Recurrent 6th nerve palsy in a child following different live attenuated vaccines: case report

Abstract

BackgroundRecurrent benign 6th nerve palsy in the paediatric age group is uncommon, but has been described following viral and bacterial infections. It has also been temporally associated with immunization, but has not been previously described following two different live attenuated vaccines.Case presentationA case is presented of a 12 month old Caucasian boy with recurrent benign 6th nerve palsy following measles-mumps-rubella and varicella vaccines, given on separate occasions with complete recovery following each episode. No alternate underlying etiology was identified despite extensive investigations and review.ConclusionsThe majority of benign 6th nerve palsies do not have a sinister cause and have an excellent prognosis, with recovery expected in most cases. The exact pathophysiology is unknown, although hypotheses including autoimmune mechanisms and direct viral invasion could explain the pathophysiology behind immunization related nerve palsies. It is important to rule out other aetiologies with thorough history, physical examination and investigations. There is limited information in the literature regarding the safety of a repeat dose of a live vaccine in this setting. Future immunizations should be considered on a case-by-case basis.

Benign Recurrent Sixth Nerve Palsy in a Child

“…This condition typically occurs following viral illnesses, infections, and immunization involving attenuated live vaccinations. In general, prognosis for benign recurrent 6th nerve palsy is excellent, and majority of patients recover full muscle function [ 6 ]. Failure to improve suggests more serious intracranial pathology [ 9 ].…”

“…Benign causes account for just 9 to 14% of all 6th nerve palsies in children [ 4 ]. A recurrent benign form of 6th nerve palsy, a rarer still palsy, has been described in the literature, and it is of presumed inflammatory etiology, associated with live attenuated vaccines, or following viral and bacterial infections such as Varicella zoster , Epstein-Barr virus, Cytomegalovirus, or Coxiella burnetii [ 5 , 6 ].…”

Adverse events following measles-mumps-rubella-varicella vaccine: an independent perspective on Italian pharmacovigilance data

“…More importantly, they do not question the plausibility of such an adverse reaction, because cranial nerve palsy may sometimes be the harbinger of encephalomyelitis, which may, although rarely, be caused by vaccinations. Cases of oculomotor nerve palsy occurring after MMR vaccination has already been described in the scientific literature 33 , 34 . Case 4 Case n. 23 cited in the paper of Stefanizzi et al 5 : “ The case involves a male child aged 30 months: few hours after vaccination, he developed hyperpyrexia with an episode of febrile seizure.…”

“…More importantly, they do not question the plausibility of such an adverse reaction, because cranial nerve palsy may sometimes be the harbinger of encephalomyelitis, which may, although rarely, be caused by vaccinations. Cases of oculomotor nerve palsy occurring after MMR vaccination has already been described in the scientific literature 33,34 .…”

Commentary

“…However, recurrent CN VI palsy has been reported in a child following vaccination against varicella, measles, mumps and rubella. [ 9 ] Although the live attenuated zoster vaccine has been noted to be not as effective in patients with reduced immune response, and is contraindicated in immunosuppressed patients, it is specifically these patients that require the most protection. Therefore, an efficacious-inactivated VZV vaccine is also needed to protect patients most at risk.…”