We read with interest the case report by Reis Carneiro et al. about a 62 years old female who developed fatigue, impaired concentration, dizziness, myalgia, unstable gait, and mild headache one day after the first jab with the BNT162b-Pfizer anti-SARS-CoV-2 vaccine [1]. Upon the clinical presentation and pleocytosis in the absence of documenting an infectious agent, aseptic meningitis was diagnosed [1]. Under steroids complete recovery was achieved [1]. The study is appealing but raises comments and concerns.
We do not agree with the diagnosis aseptic meningitis [1]. Since the erythrocyte count was high with each of the spinal taps, contamination of the specimen with peripheral blood leucocytes is quite likely and thus a false positive leukocyte count in the cerebro-spinal fluid (CSF) cannot be excluded.
Missing are the time points at which the three spinal taps were taken. To assess if steroids were truly effective, it is crucial to know which of the three spinal taps have been done before and which after initiation of steroids.
Missing are the results of the magnetic resonance venography (MRV). Since SARS-CoV-2 vaccinations can be complicated by venous sinus thrombosis (VST) [2], and since the clinical presentation is also compatible with VST, it is essential that VST had been appropriately excluded by MRV and determination of the D-dimer.
Missing are the profiles of the cytokines and chemokines in the CSF. Since cytokines and glial markers can be elevated or reduced in immune-reactions to a SARS-CoV-2 vaccination [3], it would be helpful to know the titres of these markers in the CSF.
We also disagree with the notion that the index patient had postural tachycardia [1]. Tachycardia is defined as a heart rate > 100. However, the patient presented with heart rates < 100.
The patient had myalgias, which do not comply with the diagnosis of a septic meningitis. A pathophysiological explanation of the myalgias should be provided.
There is a discrepancy between the statement “there was no fever or systemic complaints” and the symptoms fatigue and myalgia [1]. Fatigue and myalgia are regarded as systemic symptoms.
There is a discrepancy between the normal clinical, neurologic examination and the symptom “unstable gait”. We should know if the patient had a gait disturbance or not.
It is not mentioned if the cerebral MRI was carried out with or without contrast medium. Application of contrast medium is crucial to exclude encephalitis and whether the meninges enhanced or did not.
Overall, the interesting study has limitations which challenge the results and their interpretation. Addressing these limitations would strengthen the conclusion.
Funding
None received.
Author contribution
JF: design, literature search, discussion, first draft, critical comments, FS: literature search, discussion, critical comments, final approval.
Competing interests
None.
Ethical approval and consent to participate
Not applicable.
Consent for Publication
Not applicable.
Availability of data and material
All data reported are available from the corresponding author.
Acknowledgements
None.
References
- 1.Reis Carneiro D., Matos A., Morgadinho A. Steroid-responsive aseptic meningitis after BNT162b2 SARS-CoV-2 vaccine. Rev Neurol (Paris) 2021 doi: 10.1016/j.neurol.2021.10.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Associated Data
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Data Availability Statement
All data reported are available from the corresponding author.