Diphtheria-Tetanus-Acellular Pertussis and Inactivated Poliomyelitis Vaccination as a Possible Cause of Bell's Palsy

대 한 소 아 신 경 학 회 지

Vol. 18, No. 2, November, 2010

- 307 -

1)

Introduction

Bell's palsy is the most common cause of facial paralysis worldwide

. The definition of Bell s palsy is a lower motor neuron facial ’ nerve paralysis of acute onset without identifi- able causes. The incidence is 2.7 per 100,000 under age 10 years and 10.1 per 100,000 between ages 10 and 20 years, and it is ra- rely reported in infants

. The pathogenesis and etiology of Bell s palsy remain controver ’ -

Received : 25 August, 2010, Revised : 6 October, 2010 Accepted : 11 October, 2010

Correspondence : Young Mi Kim, M.D.

Department of Pediatrics, College of Medicine, Pusan National University Hospital

Tel : +82.51-240-7298, Fax : +82.51-248-6205 E-mail : [email protected]

sial. Bell s palsy is largely a diagnosis of the ’ exclusion of other possible causes, such as central or peripheral neurologic lesions, sys- temic infections, and inflammatory conditions

3)

. Some researchers have suggested vaccina- tion as a cause of Bell s palsy ’

.Here, we de- scribe two infants who suffered from Bell s ’ palsy following the immunization for DTaP and IPV and recovered completely after only eye care.

Case Report

Case 1

A 65-day-old girl came to our outpatient

Diphtheria-Tetanus-Acellular Pertussis and Inactivated Poliomyelitis Vaccination

as a Possible Cause of Bell's Palsy

Peter Chun, M.D., Kyung Yeon Lee, M.D.

, Young Mi Kim, M.D., Hye Young Kim, M.D., Yoon Jin Lee, M.D. and Sang Wook Nam, M.D.

Department of Pediatrics, Pusan National University Hospital, Pusan National University Medical School, Busan, Korea

Department of Pediatrics

, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

= Abstract =

Bell's palsy is an idiopathic peripheral facial nerve palsy of acute onset. Although some studies have reported cases of Bell's palsy after certain vaccinations, reports of Bell s palsy in association with diphtheria-tetanus-acellular pertussis (DTaP) and’ inactivated poliomyelitis vaccination (IPV) have been rare. Here, we report two infants who suffered from Bell s palsy after immunization with DTaP and IPV and re’ - covered completely without neurologic deficits.

Key Words : Bell's palsy, Diphtheria-Tetanus-acellular Pertussis vaccine, Poliovirus vaccine, Inactivated

― Peter Chun, et al : Bell s Palsy Due to Vaccination ’ ―

- 308 - clinic due to an acute onset of right facial palsy for 1 day. She had received the DTaP (Infanrix, GlaxoSmithKine Biologicals, US) and IPV (Imovax polio, Sanofi Pasteur, Lyon, France) vaccines 2 days ago. She was pre- viously healthy and had no history of recent infections, medications, and allergies. She was a full-term baby delivered via spontaneous vaginal delivery. This baby received hepatitis B vaccine on her 1

and 30

days and Bacillus Calmette-Guérin (BCG) on her 10

day after birth. She had no personal or family history of neurologic disorders.

On physical examination, her body weight (6.5 kg, 90-97 percentile), height (63 cm, 90-97 percentile), and head circumference (40 cm, 75-90 percentile) were within normal range. Blood pressure (80/50 mmHg), body temperature (36.6 ), pulse rate (120/minute), ℃ and respiration rate (32/minute) were normal.

The baby showed incomplete right eye clo- sure, flattening of the right nasolabial fold, lip drooping, and difficulties of right facial ex- pression that were compatible with right peri- pheral facial palsy. The remainder of her physical examination, neurological examina- tion, and otoscopic findings were normal.

Her laboratory evaluation results included a white blood cell (WBC) count of 12,350/dL, with a differential of 30.5% neutrophils and 55.9% lymphocytes, hemoglobin 10.9 g/dL, and platelets 593,000/dL. CSF analysis showed no remarkable abnormal findings. Serum her- pes simplex virus (HSV) antibodies Ig M and Ig G were negative. Serum Epstein Barr virus (EBV) antibody titers were negative in anti- VCA Ig M and anti-EADR Ig M and positive in anti-VCA Ig G. Her CSF findings were all negative on bacterial culture, polymerase chain

reaction (PCR) for HSV type I and II, and PCR for enteroviruses. A magnetic resonance ima- ging (MRI) scan of brain revealed no intra- cranial abnormalities. We treated her with ap- plication of artificial tears and an eyepatch.

Her follow-up showed improvement from the 13

day after onset and complete resolu- tion of the facial nerve deficit on the 21

day after onset.

Case 2

A 6-month-old girl visited our hospital due to incomplete closure of her left eyelid and drooping on the left side of her mouth, which started 1 day ago. Her symptoms developed on the 7

day after she received DTaP (DPT-3 vaccine, SK Chemical Life Science, Republic of Korea) and IPV (Imovax polio, Sanofi Pasteur Lyon, France) vaccinations.

She was healthy and had no history of recent respiratory or ear infections. Her perinatal and birth histories were unremarkable. At 4 month's of age, she was diagnosed with grade IV bilateral vesicoureteral reflux. She had no family history of neurologic disorders and was routinely immunized including DTaP and IPV at 2- and 4-months-old.

On physical examination, her body weight (7.2 kg, 50-75 percentile), height (67 cm, 75-90 percentile), and head circumference (43 cm, 90 percentile) were within normal range. Vital sign was stable. The baby showed normal development. She was unable to move her left mouth or close her left eye. Her phy- sical examination, neurological examination, and otoscopic findings were normal except for her left peripheral facial palsy.

Her laboratory test results are following:

WBC 9,280/dL with differential neutrophils

― 대한소아신경학회지 : 제 18 권 제 2 호 2010 년 ―

- 309 - 22.3% and lymphocytes 62.4%, hemoglobin 13.8 g/dL, and platelets 303,000/dL. Myco- plasma antibody titers, HSV Ig M, varicella zoster virus Ig M, and EBV-VCA Ig M were negative. Urine analysis showed mild prote- inuria due to the known bilateral vesicoure- teral reflux. An MRI scan of her head showed no remarkable abnormal findings. Artificial tears were the sole treatment.

On follow-up, she started to show impro- vement from the 5th day after onset and complete resolution of the facial nerve deficit on the 12

day after onset without specific treatment.

Discussion

Facial palsy is uncommon among infants and its causes can be idiopathic or diverse causes, such as infections, otitis media, mas- toiditis, meningitis, Ramsay-Hunt syndrome, Guillain-Barré syndrome, Kawasaki disease, trauma, malignancy, congenital conditions, and hypertension

. Bell s palsy is the most com ’ - mon cause of childhood peripheral facial palsy.

A diagnosis of Bell s palsy depends on the ’ exclusion of other facial palsy causes through careful physical examination.

We carried out some diagnostic tests, but there were no problematic causes, except for DTaP and IPV vaccinations. No diagnostic tests could explain their facial palsy. Peri- pheral facial palsy of each patient presented within 1 week after introducing the DTaP and IPV vaccines, and the patients had no recent infection history.

Katafuchi et al.

reported a 23-month-old girl with acute cerebellar ataxia and facial palsy after diphtheria, tetanus toxoids, and

whole-cell pertussis (DTP) immunizations.

Martin et al.6) reported a brachial neuritis and facial palsy after DPT vaccination. DTaP has been associated with increased risks of fever, prolonged crying, injection site reac- tions, seizures, and hypotonic hyporesponsive episodes

. However, there are no previous reports of Bell s palsy associated with DTaP ’ vaccinations.

Oral poliomyelitis vaccine is associated with the risk of vaccine-associated paralytic poli- omyelitis. In contrast, there is no studies re- ported paralytic diseases or other neurologic complications in association with the inacti- vated poliovirus vaccine (IPV)

.

Although the pathophysiology of Bell s palsy ’ in childhood may be similar to that in adults, the effectiveness of corticosteroid and acy- clovir in children is controversial

. Eye care is the most important and noncontroversial treatment in Bell s palsy. We prescribed only ’ an artificial tear solution and did not use cor- ticosteroids or acyclovir for our patients. Both cases showed complete recoveries.

We suggest that DTaP and IPV immuniza- tion can be a possible cause of Bell s palsy. ’ Well-conducted clinical trials or observational epidemiological studies are needed to confirm any causal relationship between DTaP and IPV immunizations and Bell s palsy. ’

한 글 요 약

디프테리아 파상풍 정제 백일해 백신과 - - 불활화 소아마비 사백신 접종 후

발생한 벨 마비 2 례

천베드로 ㆍ 이경연

ㆍ 김영미 ㆍ 김혜영 ㆍ 이윤진 ㆍ 남상욱

울산대학병원 소아과학교실^*

― Peter Chun, et al : Bell s Palsy Due to Vaccination ’ ―

- 310 - 벨 마비 (Bell s palsy) ’ 는 급성으로 발생하는 특 발성 말초성 안면신경마비로 소아의 가장 흔한 말초 성 안면신경마비의 원인 중 하나이다 과거에도 예 . 방접종과 관련하여 발생한 벨 마비에 대한 보고가 있었으나 디프테리아 파상풍 정제 백일해 항원 - - 혼합 백신 및 불활화 소아마비 사백신 (DTaP)

접종과 관련된 증례는 드물다 저자들은 두

(IPV) .

명의 영아에서 DTaP 및 IPV 접종 후 발생한 벨 마 비를 진단하였고 특별한 치료를 하지 않고 호전된 , 증례를 경험하였기에 보고하는 바이다.

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1989;21:465-9.

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