Small fiber neuropathy with normal intra-epidermal nerve fiber density but reduced sweat gland density after third BNT162b2 shot

Josef Finsterer


Small fiber neuropathy (SFN) has not been reported after the third dose of BNT162b2 in a previously healthy vaccinee. A 44-year-old previously healthy female developed pain and sensory disturbances in varying locations after the third BNT162b2 dose. Additionally, she developed recurrent tinnitus, headaches, arthralgia, neck stiffness, and motor dysfunction. A skin biopsy five months after symptom onset revealed normal intra-epidermal nerve fiber density (IENFD) but reduced sweat gland nerve fiber density. She is intended for a first series of intravenous immunoglobulins. SARS-CoV-2 vaccinations may be complicated by SFN; the diagnosis SARS-CoV-2 vaccination SFN may be delayed; IENFD may be normal, but sweat gland nerve fiber density may document SFN; and full recovery after SFN cannot always be achieved quickly.


small fiber neuropathy; skin biopsy; sweat gland nerve fiber density; SARS-CoV-2 vaccination; side effect

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Finsterer J, Scorza FA. Small fiber neuropathy. Acta Neurol Scand. 2022;145(5):493-503. doi: 10.1111/ane.13591. PMID: 35130356.

Egenolf N, Zu Altenschildesche CM, Kreß L, et al. Diagnosing small fiber neuropathy in clinical practice: a deep phenotyping study. Ther Adv Neurol Disord. 2021;14:17562864211004318. doi: 10.1177/17562864211004318. Erratum in: Ther Adv Neurol Disord. 2021;14:17562864211036650. PMID: 34335876; PMCID: PMC8283814.

Khokhar F, Khan A, Hussain Z, Yu J. Small Fiber Neuropathy Associated With the Moderna SARS-CoV-2 Vaccine. Cureus. 2022;14(6):e25969. doi: 10.7759/cureus.25969. PMID: 35812635; PMCID: PMC9259076.

Safavi F, Gustafson L, Walitt B, et al. Neuropathic symptoms with SARS-CoV-2 vaccination. medRxiv [Preprint]. 2022:2022.05.16.22274439. doi: 10.1101/2022.05.16.22274439. PMID: 35611338; PMCID: PMC9128783.

Watad A, De Marco G, Mahajna H, et al. Immune-Mediated Disease Flares or New-Onset Disease in 27 Subjects Following mRNA/DNA SARS-CoV-2 Vaccination. Vaccines (Basel). 2021;9(5):435. doi: 10.3390/vaccines9050435. PMID: 33946748; PMCID: PMC8146571.

Abbott MG, Allawi Z, Hofer M, et al. Acute small fiber neuropathy after Oxford-AstraZeneca ChAdOx1-S vaccination: A report of three cases and review of the literature. J Peripher Nerv Syst. 2022;27(4):325-329. doi: 10.1111/jns.12509. PMID: 35962630; PMCID: PMC9538519.

Schelke MW, Barcavage S, Lampshire E, Brannagan TH 3rd. Post-COVID-19 vaccine small-fiber neuropathy and tinnitus treated with plasma exchange. Muscle Nerve. 2022;66(4):E21-E23. doi: 10.1002/mus.27696. PMID: 35934893; PMCID: PMC9537871.

Waheed W, Carey ME, Tandan SR, Tandan R. Post COVID-19 vaccine small fiber neuropathy. Muscle Nerve. 2021;64(1):E1-E2. doi: 10.1002/mus.27251. PMID: 33851437; PMCID: PMC8250971.

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