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\begin{document}

\title{Lower Motor Neuron Facial Palsy Following COVID-19 Infection and
COVID-19 AstraZeneca Vaccine Administration: Case Reports}



\author[1]{Amira Siddig Omer}%
\author[2]{Khabab  Mohamed Ahmed}%
\author[2]{Omer A. Mohammed}%
\author[3]{Hager Abdelaziz Ahmed Awdelseed}%
\author[4]{AlHussien  Abbasher}%
\author[1]{Mohammed  Abbasher}%
\author[5]{Abubaker Alsedig  Abbasher}%
\author[2]{Abbasher Hussien Mohamed Ahmed}%
\affil[1]{Al-Neelain University Faculty of Medicine}%
\affil[2]{University of Khartoum Faculty of Medicine}%
\affil[3]{National Ribat University Faculty of Medicine}%
\affil[4]{AlYarmouk college}%
\affil[5]{Zamzam University college}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
COVID-19 is a multi-system disorder. Bell's palsy is a lower motor
neuron lesion that is uncommon after COVID-19 or related vaccinations.
We documented two incidences of Bell's palsy in this study, one after
she was exposed to COVID-19 and the other after he was exposed to
AstraZeneca Vaccine.%
\end{abstract}%



\sloppy


\textbf{Lower Motor Neuron Facial Palsy Following COVID-19 Infection and
COVID-19 AstraZeneca Vaccine Administration: Case Reports}

Amira Siddig\textsuperscript{1}, Khabab Abbasher Hussien Mohamed
Ahmed\textsuperscript{2}, Omer A. Mohammed\textsuperscript{3}, Hager
Abdelaziz Ahmed Awdelseed\textsuperscript{4}, AlHussein
Abbasher\textsuperscript{5}, Mohammed Abbasher\textsuperscript{6},
Abubaker Alsedig Abbasher\textsuperscript{7}, Abbasher
Hussien\textsuperscript{8}

\begin{enumerate}
\tightlist
\item
  AlNeelain University, Faculty of Medicine, Khartoum,
  Sudan,\emph{amirasiddig121@gmail.com}
\item
  University of Khartoum, Faculty of Medicine, Khartoum,
  Sudan,\emph{Khabab9722@gmail.com}, ORCID: 0000-0003-4608-5321
\item
  University of Khartoum, Faculty of Medicine, Khartoum, Sudan,
  omer1999aldoctor@gmail.com, ORCID: 0000-0001-9166-6892
\item
  National Ribat University, Faculty of Medicine, Khartoum, Sudan,
  hagarazizi660@gmail.com
\item
  AlYarmouk College, Khartoum, Sudan,\emph{Hussienabbashar93@gmail.com}
\item
  AlNeelain University, Faculty of Medicine, Khartoum,
  Sudan,\emph{mohabbasher01@gmail.com}
\item
  Zamzam University College, Khartoum,
  Sudan,\emph{Amirasiddig121@hotmail.com}
\item
  University of Khartoum, Faculty of Medicine, Khartoum,
  Sudan,\emph{abbashar59@yahoo.com}
\end{enumerate}

Corresponding author:

Dr. Khabab Abbasher Hussien Mohamed Ahmed,
Email:\emph{Khabab9722@gmail.com}, Mobile: 00249907712134, Khartoum,
Sudan, Postal code: 11111

\textbf{Abstract} :

COVID-19 is a multi-system disorder. Bell's palsy is a lower motor
neuron lesion that is uncommon after COVID-19 or related vaccinations.
We documented two incidences of Bell's palsy in this study, one after
she was exposed to COVID-19 and the other after he was exposed to
AstraZeneca Vaccine.

Keywords:

COVID-19; Coronavirus, SARS-CoV-2, Bell's palsy, Facial palsy;
AstraZeneca vaccine

\textbf{Key clinical message:}

COVID-19 and its vaccinations, according to the literature, can cause a
wide range of symptoms and side effects. Patients and professionals
should be aware of them so that they can seek medical help as soon as
feasible.

\textbf{Introduction:}

Coronavirus illness is caused by the SARS-CoV-2 virus (COVID-19). The
majority of people who are infected with the virus will experience mild
to moderate respiratory symptoms and will recover without needing any
treatment {[}1{]}.

Fever, sore throat, cough, shortness of breath, diarrhea, and widespread
weariness are the most prevalent symptoms. Acute distress respiratory
syndrome, myocarditis, heart failure, renal failure, and recurrent
pulmonary embolism are all complications of COVID-19 {[}2{]}.

The neurological symptoms of COVID-19 infection include convulsions,
paraplegia, hemiplegia, Guillain-Barre syndrome, transverse myelitis,
and multiple cranial nerve involvement {[}3{]}. Lower motor neuron
lesion facial palsy is referred to as Bell's palsy in clinical terms. It
is usually idiopathic; however tumors, trauma, infection, autoimmune
illnesses, vacuities, pregnancy, and medicines can all cause it.
Sarcoidosis, Guillain-Barre syndrome, and leprosy all have clinical
symptoms that include bilateral facial palsy {[}4{]}. During the
COVID-19 pandemic, there was a documented link between COVID-19 and
Bell's palsy. There is no clear explanation at this time; however it
could be caused by a direct action of the virus, an autoimmune response,
or recurrence of a coexisting herpes zoster infection {[}5{]}.

In numerous nations, including the United States, a relationship between
COVID-19 vaccines and lower motor neuron lesion facial palsy has been
observed, albeit the causative link has yet to be proved {[}6{]}.

\textbf{Cases' Presentation:}

\textbf{Case 1:}

A 65-year-old Sudanese woman was admitted to Omdurman teaching hospital
(a tertiary hospital located within Omdurman one of three cities which
form the capital of Sudan) with a high-grade fever and a dry irritating
cough. Clinical examination indicated a feverish patient with a pulse
rate of 100 beats per minute, a blood pressure of 100/70 mmhg, and a
normal systemic examination. Her SARS COVID-19 viral test came out
positive. Three days after being admitted. She began to complain of an
incomplete left eye closure and a right-sided mouth deviation. A lower
motor neuron injury was discovered during a clinical evaluation (facial
palsy). (Figure 1)

Over the course of the year, she had no skin eruptions, parotid
enlargement, or tongue fissure. The upper and lower limbs were examined
and found to be normal (she has no truncal or neck weakness and no area
of hypoesthesia). CBC, blood urea, serum creatinine, chest X-ray, and
CT-brain were among the tests performed. All of the tests came out
normal or within normal limits. Following COVID-19, a diagnosis of
Bell's palsy was made. She took prednisolone for three weeks and showed
significant improvement.

\textbf{Case 2:}

A 45-year-old Sudanese man with no history of diabetes or hypertension
presented to our private neurology clinic with facial paralysis on the
left side and the inability to close his left eye. He also detected a
rightward displacement of the mouth. (Figure 2)

The illness appeared three days after receiving the AstraZeneca COVID-19
vaccination. Facial damage, ear pain, or ear skin eruption did not
precede the paralysis. He hasn't lost his sense of taste, and the event
he described was not preceded by any transitory neurological symptoms.
During one assessment, he appeared to be sick, with a pulse rate of 87
beats per minute and a blood pressure of 130/75 mmhg. There were no
abnormalities found on a systemic evaluation. He has a full-blown
picture of left sided lower motor neuron lesion of the seventh cranial
nerve, and the abnormalities were confined to the central nervous
system. The following tests were performed: general urine, blood urea,
serum creatinine, and a brain MRI, all of which came out normal. In the
absence of any clear symptoms or signs that could lead to a diagnosis of
left sided motor neuron lesion facial palsy caused by the COVID-19
AstraZeneca vaccine, a diagnosis of left sided motor neuron lesion
facial palsy caused by the COVID-19 AstraZeneca vaccine was made. After
three weeks of corticosteroids, he exhibited significant improvement.

\textbf{Discussion:}

COVID-19 can cause neurological symptoms such as stroke, Guillain-Barre
syndrome, transverse myelitis, epilepsy, and cranial nerve palsies in
nearly 36\% of individuals. Peripheral nerve lesions affect 8\% of the
population. COVID-19 infection can cause Bell's palsy, which is one of
the neurological symptoms {[}4{]}. Bell's palsy is preferred by 15-20
people per 100,000 in the general population {[}7{]}.

Bell's palsy is a face motor neuron injury that affects the lower motor
neurons. It's usually idiopathic; however hypertension, diabetes,
obesity, pregnancy, preeclampsia, trauma, tumors, infections, autoimmune
illnesses, and vacuities have all been linked to it. The etiology of
Bell's palsy in COVID-19 is unknown, but it could be due to direct
inflammation of the facial nerve, which causes edema and nerve
compression in the canal. It could also be caused by an immune reaction.
COVID-19 infection is linked to a low lymphocyte count, which can lead
to herpes zoster virus reactivation in the facial nerve ganglia,
resulting in facial palsy. The majority of Bell's palsy cases improved
on their own over time, however 5-10\% of cases left with residual
facial weakness {[}4{]}.

Despite this, we report the first incidence of Bell's palsy following
AstraZeneca vaccine, but no conclusive proof of a link between Bell's
palsy and COVID-19 vaccination exists at this time.

According to a study conducted by Wan and colleagues in Hong Kong on the
relationship between Bell's palsy and the mRNA-based BNT162 b2 vaccine,
patients who received COVID-19 vaccine have a higher risk of getting
Bell's palsy than those who were not vaccinated {[}8{]}.

The observed prevalence of Bell's palsy among vaccinated persons was no
greater than the expected background rate, according to the US Food and
Drug Administration and the UK Medicine and Healthcare Product
Regulatory Agency {[}9{]}.

\textbf{Conclusion:}

COVID-19 is an illness that manifests itself in a variety of ways.
COVID-19 infection can cause Bell's palsy, which is a relatively rare
symptom. This case report is also important for physicians and
neurologists looking for vaccine-related adverse effects. The benefits
of immunization outweigh any potential hazards, despite the vaccine's
side effects (fever, pain at the injection site, thromboembolic events,
and facial palsy).

\textbf{Declarations:}

\textbf{Consent for publication:}

Written consent for publication has been obtained from the patient and
the authors. Patients agreed to publish their photos as figures in the
manuscript.

\textbf{Availability of data and material:}

The data used in this report is available with the corresponding author
upon reasonable request.

\textbf{Conflicts of interest:}

The authors declare that there is no conflict of interest.

\textbf{Funding:}

The study was funded by the authors themselves. No funds were granted.

\textbf{Acknowledgement:}

Not applicable

\textbf{Authors' contribution:}

AS, KAH, OAM and HAA: Wrote first draft and final draft.

AA, MA, AAA: Wrote and revised final draft

AH: Did examinations, investigations, revision and supervised the study.

All authors contributed significantly to the manuscript.

\textbf{References}

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\tightlist
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  McGonagle D., et al. ``Interleukin-6 use in COVID-19 pneumonia related
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  Incidence of Bell Palsy in Patients With COVID-19. Akina Tamaki,
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\item
  Wan EYF Chui CSL Lai FTT et al. Bell's palsy following vaccination
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  a case series and nested case-control study. Lancet Infect Dis. 2021;
  (published online Aug 16.)
  https://doi.org/10.1016/S1473-3099(21)00451-5
\item
  Cirillo N Doan R. Bell's palsy and SARS-CoV-2 vaccines---an unfolding
  story. Lancet Infect Dis. 2021; (published online June
  7.)\emph{https://doi.org/10.1016/S1473-3099(21)00273-5}
\end{enumerate}

\textbf{Hosted file}

\verb`Bell\selectlanguage{english}'s palsy Supplementary.docx`  available at \url{https://authorea.com/users/448025/articles/560731-lower-motor-neuron-facial-palsy-following-covid-19-infection-and-covid-19-astrazeneca-vaccine-administration-case-reports}

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