We present a case of a female who presented with the acute onset of neurological changes within 24 hours of receiving her third, or booster, dose of the mRNA Moderna (Cambridge, Massachusetts) coronavirus disease 2019 (COVID-19) vaccination. Her clinicoradiological findings were most consistent with posterior reversible encephalopathy syndrome (PRES). Although PRES has been reported with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this raised suspicion of a possible vaccine-induced PRES with her only confounder being hypertension managed with a beta-blocker. Extensive workup for other entities associated with PRES, including infection, autoimmune, paraneoplastic syndrome, and alcohol were unrevealing. Thus far, there have not been any reports of PRES post mRNA vaccination. We encourage providers to report similar cases with neurological manifestations post mRNA vaccination to the vaccine adverse event reporting system (VAERS). Timely diagnosis and treatment of PRES may help minimize any irreversible neurological sequelae.

Case reports of myocarditis post-coronavirus disease 2019 (COVID-19) mRNA vaccination have not uniformly reported long-term follow-up beyond 90 days. We present a 23-year-old male who is typical of a patient presenting with myocarditis post-COVID-19 mRNA-1273 Moderna vaccination (young males, onset several days after second dose of the mRNA vaccine, and excellent short term complete recovery). Follow-up at 128 days revealed no residual sequelae in our patient. Although a definitive diagnosis of myocarditis requires an endomyocardial biopsy (EMB), diagnosis is usually made clinically and with imaging in most clinical settings unless part of an approved research protocol or if indicated clinically. We recommend active surveillance and reporting for myocarditis post mRNA vaccination and even consider reporting those with symptom onset beyond 90 days.

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Clinical Case: A 76-year-old female presented to our ED with acute onset confusion, unsteady gait and blurry vision within 24 hours after receiving the m-RNA Moderna booster vaccine. Medical history: notable for uncomplicated hypertension on metoprolol. She was awake, oriented intermittently x 3, with periods of confusion, blurry vision and intermittent unsteady gait and normal speech without any focal motor or sensory deficits. BP=192/80 mmHg bilaterally. Labs: showed hypercalcemia with elevated vitamin D 25-OH. Hypertension was managed with home dose of metoprolol succinate 150 mg/day and hypercalcemia improved with IV fluids. On Day 3 the patient was found lying in bed unresponsive to sternal rub with motor twitching of left arm, seizure like activity. Transfer to ICU for BP =185/104mmHg, T = 100.8 F, airway protection and treatment with diazepam. Empirical antibiotics were started for presumed encephalitis. EEG demonstrated seizure foci in bilateral posterior quadrants. MRI imaging on day # 3 showed T2/FLAIR hyperintensities in the parieto-occipital lobes and pulvinar of the thalami suggestive of posterior reversible encephalopathy syndrome (PRES). Discussion: PRES syndrome is both a clinical and radiological diagnosis with neurological changes coupled with MRI FLAIR hyperintensities in the parietal, occipital and frontal bilateral areas. This condition has been associated with uncontrolled hypertension, endothelial injury and side effect from certain drugs. Her hypertension was aggressively managed with amlodipine, enalapril, and IV metoprolol to decrease cerebral perfusion pressure. Repeat MRI imaging on day #14 demonstrated resolution of the hyperintensities without episodic blurry vision, confusion and our patient's mentation improved. At her 7 weeks follow our patient continued to have residual deconditioning and could only follow 2 step commands. We emphasize the importance of timely diagnosis with MRI imaging and preventing delay in management with adequate anti-hypertensives to prevent irreversible neurological damage from PRES syndrome. We also encourage reporting similar findings to VAERS as we are unable to exclude a reaction to her m-RNA vaccine booster.

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