side with exposure of the sclera). No history of trauma, cold or other identifiable triggers was reported and no other signs or symptoms were present. Specifically, no history of a preceding infection, including recent SARS-CoV-2 infection, was reported and there was no evidence of a cutaneous rash suggestive of Herpes Zoster infection. The patient was referred to the Neurology Department with a provisional diagnosis of hemifacial paresis and discharged the same day with a clinical diagnosis of Bell’s palsy—an acute unilateral facial nerve paresis or paralysis with onset in less than 72 h and without identifiable cause [7]. No data are available concerning neurophysiological and cerebrospinal fluid investigations, as these were not deemed essential given that Bell’s palsy is fundamentally a clinical diagnosis and that there is no specific laboratory test to confirm the disorder. Laboratory or other diagnostic tests can surely be useful in excluding other conditions such as Lyme disease (not common in our geographical area) or neuropathies such as Gillian–Barre’ syndrome, or also brain tumors. These are especially useful when clinical presentation is not typical, and hence were not undertaken in our patient.

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