Arm Pain Following Second Mrna Sars-cov-2 Vaccination - Page #4
 

Working Diagnosis:
Shoulder injury related to vaccine administration (SIRVA) with rhabdomyolysis

Treatment:
This patient was treated non-operatively with oral fluid hydration and a home exercise program to improve range of motion. It was also recommended that she avoid nonsteroidal antiinflammatory medications and high intensity exercise. Given her occupation as a physical therapist, she also took a brief leave of absence from work.

Outcome:
At her follow up visit 5 days later, the patient reported compliance with the recommended treatment regimen and noted improvement of swelling. Her pain and function improved by approximately 50%. Repeat creatine kinase level showed a significant decrease to 329 U/L (from 1,303 U/L). At her final follow up visit 5 days later, she reported continued improvement of her symptoms and was near her baseline. She was cleared to return to work 3 weeks after the initial injury and required no work restrictions.

Author's Comments:
Since 2010, claims of SIRVA to the National Vaccine Injury Compensation Program (VICP) have been increasing. This is likely due to a generalized better understanding of SIRVA and an increased utilization of reporting systems. Since SIRVA is an iatrogenic injury, it is something that should be avoidable. It demonstrates the importance of teaching proper vaccine administration technique, especially in these times when people who are not normally giving vaccinations are being pulled from their normal duties to help administer vaccines.
Early recognition of SIRVA is beneficial as it can potentially save patients from undergoing excessive testing, as the treatment is conservative and does not generally require advanced imaging. It is important to keep SIRVA on the differential diagnosis, especially if the patient recently had a vaccination or they have an atypical presentation of shoulder pain without trauma. It is unclear how often rhabdomyolysis occurs in conjunction with SIRVA, as it has not been adequately studied. It is also unclear of the long term effects that SIRVA has on patients. These are areas for further investigation.

Editor's Comments:
Shoulder injury related to vaccine administration (SIRVA) is an entirely preventable injury that can result in unnecessary diagnostic testing, undue stress for the patient, long-term pain and functional deficits if not treated in a timely fashion, increased financial burden on the healthcare system and loss of income for patients. Improper placement of the syringe during vaccine administration can lead to an inflammatory process that affects various structures including bursae, tendons, ligaments and nerves (axillary and radial). Physical exam and diagnostic ultrasound findings will not appear to be any different from other routine shoulder injuries. SIRVA, however, is distinguished by the onset of symptoms occurring within 48 hours of vaccine administration. Further research is needed to define the prevalence of rhabdomyolysis in association with SIRVA. Emphasis should be placed on proper intramuscular injection technique with appropriate landmarking, and increased awareness of SIRVA amongst healthcare providers.

References:
Zhang, Mei-Hua. “Rhabdomyolosis and its pathogenesis.” World journal of emergency medicine vol. 3,1 (2012): 11-5. doi:10.5847/wjem.j.issn.1920-8642.2012.01.002
Hesse, Elisabeth M et al. “Shoulder Injury Related to Vaccine Administration (SIRVA): Petitioner claims to the National Vaccine Injury Compensation Program, 2010-2016.” Vaccinevol. 38,5 (2020): 1076-1083. doi:10.1016/j.vaccine.2019.11.032
Hamarat, Hatice et al. “Rhabdomyolysis probably induced by influenza vaccine and fibrate therapy.” European journal of rheumatology vol. 2,4 (2015): 169. doi:10.5152/eurjrheumatol.2015.0008
Bancsi, Ashley et al. “Shoulder injury related to vaccine administration and other injection site events.” Canadian family physician Medecin de famille canadien vol. 65,1 (2019): 40-42.

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