Case Study: Prolonged Arm Pain and Limited Mobility Following Tdap Vaccination

Case at a Glance

A 40-year-old female presents with persistent, localized arm pain and significantly decreased range of motion for 12 days following a routine Tdap vaccination, with a clinical picture highly suggestive of Shoulder Injury Related to Vaccine Administration (SIRVA).

Patient's Story

The patient, a 40-year-old woman required to update her vaccinations for nursing school, received a Tdap vaccine. She stated, "The soreness started that evening, which I expected. The next morning, however, the pain was unbelievable. The only way it didn't hurt was if I held it close to my body like it was in a sling. I could barely get dressed. It's slowly improved over the last week and a half, but it still hurts with certain movements. This can't be a normal reaction, can it?"

Initial Assessment

A 40-year-old female presented for evaluation of persistent left arm pain. Her past medical history is significant for gastric sleeve surgery, polycystic ovary syndrome (PCOS), ADHD, and depression, for which she takes methylphenidate, sertraline, and pantoprazole. The patient received a Tdap vaccine in her left deltoid 12 days prior to presentation. She reported a rapid onset of severe pain within 24 hours of administration, which significantly limited her ability to perform activities of daily living. While the initial severe pain has subsided, she continues to experience pain (rated 5/10) with specific movements. On examination, there was no erythema, warmth, or swelling at the injection site. The patient was afebrile and denied any systemic symptoms.

The Diagnostic Journey

The primary concern was to differentiate between an unusually severe local vaccine reaction, a localized infection (such as cellulitis or abscess), and a direct musculoskeletal injury. The absence of cardinal signs of infection—redness, warmth, swelling, and fever—made an infectious process unlikely. The patient's narrative, characterized by the rapid onset of severe pain, significant functional limitation far exceeding typical post-vaccination soreness, and the persistence of symptoms for nearly two weeks, raised high suspicion for Shoulder Injury Related to Vaccine Administration (SIRVA). This condition is understood to result from the inadvertent injection of vaccine antigen into the subdeltoid bursa or shoulder joint, triggering a prolonged and intense inflammatory response.

Final Diagnosis

Provisional Diagnosis: Shoulder Injury Related to Vaccine Administration (SIRVA).

Treatment Plan

The initial management plan focused on conservative measures to reduce inflammation and restore function:

1. Pharmacotherapy: A course of non-steroidal anti-inflammatory drugs (NSAIDs) was recommended to manage pain and inflammation.
2. Physical Therapy: A referral to a physical therapist was recommended to address the limited range of motion and pain through targeted exercises and modalities.
3. Further Investigation: The patient was advised that if symptoms persist, an ultrasound or MRI of the shoulder would be considered to evaluate for bursitis, tendinitis, or other soft tissue injury.
4. Reporting: The importance of reporting this adverse event to the Vaccine Adverse Event Reporting System (VAERS) was discussed.

Outcome and Follow-up

The patient planned to follow up with her primary care physician to initiate the recommended treatment plan. Close follow-up was scheduled to monitor her progress with NSAIDs and physical therapy. The prognosis for SIRVA with conservative management is generally favorable, although recovery can be prolonged over several weeks to months. Continued monitoring is essential to ensure functional recovery and to escalate care if needed.