Complex regional pain syndrome I following vaccination against human papillomavirus

Case Report: A 14-year old girl received her first dose of quadrivalent human papillomavirus vaccine in the right deltoid muscle. Within 24 hours she developed severe pain, swelling, numbness, and coldness of the right arm and hand. Diagnostics with ultrasound, nerve conduction, and sensory evoked potentials were normal. The MRI scan of the right arm and brachial plexus showed no nerve injury. The symptoms improved under physical and occupational therapy. After 2 month skin temperature was normal and swelling reduced. However, pain and lack of function is ongoing.

Discussion: Complex regional pain syndrome (CRPS, formerly known as Sudeck dystrophie) may develop following limb trauma, lesions of the peripheral or central nervous system or fractures. Incidence ranges in adults from 5.46 to 26.2/100,000/y. In the pediatric population it is even less common. Diagnosis is based on clinical criteria by the International Association for the Study of Pain. The clinical triad includes autonomic, sensory, and motor disturbances. Pathophysiological concepts discussed are neuroinflammation, pathological regulation of the sympathetic nervous system and affection of the central nervous system. Therapy includes early physical and occupational therapy.

CRPS after vaccination is described after immunization against rubella and hepatitis B. Recently in literature there were first cases published of CRPS I after immunization with Gardasil, suggesting a higher risk of developing this complication compared with other vaccines.

Conclusion: CRPS normally develops after trauma, fractures or lesions of the central or peripheral nervous system. However, immunization may also cause CRPS. Therefore, CRPS should be considered in patients with typical symptoms after vaccination.