Neuralgic amyotrophy in COVID-19 infection and after vaccinationLETTER TO THE EDITOR Dear Editor, Various neurological manifestations associated with coronavirus disease 2019 (COVID-19) have been described, 1 conditions which left a significant proportion of patients with permanent disability. Continued vigilance is crucial with emergence of new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants that cause the disease. Vaccination against COVID-19 remains the key strategy to reduce disease severity and transmission. 2 However, the novel mRNA technology and reports of neurological adverse effects raise concerns about COVID-19 vaccine safety, especially since multiple doses are needed to combat the waning immunity of such vaccines. 3 Neuralgic amyotrophy (NA), or Parsonage-Turner syndrome/brachial neuritis, is characterised by male predisposition, severe pain and limb weakness in the 3rd to 7th decade of life. 4 It has rarely been reported in COVID-19 infections or within 6 weeks of vaccination. 5 Hypothesised causes focus on immune-mediated processes, 3 although the underlying pathophysiology remains unclear. With the COVID-19 pandemic, the challenge lies in differentiating the trigger for NA in vaccinated individuals who develop breakthrough COVID-19 infections. Comparisons of disease characteristics in COVID-19 patients with those occurring after COVID-19 vaccinations may shed some light, but such data are lacking. We illustrate a case and review the literature by searching PubMed, Embase and Google Scholar from 1 December 2019 to 30 November 2021 using the following keywords: "Parsonage-Turner Syndrome", "brachial plexopathy", "brachial neuritis", "brachial plexitis", "neuralgic amyotrophy", "SARS-CoV-2" and "COVID-19". We analysed cases with confirmed COVID-19 (World Health Organization guidelines) 6 occurring in symptomatic individuals and in those presenting within 6 weeks of COVID-19 vaccination (time frame conventionally used to study vaccine-related adverse events). 7 Cases with inadequate data, unclear temporality and non-English reports were excluded. The study was approved by the Singapore Health Services institutional review board (CIRB 2020/2410), and waiver of consent was granted.A 34-year-old healthy man presented on day 4 of symptomatic COVID-19 with a 3-day history of shoulder pain, weakness and numbness of the left upper limb. There was no trauma, recent neck manipulation nor other constitutional symptoms. He had received the

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A 59-year-old man with a history of smoking presented with acute right hemiparesis, pain, and temperature loss on the left below T4 and impaired left-sided abdominal reflexes. Proprioception and vibration were normal. MRI (day 3) showed a short segment of T2 hyperintensity at the right half of C5 spinal cord (figure 1); diffusion-weighted MRI (day 5) demonstrated restricted diffusion (figure 2), confirming hemicord infarct. Sulcal artery occlusion presents with incomplete Brown-Sequard syndrome and is uncommon, unlike the more common anterior spinal artery syndrome. 1 It preferentially involves the cervical cord. 2 With physiotherapy, aspirin, and statins, this patient recovered well.