Vaccines | Free Full-Text | Right Biceps Pseudo-Tumor from COVID-19 Vaccination
2. Case Presentation
A 49-year-old male presented to his primary care physician with a four-day history (6 months after receiving the booster dose) of a firm mass in the proximal-medial short-head of the right biceps muscle. He had no history of trauma prior to the recognition of the mass other than the injection of his Moderna vaccine booster dose administered into his right upper arm. Past medical history revealed no major medical, oncologic, rheumatologic, or orthopedic conditions. He had no known drug allergies. He described two lipomas in the right forearm that had remained unchanged for over 10 years. After each of his two initial Moderna vaccination doses, he experienced transient injection site soreness but no other acute or chronic symptoms following completion of the primary series.
Eight months after completing the primary series, the patient went to a walk-in vaccination center to receive a booster dose of the Moderna vaccine. Discussion with the patient revealed that the needle was inserted below the bulk of the deltoid muscle, approximately one finger breadth above the deltoid tuberosity. Immediately after receiving the booster dose, the patient developed constitutional symptoms, including diaphragmatic breathing, fatigue, and reduced exercise tolerance. After one week, the patient consulted his primary care physician, who diagnosed him with viral syndrome and recommended ibuprofen, fluids, and rest. However, these symptoms persisted over the next several months despite following the treatment protocol.
During follow-up, there was no palpable mass, the pain improved, and his full passive ROM was restored. Six months after excision, a third MRI of the right arm was ordered and showed no residual mass or edema. However, his systemic symptoms of diaphragmatic breathing, fatigue, and reduced exercise intolerance had finally resolved around the time of this final follow-up two weeks following removal of the mass.
This delayed reaction occurred only after receiving the booster dose of the Moderna vaccine. He did not experience a similar reaction to the recommended pediatric and adolescent vaccines or to the initial two doses of the Moderna vaccine.
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