Astra zeneca Covid vaccination conversion reaction

Advising the patient allowed her to accept that, when all the tests came back normal, it did not refl ect lack of knowledge to make a correct diagnosis. The correct procedure is to make a provisional diagnosis (namely conversion reaction) and to exclude differential diagnoses, such as clotting. It is believed that this represents the fi rst reported case of an AstraZeneca Covid vaccination conversion reaction but it is highly unlikely that it will be the last one to be encountered. Case Report


Introduction
There are more than a dozen vaccines, designed to protect people against Covid-19 infections, approved for human consumption around the world, in countries such as China, Citation: Beran  pain; nausea; fever and rigors; malaise; and joint pain [5].
Less common adverse events include: enlarged lymph nodes; pain in limbs; dizziness or light headedness; anorexia; and abdominal pain [5]. Very rare adverse consequences, from the AstraZeneca vaccination, include: anaphylaxis (said to occur in approximately 1 in a million recipients of the vaccine); and unusual clotting (which may affect various body parts including the brain, possibly causing cerebral venous sinus thrombosis) and low platelet count (which may result in bleeding) which is estimated to occur in 4 to 6 people per million people who receive their fi rst dosage of the AstraZeneca vaccine [5]. These very rare adverse events start about 4 to 20 days after receiving the inoculation with the AstraZeneca vaccine [5].
The paper to follow reports a patient who presented with hemiparesis and hemisensory hypo-aesthesia which she felt was as a consequence of the AstraZeneca vaccine but on formal neurological examination was determined to represent a conversion reaction unrelated to the effects of the Covid-19 inoculation.

Case report
A 60 year old, Vietnamese lady presented to the Accident fl exors in the lower limb, as referred to as being weakness in the antigravity muscles, together with lack of refl ex asymmetry, down going plantar responses and an absence of hand drift, plus evidence of use of antagonistic muscles when testing maximal muscle power [9][10][11][12]. She also reported a change in the loss of sensation that ignored the midline and she identifi ed that the increase in sensation occurred in the midclavicular line, well to the right of the midline, across her torso.
When testing cranial nerves, there was a lack of respect for the anatomical demarcation of the trigeminal nerve [13] such that she reported a change in sensation in the middle of the right side of her face, involving the right cheek (disrespecting the midline), together with a change in the loss of sensation at the hairline, rather than the binaural plane, plus a change in sensation at the angle of the jaw, following the mandible.
The patient was reassured that, on clinical grounds, it was felt that her presentation represented a non-organic conversion reaction, rather than the expression of the potential clotting that may be associated with the AstraZeneca vaccine.
To reinforce this evaluation, she did undergo cerebral magnetic resonance imaging, including arteriography and venography, together with a psychiatric assessment, prior to her discharge from hospital. She was to be followed by the community psychiatry team, together with a fi nal visit with the neurologist, to reinforce the non-organic nature of her complaints.

Discussion
The AstraZeneca Covid-19 vaccine has received a signifi cant amount of publicity, regarding the very rare potential for clotting to occur, known as thrombosis in combination with thrombocytopenia [14] which is reported to occur, as a consequence of the fi rst administered dose, in: 3.1/100,000 for those less than 50 years old; 2.7/100,000 in 50-59 year olds; 1.4/100,000 for those aged 60-69; 1.8/100,000 for people aged 70-79; and 1.9/100,000 for those aged 80 and over [14]. This amounts to an uncommon, unwanted effect of the vaccine but it has caused considerable concern and confusion amongst the Australian population. Professor Paul Kelly, the Australian Government Chief Medical Offi cer, released a statement, on 16 July 2021, which included the following statement, "Evidence from the UK shows the rate of thrombosis with thrombocytopenia syndrome (TTS) after a second dose of AstraZeneca is signifi cantly lower than for fi rst doses…ATAGI's updated advice is based on new evidence demonstrating a higher risk than originally thought of the rare blood-clotting TTS among people aged 50 to 59. " [15] . This This case does highlight the very real consequences of the concern, raised in the community, regarding the AstraZeneca vaccine and its propensity to cause very serious side effects which this patient believed she had encountered. The case confi rms the need to be circumspect regarding those who present with well publicised and widely accepted adverse events, reportedly associated with medical intervention. It also amplifi es the approach which was adopted in this case. On the basis of the physical examination, it was felt that her signs provided hard evidence of a non-organic complaint [16][17][18][19]. It was also considered that the signs were of suffi cient veracity to allow the provisional diagnosis of a conversion reaction, without adopting the approach of insisting that a non-organic diagnosis should be a diagnosis of last resort and a diagnosis of exclusion. It must be stated that the conversion reaction, experienced by this patient, was not caused by the vaccine, per se, but rather by the fear of the vaccine and its potential consequences.
Providing the patient with the provisional diagnosis of a non-organic disease allowed the patient to accept that, when all the tests came back as normal, as was to be expected, it is not a case of the attending physician being too ignorant to make a correct defi nitive diagnosis [16]. Adopting the approach that the attending doctor will order a large and exhaustive range of tests and, only when they come back as being normal, can the diagnosis of non-organic disease be accepted, suggests to the patient that the doctor expected there to be a serious medical problem for which none of the tests proved helpful [16]. Within the latter scenario, the fact that the tests came back normal does not instil confi dence that the doctor can assume that the diagnosis is that of a non-organic problem and may merely refl ect that the doctor could not determine the right test to be done, to reach the correct diagnosis [16].
As with all medicine, the correct procedure is to make a provisional diagnosis and then to ensure that the tests exclude alternative differential diagnoses. Dealing with non-organic disease is no different and, where a conversion reaction appears to be the correct diagnosis, it should also constitute the initial provisional diagnosis and be shared with the patient, as was the situation in the present case. She still underwent cerebral imaging, to reassure her that there was no evidence of thrombotic lesions, and she was also seen be the psychiatrist who reaffi rmed the provisional diagnosis of conversion reaction. It is believed that this presentation represents the fi rst reported case of an AstraZeneca Covid vaccination conversion reaction but it is highly unlikely that it will be the last one to be encountered.