CukurovaMedicalJournal
CukurovaMed J 2022;47(3):1375-1377
ÇUKUROVA ÜNİVERSİTESİ TIP FAKÜLTESİ
DOI: 10.17826/cumj.1124528
YazışmaAdresi/Address for Correspondence: Dr. Hatice Kaplanoğlu, Health Sciences University
DışkapıYıldırımBeyazıt Training and Research Hospital, Department of Radiology, Ankara, Turkey
E-mail: [email protected]
Geliştarihi/Received: 01.06.2022 Kabul tarihi/Accepted: 01.08.2022
EDİTÖRE MEKTUP / LETTER TO THE EDITOR
Shoulder injury related to rabies vaccine administration: a case report
Kuduz aşısı uygulamasına bağlı omuz yaralanması: bir olgu sunumu
Hatice Kaplanoğlu
1
, Veysel Kaplanoğlu
2
, Aynur Turan
1
, EceÜnlü Akyüz
3
1
Health Sciences University DışkapıYıldırımBeyazıt Training and Research Hospital, Department of Radiology, Ankara,
Turkiye
2
Health Sciences University Keçiören Training and Research Hospital, Department of Radiology, Ankara, Turkiye
3
Health Sciences University DışkapıYıldırımBeyazıt Training and Research Hospital, Department of Physical Therapy and
Rehabilitation, Ankara, Turkey
Cukurova Medical Journal 2022;47(3):1375-1377
To the Editor,
Adverse reactions at vaccine injection sites are
widespread, although the symptoms are generally
mild and transient
1
. The most common findings are
pain, swelling and redness at the injection
site
2.
Shoulder injury related to vaccine administration
(SIRVA) has been defined as shoulder pain and
limited range of motion in the shoulder after the
administration of a vaccine into the upper arm,
1
and
can be expected to become more common due to the
increase in vaccination campaigns
3
. Although most
cases are self-limiting, some people experience severe
and persistent shoulder pain that requires treatment
3
.
A 26-year-old female patient presented to our
hospital for rabies vaccination after being scratched
by a stray cat. The patient was scheduled for four
doses of the rabies vaccine, but after the second dose
the patient started to experience pain, mild swelling,
redness and limited range of motion in her left arm.
The pain had not dissipated one week after the
second dose and increased with movement, limiting
her daily activities, and so she presented to the
physical therapy outpatient clinic. The patient had no
history of disease or previous complaints of shoulder
dysfunction. A physical examination revealed mild
swelling, redness and generalized tenderness in the
left upper arm at the level of the humeral head.
Rotator cuff muscle strength and normal passive
range of motion were preserved, but the active range
of motion of the left shoulder was limited and
painful. Shoulder impingement syndrome tests and
Hawkins, Yergason, and Neer tests were positive. A
shoulder magnetic resonance (MRI) examination
performed approximately 1 month after the second
dose vaccination revealed signal changes consistent
with marked edema in the teres minor muscle, as well
as focal bone marrow edema in the greater
tuberculum at the teres minor tendon insertion level
at the humeral head (Figure 1a, b). Effusion in the
subdeltoid bursa, and an increased signal in the distal
teres minor tendon and surrounding fluid were also
noted (Figure 1c).
The patient was started initially on non-steroidal anti-
inflammatory drugs, but a steroid injection was
subsequently administered into the subdeltoid bursa
under ultrasonography guidance after she described
increased pain. Physical therapy consisting of
superficial and deep warming and analgesic currents
was applied to the shoulder area for two weeks, and
shoulder joint range of motion and muscle
strengthening exercises were prescribed. One month
later, the patient’s shoulder movements were painless
at follow-up, shoulder impingement syndrome tests
were negative and the patient reported reduced pain.
The patient provided informed consent for this case
report.
Kaplanoğlu et al.
Cukurova Medical Journal
In a patient with no previous history of chronic pain
or inflammatory disease, the diagnosis of SIRVA is
based on rapid-onset pain after intramuscular vaccine
administration, consistent with a local immune-
mediated inflammatory reaction in the affected
shoulder
4
. Mild pain, erythema, inflammation and
induration at the vaccination site are the most
common local side effects.
2
Complaints affecting the
shoulder due to vaccine injections are usually self-
limiting and resolve within 24 to 48 hours,
5
while
SIRVA, characterized by prolonged and debilitating
shoulder pain, develops in very few cases
3
. For a
diagnosis of SIRVA there should be no significant
history of the shoulder before the injection,
complaints should begin within 48 hours and there
should be no response to analgesics
6
.
Figure 1.Fat-suppressed proton density-weighted MRI images of the patient presenting with persistent
shoulder pain after the second dose of a rabies vaccine: (a) sagittal and (b) coronal images show and increased
signal consistent with intense edema in the teres minor muscle (black arrow) and subchondral bone marrow
edema in the tuberculum majus of the humeral head (red arrow), (c) axial image shows fluid in the subdeltoid
bursa (black arrow) and increased signal in the distal teres minor tendon and surrounding effusion (red arrow).
Most cases of SIRVA are associated with needle
misplacement and/or a local reaction to the serum
administered during the vaccine administration
3
. The
majority of reported SIRVA cases are women
(71.1%) with a mean age of 53.6 (range: 22–89) years
7
The vaccines most frequently associated with SIRVA
are influenza and pneumococcal vaccines, followed
by diphtheria-tetanus-pertussis, diphtheria-tetanus
toxoid, human papillomavirus and hepatitis A
vaccines
3,8
although SIRVA has also been reported
following COVID-19 vaccinations during the
pandemic
3,6
Shoulder injuries following vaccinations are injuries
that are more severe than should be expected from a
simple needle trauma
1
. The most common shoulder
lesion is bursitis.
3
If the injection is made deep into
the shoulder capsule, it can result in inflammation of
the shoulder joint or bursal inflammation (synovitis)
or infection (septic arthritis or bursitis); if into the
rotator head, rotator cuff injury (tendinitis or rotator
cuff rupture) can occur; and if into the subacromial
or subdeltoid space, bursitis and/or adhesive
capsulitis can develop
3
.
Patients with SIRVA typically complain of shoulder
pain, weakness in the shoulder, decreased range of
motion, paresthesia and tingling in the vaccinated
arm
3
.Cases with shoulder pain lasting longer than 48
hours after vaccination and gradually worsening
should be evaluated clinically
3
.Radiography (x-ray)
images can be easily obtained, but will often not be
positive or diagnostic in the early period
9
, and so the
preferred imaging modality is MRI
9
. The most
frequently reported MRI findings are increased fluid
in the glenohumeral joint and
subdeltoid/subacromial bursa, bone marrow edema,
rotator cuff tear, a fluid signal in the bicipital groove
Cilt/Volume 47Yıl/Year 2022
Shoulder injury related to rabies vaccine administration
and biceps tendinitis
6
. In most injuries of this kind,
no contrast material is used in the MRI evaluation
3
,
although MRI with contrast enhancement is
recommended if infection is suspected. Furthermore,
MRI can effectively show the extent of damage to the
bone and the surrounding soft tissue
3
.
There will likely be an increase in SIRVA cases with
the increase in vaccination programs
3
, and so the first
approach should be to prevent SIRVA through the
use of appropriate injection techniques, and proper
syringe, needle thickness and needle length selection
3
.
The leading cause of SIRVA is the injection being
applied “too high” into the deltoid region
6
. The
subacromial bursa may extend 3–6 cm distally from
the acromion, and its distance from the skin is 0.8–
1.6 cm. Injections into the upper 1/3 of the deltoid
muscle may affect the subdeltoid/subacromial bursa,
and so injections should not be made in this area
6
.
Instead, the needle should be inserted into the
thickest part of the deltoid muscle
3
.
Shoulder injuries should be considered as one of the
adverse effects of vaccination. To minimize the risk
of post-vaccination shoulder complications,
healthcare professionals should strictly adhere to the
standards defined in intramuscular injection practice
guidelines
Yazar Katkıları:Çalışma konsepti/Tasarımı: HK, VK, AT, EÜA; Veri
toplama: HK, VK, AT, EÜA; Veri analizi ve yorumlama: HK, VK, AT,
EÜA; Yazı taslağı: HK, VK, AT, EÜA; İçeriğineleştirelincelenmesi: HK,
VK, AT, EÜA; Son onay ve sorumluluk: HK, VK, AT, EÜA; Teknik
ve malzeme desteği: -; Süpervizyon:HK, VK, AT, EÜA; Fon sağlama
(mevcutise): yok.
Etik Onay: Bu çalışma için etik onay gerekli değildir. Olgudan
aydınlatılmışn onam alınmıştır. .
Hakem Değerlendirmesi: Editoryal değerlendirme
Çıkar Çatışması:Yazarlar çıkar çatışması olmadığını beyan etmişlerdir.
Finansal Destek:Yazarlar finansal destek almadıklarını beyan
etmişlerdir.
Author Contributions: Concept/Design :HK, VK, AT, EÜA; Data
acquisition: HK, VK, AT, EÜA; Data analysis and interpretation: HK,
VK, AT, EÜA; Drafting manuscript: HK, VK, AT, EÜA; Critical
revision of manuscript: HK, VK, AT, EÜA; Final approval and
accountability: HK, VK, AT, EÜA; Technical or material support: -;
Supervision: HK, VK, AT, EÜA; Securing funding (if available): n/a.
Ethical Approval: For this type of study ethical approval is not
required. The patient provided informed consent.
Peer-review: Editorial review.
Conflict of Interest:The authors declare no conflict of interest.
Financial Disclosure:For this type of study formal consent is not
required.
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