LAUSR

Dear Editor, The stepping up of an effective mass vaccination programme against the novel SARS-CoV-2 virus worldwide has led to the emergence of a host of adverse events involving various systems, a majority of which are self-limiting. Central nervous system inflammation is one of the rare adverse effects of post-COVID vaccination and has been described in a few case reports. We hereby report a reversible frontal lobe syndrome in a patient following ChAdOx1 nCoV-19 vaccination. A 45-year-old male without any prior comorbidities developed behavioural abnormalities and weakness of both the lower limbs, 3 days after receiving the first dose of ChAdOx1 nCoV-19 vaccination (COVISHIELD). The patient was apparently asymptomatic prior to the vaccination. Three days after vaccination, he developed mild fever, became confused, had short-term memory impairment, and had decreased attention span. Over the next 2 days, he became dependent on family members for walking, and developed buckling of the knees, with slippage of slippers with knowledge. Almost at the same time, family members noticed he had developed aggressive behaviour and started to use abusive language to his family members. He began to defecate and urinate at inappropriate places and was not concerned for the same. There was no past history of any fever, focal neurological deficit, seizure, head injury, drug or toxin exposure, high-risk behaviour, or any other systemic illness. For the abovementioned complaints, he consulted a local physician and was started on antipsychotics medication without any improvement in his symptoms. After 2 weeks of illness, he presented to the neurology ward and was found to be afebrile, with stable vitals and a Glasgow Coma Score of 14 (E4M6V4). His attention span forward was 2 and backward was 1 and patient was disoriented to time, place, and person. His power in both the upper limbs was at least MRC grade 3/5 in both the lower limbs and normal in both the upper limbs, deep tendon reflexes were normal in both the upper limbs, and were brisk in both lower limbs. The plantar response was bilaterally extensor. All the frontal release signs were present. His routine haematological and biochemical parameters were normal. Thyroid profile, HIV, vasculitis workup, anti-TPO, autoimmune and paraneoplastic panel workup, and USG abdomen and X-ray chest were normal. (A CT chest abdomen and pelvis was planned but could not be done due to financial constraints.) Cerebrospinal fluid analysis was unremarkable including a panel for common regional aetiologies of viral encephalitis. An initial magnetic resonance imaging (MRI) of the brain had revealed diffusion restriction and patchy and flair hyperintensity in b/l frontal subcortical and deep white matter without any contrast uptake (Fig. 1). The patient was managed with intravenous pulse methylprednisolone (1 gm) for 5 days, after which he had a dramatic improvement. His aggressive behaviour became normal, started to tell regarding urination and defecation, started to walk by taking support of one stick, and had significant improvement in his attention. He was discharged on oral steroids. Repeat MRI done 4 weeks later showed a significant decrease in lesion load (Fig. 2). Thus, our patient presented with a frontal lobe syndrome, with features of acute central nervous system inflammation on MRI consistent with ADEM (acute disseminated encephalomyelitis), 3 days after vaccination. This may be explained possibly by either direct local effect of S protein or noxious effect of anti-S protein * Deepika Joshi [email protected]