The National Health Service defines Polymyalgia Rheumatica (PMR) as a condition that causes pain, stiffness, and inflammation in the muscles around the shoulders, neck, and hips.
Poly means many, and myalgia means muscle pain. Thus, PMR presents as muscle pain in several areas of the body.
This article features several case reports of PMR after the Pfizer Biontech BNT162b2 and Moderna mRNA-1273.
Pfizer
The first case is from Italy. [1]
In February 2021, the day after the first dose of the BNT182b2 vaccine, a 69‐year‐old woman complained of sudden bilateral pain in the shoulder and pelvic girdles associated with morning stiffness lasting > 2 hours, fever, and general malaise.
Until then, she enjoyed excellent health and worked occasionally as a domestic helper. Significant restrictions in her self‐care activities of daily living (ADL) depending on the affected areas were present.
She took acetaminophen 1000 mg twice daily for 3 days with resolution of fever, but no improvement on pain.
She went to the hospital and was diagnosed with PMR using 18‐fluorodeoxyglucose positron emission tomography (18‐FDG/PET) associated with total body computed tomography (CT).
The image below is her PET scan showing increased tracer uptake (highlighted) in the peri‐articular and extra‐articular synovial structures of the shoulder (see arrows in the right image) and pelvic girdles (see arrows in the left image)
She was started treated with prednisone 15 mg/day, and her clinical manifestations and activities of daily living (ADL) quickly improved.
The second dose of the anti-SARS-CoV-2 vaccine was not administered. After 5.5 months, she takes 7.5 mg/day of prednisone and is fine.[1]
Another case is from Japan.[2]
An 80-year-old Japanese woman presented with bilateral shoulder and hip pain lasting for a month. Her symptoms started two days after the second dose of the BNT162b2 COVID-19 vaccine.
Her physical findings, laboratory data, and ultrasonographic findings of bilateral biceps tenosynovitis and lateral subacromial bursitis were consistent with a diagnosis of polymyalgia rheumatica (PMR). She was successfully treated with oral prednisolone 15 mg/day.
Moderna
The third case is from Japan.[3]
A 70-year-old man presented with a sudden onset of severe pain and stiffness of the neck, shoulder girdle, pelvic girdle, and thigh with restricted motion 7 days after receiving the second dose of the mRNA-1273 vaccine.
Before that, the patient had developed a low-grade fever and slight malaise after the second injection. Those symptoms had been progressing, with the additional development of a headache, jaw claudication, and scalp tenderness simultaneously.
The patient had previously been healthy without any medication and no family history of connective tissue disorders.
The PET/CT showed increased uptake of fluorine-18 fluorodeoxyglucose around the shoulder joints, hip joints, and ischial tuberosity with no signs of temporal arteritis or large-vessel vasculitis.
The patient met the classification criteria for PMR, and the imaging findings were typical for PMR.
His symptoms improved with only acetaminophen up to 1,500 mg/day. One month after the onset, the patient’s condition was resolved.[3]
Case series of ten patients
Ten patients who developed PMR were reported from France. [4]
The median age of the patients (70% women) was 74.5 years (range 65–89). Seven patients had new-onset PMR. Three had PMR relapse after respectively one, two, and 11 years of free-drug remission.
All patients fulfilled the 2012 ACR/EULAR (American College of Rheumatology/ European League Against Rheumatism) criteria for PMR.
Symptoms
All patients had inflammatory pain and stiffness of the shoulders and pelvic girdle. The median symptom duration was 10.5 weeks (range 3–24).
COVID-19 vaccines were BNT162b2 (Pfizer/BioNTech) for nine patients and mRNA-1273 (Moderna) for the remaining patient.
The median delay between vaccination and the first PMR symptoms was 10 days (range 5–15).
Testing for PMR
All patients had negative PCR tests for SARS-CoV-2. Seven patients underwent ultrasonography of the hip and shoulder, and all showed typical features of PMR.
All patients underwent (PET/CT) showing 18F-FDG uptake in PMR-related sites (shoulders, hips, trochanteric and ischiatic bursitis, symphysis, sternoclavicular joints, interspinous bursitis).
The median C-reactive protein level was 26 mg/l (range 3–224).
Treatment
Steroid therapy was used in nine patients, methotrexate in three, and tocilizumab in one patient. All improved. One patient was only treated by local steroid injection.
How can the COVID shots cause PMR?
In their discussion, Ottaviani and colleagues [4] cited several authors for the explanation. Polack et al. said that COVID-19 mRNA vaccines have no adjuvant but stimulate innate immunity by activating Toll-like receptors (TLRs), notably TLR-7 and TLR-9.[5]
In patients with active PMR, TLR-7 and TLR-9 are overexpressed in the mononuclear cells, according to the work of Alvarez-Rodriguez et al. Therefore, the increase in the TLR-7 and TLR-9 can explain why PMR can initiate or relapse after the COVID injections.[6]
Take away message
This article presents only a few cases of Polymyalgia Rheumatica from developed countries. Most likely, cases of PMR after the COVID jabs are under-reported. Not all medical providers may be able to diagnose and have the time to make a case report.
If you know someone who developed diffuse muscle pain after the COVID shots and does not have a proper diagnosis, they should talk to their doctor if they have considered PMR.
References:
- Manzo C, Natale M, Castagna A. Polymyalgia rheumatica as uncommon adverse event following immunization with COVID-19 vaccine: A case report and review of literature. Aging Med (Milton). 2021 Aug 15;4(3):234-238. doi: 10.1002/agm2.12171. PMID: 34518809; PMCID: PMC8426911.
- Osada A, Sakuragi C, Toya C, Mitsuo A. New-onset Polymyalgia Rheumatica Following the Administration of the Pfizer-BioNTech COVID-19 Vaccine. Intern Med. 2022 Mar 1;61(5):749-753. doi: 10.2169/internalmedicine.8651-21. Epub 2021 Dec 11. PMID: 34897152; PMCID: PMC8943385.
- Izuka S, Komai T, Natsumoto B, Shoda H, Fujio K. Self-limited Polymyalgia Rheumatica-like Syndrome Following mRNA-1273 SARS-CoV-2 Vaccination. Intern Med. 2022 Mar 15;61(6):903-906. doi: 10.2169/internalmedicine.8829-21. Epub 2021 Dec 28. PMID: 34980802; PMCID: PMC8987264.
- Ottaviani S, et al. Polymyalgia rheumatica following COVID-19 vaccination: A case-series of ten patients. Joint Bone Spine. 2022 Mar;89(2):105334. doi: 10.1016/j.jbspin.2021.105334. Epub 2021 Dec 22. PMID: 34954076; PMCID: PMC8694785.
- Polack FP, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020 Dec 31;383(27):2603-2615. doi: 10.1056/NEJMoa2034577. Epub 2020 Dec 10. PMID: 33301246; PMCID: PMC7745181.
- Álvarez Rodríguez L, et al. Expression and function of toll-like receptors in peripheral blood mononuclear cells of patients with polymyalgia rheumatica and giant cell arteritis. Ann Rheum Dis. 2011 Sep;70(9):1677-83. doi: 10.1136/ard.2010.140194. Epub 2011 Jun 13. PMID: 21670089.