COVID-19 vaccines have brought us a ray of hope to effectively fight against deadly pandemic of COVID-19 and hope to save lives. Many vaccines have been granted emergency use authorizations by many countries. Post-authorization, a wide spectrum of neurological complications is continuously being reported following COVID-19 vaccination. Neurological adverse events following vaccination are generally mild and transient, like fever and chills, headache, fatigue, myalgia and arthralgia, or local injection site effects like swelling, redness, or pain. The most devastating neurological post-vaccination complication is cerebral venous sinus thrombosis. Cerebral venous sinus is frequently reported in females of childbearing age, generally following adenovector-based vaccination. Another major neurological complication of concern is Bell's palsy that was reported dominantly following mRNA vaccine administration. Acute transverse myelitis, acute disseminated encephalomyelitis, and acute demyelinating polyneuropathy are other unexpected neurological adverse events that occur as result of phenomenon of molecular mimicry. Reactivation of herpes zoster in many persons, following administration of mRNA vaccines, has been also recorded. Considering the enormity of recent COVID-19-vaccinated population, the number of serious neurological events is miniscule. Large collaborative prospective studies are needed to prove or disprove causal association between vaccine and neurological adverse events occurring vaccination.

/pdf/spectrum-of-neurological-complications-following-covid-19-3zdy1fagqq.pdf

Spectrum of neurological complications following COVID-19 vaccination.

The coronavirus disease 2019 (COVID-19) pandemic has affected millions of individuals worldwide. The global scientific effort to design an effective vaccine against this virus has led to the development of several vaccine candidates. The expedited rollout of these vaccines has created some public distrust regarding the safety of these new vaccines. This review compiles clinical data from reports of diagnosed immune-related neurological events that have occurred after COVID-19 vaccine administration with the exception of those secondary to hematological abnormalities. A systematic literature search was performed, using several databases, to identify reports of postvaccination adverse neurological events. The search resulted in 18 studies that met our criteria. These studies included 61 patients who had received COVID-19 vaccines and experienced at least 1 neurological adverse effect. The most common neurological event was facial nerve palsy (50% of all events). Other less frequently reported events included the reactivation of herpes zoster, Guillain-Barre syndrome, other demyelinating diseases, and neuropathy. The underlying mechanism was hypothesized to be related to vaccine-induced type 1 interferon production leading to decreased tolerance of the myelin sheath antigens. Other hypotheses include vaccine-induced transient lymphopenia and immune dysregulation. Most of the reported events were time limited and resolved spontaneously. Given the rarity of reported neurological events compared to the total number of vaccines administered, and the similarity in the incidence of events between COVID-19 vaccines and other more common vaccines, there is little evidence to support a causal relationship between COVID-19 vaccines and adverse neurological events. 

Neurological Immune‐Related Adverse Events After COVID‐19 Vaccination: A Systematic Review

Acute Myocardial Infarction Within 24 Hours After COVID-19 Vaccination: Is Kounis Syndrome the Culprit?

In an important report published in the American Journal of Cardiology,1Sung JG Sobieszczyk PS Bhatt DL Acute myocardial infarction within 24 hours after COVID-19 vaccination.Am J Cardiol. 2021; 156: 129-131Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar 2 patients (1 female and 1 male) who received the same COVID-19 vaccine messenger RNA-1273 (Moderna) developed acute myocardial infarction 1 day after the first dose. The authors speculated that the Moderna vaccine can induce an antibody response with a lipid-nanoparticle-encapsulated messenger RNA, whereas the ChAdOx1 nCoV-19 vaccine (AstraZeneca) can trigger an immune response by the nCoV-19 spike protein. Recent reports have shown Kounis hypersensitivity-associated acute myocardial infarction to be associated with other COVID-19 vaccines including BNT162b2 (Pfizer-BioNTech),2Tajstra M Jaroszewicz J Gąsior M Acute coronary tree thrombosis after vaccination for COVID-19.JACC Cardiovasc Intv. 2021; 14: e103-e104Crossref PubMed Scopus (33) Google Scholar Covishield vaccine,3Chatterjee S Ojha UK Vardhan B Tiwari A Myocardial infarction after COVID-19 vaccination-casual or causal?.Diabetes Metab Syndr. 2021; 15: 1055-1056Crossref PubMed Scopus (27) Google Scholar,4Srinivasan KN Sathyamurthy I Neelagandan M Relation between COVID-19 vaccination and myocardial infarction–casual or coincidental?.IHJ Cardiovascular Case Rep. 2021; 5: 71-74Google Scholar and Sinovac (Coronavac)5Özdemir İH, Özlek B, Özen MB, Gündüz R, Bayturan Ö. Type 1 Kounis syndrome induced by inactivated SARS-COV-2 vaccine [published online May 7, 2021]. J Emerg Med doi:10.1016/j.jemermed.2021.04.018.Google Scholar in addition to Moderna2Tajstra M Jaroszewicz J Gąsior M Acute coronary tree thrombosis after vaccination for COVID-19.JACC Cardiovasc Intv. 2021; 14: e103-e104Crossref PubMed Scopus (33) Google Scholar,6Boivin Z Martin J Untimely myocardial infarction or COVID-19 vaccine side effect.Cureus. 2021; 13: e13651PubMed Google Scholar,7Maadarani O Bitar Z Elzoueiry M Nader M Abdelfatah M Zaalouk T Mohsen M Elhabibi M Myocardial infarction post COVID-19 vaccine - coincidence, Kounis syndrome or other explanation - time will tell.JRSM Open. 2021; 1220542704211025259Google Scholar and AstraZeneca.7Maadarani O Bitar Z Elzoueiry M Nader M Abdelfatah M Zaalouk T Mohsen M Elhabibi M Myocardial infarction post COVID-19 vaccine - coincidence, Kounis syndrome or other explanation - time will tell.JRSM Open. 2021; 1220542704211025259Google Scholar Kounis syndrome is a condition associated with hypersensitivity reactions caused by drugs, metals, environmental exposures, conditions, and foods.8Kounis NG Koniari I de Gregorio C COVID-19 and Kounis syndrome: deciphering their relationship.Balkan Med J. 2021; 38: 145-149Crossref PubMed Scopus (11) Google Scholar In a recent report that dealt with 2 patients who developed myocarditis after getting vaccinated with Moderna and Pfizer-BioNTech, respectively, endomyocardial biopsy specimens showed inflammatory infiltrates comprising eosinophils and other interacting inflammatory cells, including T cells, B cells, plasma cells, and macrophages, indicating hypersensitivity reactions.9Verma AK Lavine KJ Lin CY Myocarditis after COVID-19 mRNA vaccination.N Engl J Med. 2021; 385: 1332-1334Crossref PubMed Scopus (130) Google Scholar Indeed, all currently used vaccines contain excipients (constituents of a pharmaceutical form apart from the active substance) that are speculated to induce hypersensitivity reactions. The viral vector Covishield vaccine, which is similar to AstraZeneca and manufactured in India, contains polysorbate 80, disodium edetate dihydrate (ethylenediaminetetraacetic acid), and aluminum hydroxide. The Moderna vaccine contains polyethylene glycol and tromethamine, also known as trometamol. The Pfizer-BioNTech vaccine contains polyethylene glycol. The Johnson & Johnson vaccine contains polysorbate 80. The Sputnik V vaccine contains polysorbate 80 and disodium ethylenediaminetetraacetic acid dehydrate. The Sinovac (Coronavac), which is manufactured in China, contains disodium hydrogen phosphate, sodium dihydrogen phosphate monohydrate, and sodium chloride. These excipients are also found in creams, ointments, lotions, other cosmetics, various dental materials, and anticancer drugs which could sensitize their users. It is estimated that 1% to 5.4% of the population is already sensitized to cosmetics or cosmetic ingredients.10Lyapina MG Stoyanova Dencheva M Contact sensitization to ingredients of dental materials and cosmetics in dental students: a pilot study.Cent Eur J Public Health. 2019; 27: 73-77Crossref PubMed Scopus (14) Google Scholar Free polysorbate oncology medications are already in the market.11Schwartzberg LS Navari RM Safety of polysorbate 80 in the oncology setting.Adv Ther. 2018; 35: 754-767Crossref PubMed Scopus (97) Google Scholar Alternatives to these excipients, such as alkylsaccharides, are promising agents because they can reduce immunogenicity, improve stability, suppress oxidative damage problems, and may prevent thrombotic and cardiovascular events.12Kounis NG Koniari I de Gregorio C Assimakopoulos SF Velissaris D Hung MY Mplani V Saba L Brinia A Kouni SN Gogos C Giovannini M Novembre E Arumugham V Ricke DO Soufras GD Nugent K Sestili P Malone RW COVID-19 disease, women's predominant non-heparin vaccine-induced thrombotic thrombocytopenia and Kounis syndrome: a passepartout cytokine storm interplay.Biomedicines. 2021; 9: 959Crossref PubMed Scopus (13) Google Scholar COVID-19 free allergenic vaccines would be beneficial. The authors have no conflicts of interest to declare. 

http://www.ajconline.org/article/S0002914921009565/pdf

Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.

https://academic.oup.com/ehjacc/article-pdf/11/10/786/46754197/zuac104.pdf

Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance.

A case of ST elevation myocardial infarction reported post Coronavirus disease 2019 (COVID-19) vaccine. Probably premature to draw a link between COVID-19 vaccine and myocardial infarction.

Myocardial infarction post COVID-19 vaccine - coincidence, Kounis syndrome or other explanation - time will tell.

Neuroleptic malignant syndrome following COVID-19 vaccination.

The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension.

If not detected early, euglycemic diabetic ketoacidosis can be a serious adverse effect of sodium–glucose cotransporter‐2 (SGLT2) inhibitors. Unfortunately, euglycemic diabetic ketoacidosis is underreported in recent trials and missed because of normal blood sugar levels and nonspecific symptoms on presentation. We present two patients with type 2 diabetes mellitus who developed dapagliflozin‐associated euglycemic diabetic ketoacidosis followed by hyperglycemic ketoacidosis. The second patient had euglycemic ketoacidosis twice despite instructions to stop using the medication dapagliflozin.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/ccr3.5440

Sodium–glucose cotransporter‐2 inhibitors induced euglycemic diabetic ketoacidosis: Two case reports and a review of the literature

https://doi.org/10.1016/j.ijscr.2022.106830

Mahmoud Elzoueiry

Papers

Myocardial infarction post COVID-19 vaccine - coincidence, Kounis syndrome or other explanation - time will tell.

Neuroleptic malignant syndrome following COVID-19 vaccination.

The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension.

Sodium–glucose cotransporter‐2 inhibitors induced euglycemic diabetic ketoacidosis: Two case reports and a review of the literature

Detecting spontaneous retroperitoneal hemorrhage using a modified RUSH protocol: a case report