Subacromial-subdeltoid bursitis following COVID-19 vaccination: a case of shoulder injury related to vaccine administration (SIRVA)

Abstract

Vaccination injection site adverse reactions are usually mild and transient, and post-vaccination musculoskeletal symptoms, such as myalgia and arthralgia, are very common. Shoulder injury related to vaccine administration (SIRVA), defined as shoulder pain and limited range of motion occurring after the administration of a vaccine intended for intramuscular administration in the upper arm, is a well-established condition in the medical literature, yet underreported. In such cases, subacromial-subdeltoid bursitis may occur, leading to shoulder dysfunction and ongoing pain. Millions of doses of vaccines for the prevention of COVID-19 have been administered to adults worldwide during the pandemic. We report a case of subacromial-subdeltoid bursitis after COVID-19 vaccination, related to the unintentional injection of vaccine solution into the bursa resulting in a robust immune-mediated inflammatory reaction.

Keywords: Bursitis; COVID-19; MRI; SIRVA; Shoulder; Ultrasound; Vaccine.

Fig. 1

Photograph of the patient receiving her first dose of the COVID-19 vaccine (Oxford-AstraZeneca, Serum Institute of India) in Brazil’s vaccination program into the upper third of the right deltoid muscle, which is considered higher than the recommended area (red circle)

Fig. 2

Subacromial-subdeltoid bursitis on the right shoulder 8 weeks after the COVID-19 vaccination. (a) Radiograph of the right shoulder in AP view shows soft tissue density of fat pad adjacent to the subacromial-subdeltoid bursa (arrow). The (b) coronal and (c) sagittal T2-weighted fat-suppressed MR images, and the (d) axial proton density-weighted axial image demonstrating the lateral to medial extension of fluid in the subacromial-subdeltoid bursa (arrowheads) with synovial hypertrophy (red arrows). Supraspinatus tendinosis is seen with the signal-alteration (asterisk). Ultrasound of the right shoulder (e) demonstrates hypoechoic fluid accumulation within the subacromial-subdeltoid bursa (arrowheads) more than 3.0 mm. Thickening of the bursal walls is also noted (arrow). (f) Longitudinal power Doppler sonogram shows moderate increase of surrounding perfusion in adjacent soft tissue (arrows)

Fig. 3

a Deltoid muscle is recommended for routine intramuscular vaccination for adults. The safest anatomical site in adults of both sexes would be approximately 7–13 cm (three fingerbreadths) below the mid-acromion, anatomically midway between the acromion and the deltoid tuberosity (red circle). Intramuscular injections are administered at an angle between 72 to 90° to the skin. A 2.5-cm (1-in.) needle depth is appropriate for most patients; it is long enough to reach the muscle mass and prevent overpenetration. b The upper third of the deltoid muscle should not be used for vaccine injections. An angle close to 45° is not recommended for intramuscular vaccinations, as it can lead to the application of the vaccine in the dermis or subcutaneous