Adverse Vaccine Event or Coincidence?

October 19, 2015
Terry Brenneman, MD
Terry Brenneman, MD

Significant arm pain brings a 49 y/o man to see you. He wonders if the shot he got a few weeks ago might be to blame. What do you tell him?

[[{"type":"media","view_mode":"media_crop","fid":"41129","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4393983454792","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4293","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 298px; width: 435px; float: right;","title":"©HiperCom/Shutterstock.com ","typeof":"foaf:Image"}}]]Vaccines have been blamed for a lot of things that have been shown scientifically not to be related. Gardasil, in particular, has been under fire for a long time. If it were my child that developed  Guillain-Barré syndrome 2 weeks after getting vaccinated, how difficult would it be for me and those around me to accept that this was a a coincidence and not cause and effect.

That said, while vaccines are, on the whole, extremely safe, they can cause rare adverse side effects. Let's see what you think about this case.

A 49-year-old man goes to his local drug store and gets a dT vaccine. Several weeks later he develops severe, unrelenting pain in his biceps on the same side he got the shot. He comes to you for consultation. He doesn't remember specifically where he got the shot, but thinks it was more on his outer arm and higher up than where he currently locates the pain. His exam is normal to you except for a minimal decrease in the biceps reflex as compared to the other side.  He asks, “Could this be related to my dT vaccination?” 

How do you answer his question? You tell him:

A. “No.” 

B. “No, unless the pharmacist gave you the shot in the wrong location and damaged a nerve.”

C. “Maybe,” and start a work-up for Guillain-Barré syndrome.

D. “Maybe; sometimes vaccines can cause a weird autoimmune problem that involves the brachial plexus nerves and you might be eligible for some money from the Vaccine Court.”

For answer and discussion, please click here.

Answer: D. You tell him, "Maybe; sometimes vaccines can cause a weird autoimmune problem that involves the brachial plexus nerves and you might be eligible for some money from the Vaccine Court.”

The patient probably has Parsonage Turner syndrome (PTS), also known as acute brachial neuritis or brachial plexus neuropathy. This rare, but perhaps a little more common than Guillain-Barré, neurologic problem leads to sometimes severe pain in the shoulder, neck, and arm as well as sensory changes and weakness. Guillain-Barré does not usually present in the upper extremities first.

According to the National Organization for Rare Disorders, “Researchers believe that most cases [of PTS] result from an immune-mediated inflammatory response to some infection or environmental trigger that damages the nerves of the brachial plexus. A recent viral illness is the most common ‘triggering’ factor associated with the development of the disorder. Additional triggers that have been linked to PTS are recent immunization, surgery on the brachial plexus, unaccustomed strenuous exercise, minor trauma, bacterial infection, parasitic infection, anesthesia, rheumatologic diseases such as connective tissue disorders, and autoimmune disorders such as lupus, temporal arteritis, or polyarteritis nodosa. In women, childbirth can trigger PTS. In some cases, no triggering event or underlying factor can be identified.”

The Vaccine Injury Compensation Trust Fund was set up by the National Childhood Vaccine Injury Act of 1986 and is funded by an excise tax on vaccines. A number of specific injuries are paid automatically. Others may have to be adjudicated. A brachial plexus injury as described above following a dT vaccination is covered. Other covered injuries include anaphylaxis, chronic arthritis following MMR, encephalitis following a pertussis antigen containing vaccine, and others.  If you would like to learn more about this program, go to the Health Resources and Services Administration Web site. To learn more about Parsonage Turner syndrome go to tne National Organization for Rare Disorders Web site.

I must confess, I have given a lot of vaccines in my 35 years as a pediatrician and until about 2 weeks ago had never evenheardof PTS. One of the humbling, and exciting, things about the practice of medicine is that there is always something new to learn.