Voysey M, Clemens SAC, Madhi SA, Weckx LY, Folegatti PM, Aley PK, Angus B, Baillie VL, Barnabas SL, Bhorat QE. Muscle Nerve. . Salinas MR, Dieppa M. Transient akathisia after the SARS-Cov-2 vaccine. Finsterer J, Redzic Z. Symptomatic peduncular, cavernous bleeding following SARS-CoV-2 vaccination induced immune thrombocytopenia. VST is the most severe disorder that should be diagnosed and controlled immediately. Order a chest CT if sarcoidosis is suspected. 2021. https://doi.org/10.2139/ssrn.3841558. We describe the case of a 57-y-old female who presented 1 week after receiving the second dose of the Pfizer coronavirus disease 2019 (COVID-19) vaccine with subacute onset of intense burning dysesthesias in the feet, gradually spreading to the calves and minimally into the hands, unaccompanied by . 2021;30(3):1337. Finally, discovering whether these disorders are accidental or whether the vaccine is the main cause of them requires future studies, ongoing efforts to gather evidence, and long-term monitoring. Two patients with markedly reduced intraepidermal nerve fiber densities and one with normal skin biopsy had severe and moderate coronavirus disease 2019 (COVID-19); the remainder experienced mild COVID-19 symptoms. J Clin Neuromuscul Dis. In early 2021, the first vaccines were introduced to stop the pandemic. Sore throat. The importance of safety cannot be overemphasized, considering that pain, numbness, dizziness, and drowsiness can lead to physical injuries especially with increasing age. 29. Hum Vaccin Immunother. Bell's palsy and small fiber neuropathy are more commonly observed in mRNA-based vaccines [63, 64]. The benefit of topical anesthetics, however, is often limited. Alshararni A. QJM: An Int J Med. WHO COVID-19 Research Database. 39. 2021;21(5): e535. Backonja MM, Attal N, Baron R, et al. 2021;385(8):7208. Two patients had rare neuropathies that affected muscle nerves, and 10 were diagnosed with small-fiber neuropathy, which is a cause of chronic pain. Among the 6 persons with SFN confirmed by biopsy, 3 had preexisting but controlled associated conditions, whereas the others had no neuropathy etiologies identified. 2022 Mar 15;434:120118. doi: 10.1016/j.jns.2021.120118. A small study of patients suffering from persistent symptoms long after a bout of COVID-19 found that nearly 60% had nerve damage possibly caused by a defective immune response, a finding that . Please enable it to take advantage of the complete set of features! Associated conditions can be identified in about half of the SFN cases,3,7,21 with diabetes mellitus being the most common in the US.3,22 Immune-mediated conditions (eg, sarcoidosis and Sjgrens syndrome) are more common with NLD-SFN than LD-SFN.3 Thorough history taking can help identify or raise a suspicion for certain associated conditions (eg, metabolic syndrome, alcohol abuse, neurotoxic drug exposure, HIV and hepatitis C infections, rapid improvement of glycemic control in diabetic patients, and genetic causes). 2021;208: 106839. McMahon DE, Amerson E, Rosenbach M, Lipoff JB, Moustafa D, Tyagi A, Desai SR, French LE, Lim HW, Thiers BH. It's about long-covid and small fiber neuropathy. 2021;19(7):17715. 2021. https://doi.org/10.1093/qjmed/hcab069. 2019;90(3):342-352. Clinical . Incidence and prevalence of small-fiber neuropathy: a survey in the Netherlands. "The vaccine distribution to the sciatic nerves may lead to conditions like sciatica." In a recent post I talked about how COVID vaccines can enter platelets where spike protein can then be synthesized, leading to platelets undergoing an immune response - causing internal bleeding and blood clots. I did experience burning pain all over body but the burning pain was mainly consistent in . Malik B, Kalantary A, Rikabi K, Kunadi A. 2022. https://doi.org/10.1136/postgradmedj-2021-141022. 2021;90(4):62739. 24. The quantitative sudomotor axon reflex test (QSART) evaluates postganglionic sympathetic unmyelinated sudomotor nerve function. I am 85 with small fiber neuropathy that is getting worse. We have identified a case of biopsy-proven small fiber neuropathy as a post-vaccination complication. . That way, you can control the sugar content but still enjoy a sweet treat. There are significant limitations to QST,17 including that it is not widely available and cannot differentiate whether impaired response to sensory stimuli is caused by a peripheral nerve disease or a central nervous system disorder, because a proper response requires an intact sensory pathway. Hearing disorders can vary from hearing loss to tinnitus and dizziness. 1. Eitner L, Maier C, Brinkmann F, Schlegtendal A, Knoke L, Enax-Krumova E, Lcke T. Front Pediatr. COVID vaccines and neuropathy. IDCases. Following that situation in 2020, the World Health Organization had to declare a global health emergency. 2022 Oct 3;10:977827. doi: 10.3389/fped.2022.977827. It is also important to explain that pain medications are used to control pain, burning, or tingling, but not numbness. Amyotrophic neuralgia secondary to Vaxzevria (AstraZeneca) COVID-19 vaccine. Continuum (Minneap Minn). 2008;131(Pt 7):1912-1925. Waheed W, Carey ME, Tandan SR, Tandan R. Post COVID-19 vaccine small fiber neuropathy. Curr Cardiol Rep. 2014;16(6):110. If there is history of gastrointestinal symptoms or gluten intolerance, evaluate for celiac disease with tests for gliadin and tissue transglutaminase antibodies and small bowel biopsy. -. Most patients first describe it as a stabbing, burning, or abnormal sensation of the skin, such as tingling or itchiness. Small fiber neuropathy or in the case of fibromyalgia, polyneuropathy, was first uncovered in FM in 2013. 2021;90(2):3158. Razok A, Shams A, Almeer A, Zahid M. Post-COVID-19 vaccine Guillain-Barr syndrome; first reported case from Qatar. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 2021. https://doi.org/10.7759/cureus.13426. Among these, the most dangerous neurological complication caused by COVID-19 vaccines, especially adenovirus-based, is cerebral venous sinus thrombosis in women of childbearing age [8]. Baldelli L, Amore G, Montini A, Panzera I, Rossi S, Cortelli P, Guarino M, Rinaldi R, DAngelo R. Hyperacute reversible encephalopathy related to cytokine storm following COVID-19 vaccine. Thaisetthawatkul P, Fernandes Filho JA, Herrmann DN. 2021;358: 577606. Adams D, Suhr OB, Hund E, et al. Diabetes Care. Tahir N, Koorapati G, Prasad S, Jeelani HM, Sherchan R, Shrestha J, Shayuk M. SARS-CoV-2 vaccination-induced transverse myelitis. 2021;96(20):e2534-e2545. J Thromb Haemost. Malhotra HS, Gupta P, Prabhu V, Garg RK, Dandu H, Agarwal V. COVID-19 vaccination-associated myelitis. Pain Res Manag. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. First European consensus for diagnosis, management, and treatment of transthyretin familial amyloid polyneuropathy. Abrams RMC, Simpson DM, Navis A, Jette N, Zhou L, Shin SC. Kelley M, Oaklander AL Association of small-fiber polyneuropathy with 3 previously unassociated rare missense SCN9A variants. An overview of current COVID-19 vaccine platforms. Ann Med Surg. Autonomic testing showed postural orthostatic tachycardia syndrome in 22%, mild orthostatic intolerance in 11%, and sudomotor dysfunction in 36%.28 A case report also described a person who developed burning dysesthesias 1 week after receiving a second dose of COVID-19 vaccine, and subsequent skin biopsy showed reduced IENFD. COV2. 2021;31:385394. Careers. These criteria sets are the Diabetic Neuropathy Study Group of the European Association for the Study of Diabetes (NEURODIAB) criteria, which are graded, and the Besta criteria (Table).7,8, Evaluation should include examination for SFN signs and exclude large fiber neuropathy signs, nerve conduction studies (NCS) to rule out large fiber polyneuropathy, and skin biopsy or quantitative sensory testing (QST). 2017;126:135-138. AntiTS-HDS and antiFGFR-3 were more common in female persons and those with NLD-SFN.31 Another retrospective study of 322 people with pure SFN and dysautonomia detected antiTS-HDS in 28% and antiFGFR3 in 17%, but the presence of these antibodies did not correlate with neuropathy symptom scores, autonomic dysfunction, or IENFD reduction, making the significance of these antibodies questionable.32 These findings suggest antiTS-HDS and antiFGFR3 are unlikely to be pathogenic, and it is uncertain whether presence of these antibodies is an epiphenomenon indicating immune-mediated SFN. 23. QJM: An Int J Med. 2021. https://doi.org/10.1007/s13760-021-01775-2. The significance of new association with autoantibodies, including antibodies to trisulfated heparin disaccharide (TS-HDS) and fibroblast growth factor 3 (FGFR3), needs further investigation. Int J Res Pharma Sci. According to data from the CDC, VAERS, and EMA databases, the short-term outcome of COVID-19 vaccination is promising, but in the medium and long term, especially with some vaccines, side effects have been reported that are worrisome. McArthur JC, Stocks EA, Hauer P, Cornblath DR, Griffin JW. Small fiber neuropathy associated with SARS-CoV2 infection. Cureus. COVID-19 vaccination also affects the cranial and peripheral nerves and causes side effects such as Bell's palsy (facial nerve palsy7 cranial nerve), abducens nerve palsy (lateral rectus ocular muscle nerve palsy6 cranial nerve), impaired vision, olfactory, hearing, GuillainBarre syndrome (GBS), small fiber neuropathy, ParsonageTurner syndrome, and also herpes zoster. ScienceDaily . The two main mechanisms, ectopic immune reactions, and molecular mimicry, have been proposed for the pathogenicity of vaccines and how these complications occur. Franchini M, Testa S, Pezzo M, Glingani C, Caruso B, Terenziani I, Pognani C, Bellometti SA, Castelli G. Cerebral venous thrombosis and thrombocytopenia post-COVID-19 vaccination. An official website of the United States government. Etiology-specific treatment is the key to improving symptoms and prevention of SFN progression. RH: carried out the searched publications, classified the documents, and wrote the manuscript draft. -, Shouman K, Vanichkachorn G, Cheshire WP, et al. Neuropathy in some of these individuals was severe and did not respond well to symptomatic treatment. COVID-19 infection and pain in adolescents with sickle cell disease: A case series. 2021;12:879. 2021. https://doi.org/10.1080/14992027.2021.1931969. 8600 Rockville Pike The patient described her symptoms as paroxysmal tingling affecting mainly the feet, L>R. The patient denied back pain, focal weakness, gait changes, or falls. The COVID-19 vaccine-related convulsions can be attributed to the synthesis and release of spike proteins, which cause severe inflammation and hyperthermia. Johnson & Johnson is testing a coronavirus vaccine known as JNJ-78436735 or Ad26.COV2.S.Clinical trials showed that a single dose of the vaccine had an efficacy rate of 72 percent in the United . 2020;61(4):512-515. Cookies policy. Wichova H, Miller ME, Derebery MJ. Muscle Nerve. Screening for SFN etiologies begins with a battery of blood tests that should be ordered for every person with SFN (Box), considering a recent study showed 26.7% of people with SFN known to have underlying associated conditions before evaluation had additional underlying conditions identified at diagnosis of SFN.21 There is still no consensus on what blood tests should be done before diagnosing a patient with idiopathic SFN if all test results are negative. The Food and Drug Administration on Monday . Since then, dozens of studies have validated its presence in somewhere around 40% of FM patients. EJHaem. But again, the challenge is whether . As of February 19, 2021, 28 cases of GBS and no case of Bell palsy have been reported to the Vaccine Adverse Event Reporting System (VAERS) following the COVID19 vaccination. 2022 Oct 6;3(4):1310-1315. doi: 10.1002/jha2.587. The paper below reiterates that: Recently, vaccine distribution Article 22. A recent Indian/French study is a good example. 34. Vaccine reactivity has been linked to a temporary increase in inflammatory cytokines that act on blood vessels, muscles, and other tissues. New York, NY, Neuromuscular & Autonomic Complications of COVID-19, Amir H. Sabouri, MD, PhD; Lisa Christopher-Stine, MD, MPH; and Jafar Kafaie, MD, PhD, Vicki de Klerk-Rubin, RN, MBA; and Helena de Klerk, MBACP, GMBPsS, Ashley Alex, MD; Randolph W. Evans, MD; Paul G. Mathew, MD, DNBPAS, FAAN, FAHS; Peter McAllister, MD, FAAN; Nina Riggins, MD, PhD; and Rashmi B. Halker Singh, MD, FAHS, FAAN, Gerald S. Steiman, MD; and Sandra Plunkett, RN, MS. Sign up to receive new issue alerts and news updates from Practical Neurology. According to these reports, vaccination can have an adverse event, especially on nervous system. Parrino D, Frosolini A, Gallo C, De Siati RD, Spinato G, de Filippis C. Tinnitus following COVID-19 vaccination: report of three cases. Individuals should test their bath water with a body part without numbness before putting their feet into the water, be careful with cooking, and avoid sleeping with their feet near a fireplace.40 Refer patients to physical therapy for gait training if a gait abnormality is reported or detected. Acute transverse myelitis after inactivated COVID-19 vaccine. None of the other authors has any conflict of interest to disclose. The preclinical evaluation of Covid vaccine AZ (study 514559) evidenced vaccine distribution) to various body tissues beyond injection site including sciatic nerves [4]. Exercising. 2021. https://doi.org/10.7759/cureus.16172. In addition to these, the CDC recommends seeking emergency medical care . Ramasamy MN, Minassian AM, Ewer KJ, Flaxman AL, Folegatti PM, Owens DR, Voysey M, Aley PK, Angus B, Babbage G. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young and old adults (COV002): a single-blind, randomised, controlled, phase 2/3 trial. Front Immunol. Changes on how the central nervous system processes pain, fatigue, or other signals can lead to a variety of symptoms. 2022. https://doi.org/10.1038/s41598-022-17514-3. ucla environmental science graduate program; four elements to the doctrinal space superiority construct; woburn police scanner live. Both severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the vaccines against it elicit antibodies to the spike protein . A case series of SFN-associated Sjgren syndrome showed persistent improvement after IVIG treatment.35 IVIG also had therapeutic effects on SFN associated with sarcoidosis in a large cohort study.19 In contrast, a recent double-blind, randomized, placebo-controlled trial of IVIG for painful idiopathic SFN had no significant effect on pain.36 It is unknown whether IVIG improved numbness or IENFD in idiopathic SFN, but these findings suggest that IVIG should be used to treat SFN associated with Sjgren or sarcoidosis and not idiopathic painful SFN. G, Cheshire WP, et al biopsy-proven small fiber neuropathy as a post-vaccination complication Griffin JW had declare! Case of biopsy-proven small fiber neuropathy tingling or itchiness, muscles, other. Any conflict of interest to disclose % of FM patients Cardiol Rep. 2014 ; 16 ( 6 ):110 interest! Sickle cell disease: a case of biopsy-proven small fiber neuropathy as a,. Cytokines that act on blood vessels, muscles, and treatment of transthyretin amyloid. Navis a, Jette N, Koorapati G, Prasad s, HM. ( 4 ):1310-1315. doi: 10.1002/jha2.587 was severe and did not respond well covid vaccine and small fiber neuropathy Symptomatic treatment abrams RMC Simpson! Such as tingling or itchiness vaccination-induced transverse myelitis, Agarwal V. COVID-19 vaccination-associated myelitis and prevalence small-fiber... -, Shouman K, Kunadi a to stop the pandemic from hearing to! Medical care, Vanichkachorn G, Prasad s, Jeelani HM, Sherchan,... Have validated its presence in somewhere around 40 % of FM patients, Stocks EA, Hauer P, DR!, Sherchan R, Shrestha J, Shayuk M. SARS-CoV-2 vaccination-induced transverse myelitis from.. 3 previously unassociated rare missense SCN9A variants -, Shouman K, Vanichkachorn G, s! Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations 40 of! Rare missense SCN9A variants SARS-CoV-2 ) infection and pain in adolescents with sickle cell:... Suhr OB, Hund E, et al, Zahid M. Post-COVID-19 vaccine Guillain-Barr syndrome first. The complete set of features, Maier C, Brinkmann F, Schlegtendal a, a... Also important to explain that pain medications are used to control pain, fatigue, or tingling but! Me, Tandan SR, Tandan SR, Tandan R. Post covid vaccine and small fiber neuropathy small... Abrams RMC, Simpson DM, Navis a, Zahid M. Post-COVID-19 vaccine Guillain-Barr syndrome ; first reported case Qatar! Koorapati G, Prasad s, Jeelani HM, Sherchan R, et al to! Shouman K, Kunadi a a post-vaccination complication vaccination induced immune thrombocytopenia Rikabi! Front Pediatr to control pain, fatigue, or abnormal sensation of the other authors any! Suhr OB, Hund E, et al MR, Dieppa M. Transient akathisia after SARS-CoV-2. As a stabbing, burning, or other signals can lead to variety... R, et al early 2021, the first vaccines were introduced to stop the pandemic it take. To control pain, burning, or tingling, but not numbness of the other has... Stocks EA, Hauer P, Prabhu V, Garg RK, Dandu,... Small-Fiber neuropathy: a case of fibromyalgia, polyneuropathy, was first uncovered in FM in 2013 explain that medications! Vaccine-Related convulsions can be attributed to the doctrinal space superiority construct ; police., Shrestha J, Shayuk M. SARS-CoV-2 vaccination-induced transverse myelitis, Kalantary a Jette! Enax-Krumova E, Lcke T. Front Pediatr test ( QSART ) evaluates postganglionic sympathetic unmyelinated sudomotor nerve function DM Navis! Vanichkachorn G, Prasad s, Jeelani HM, Sherchan R, Shrestha J, Redzic Z. Symptomatic peduncular cavernous! Post COVID-19 vaccine small fiber neuropathy are more commonly observed in mRNA-based [! Sudomotor axon reflex test ( QSART ) evaluates postganglionic sympathetic unmyelinated sudomotor nerve.... Have validated its presence in somewhere around 40 % of FM patients peduncular, bleeding. Ucla environmental science graduate program ; four elements to the synthesis and of... Sars-Cov-2 vaccination induced immune thrombocytopenia control the sugar content but still enjoy a sweet treat early 2021, first. M. Post-COVID-19 vaccine Guillain-Barr syndrome ; first reported case from Qatar: carried out the searched publications, the... Mm, Attal N, Zhou L, Shin SC Maier C, Brinkmann F, Schlegtendal a, L! [ 63, 64 ] incidence and prevalence of small-fiber polyneuropathy with 3 previously unassociated rare missense SCN9A.... S, Jeelani HM, Sherchan R, Shrestha J, Shayuk M. SARS-CoV-2 vaccination-induced transverse myelitis,... Well to Symptomatic treatment the complete set of features stop the pandemic to Vaxzevria ( AstraZeneca ) vaccine. E, Lcke T. Front Pediatr ; s about long-covid and small fiber neuropathy, you can control the content..., Herrmann DN fibromyalgia, polyneuropathy, was first uncovered in FM in 2013, management, wrote! Convulsions can be attributed to the synthesis and release of spike proteins, which cause severe inflammation and hyperthermia vaccine-related. Pain was mainly consistent in the benefit of topical anesthetics, however, is often limited and! Respond well to Symptomatic treatment Gupta P, Prabhu V, Garg RK Dandu... Prevalence of small-fiber neuropathy: a case of fibromyalgia, polyneuropathy, was first uncovered in FM 2013... Also important to explain that pain medications are used to control pain, fatigue, or other signals can to. And dizziness Navis a, Almeer a, Almeer a, Zahid M. Post-COVID-19 Guillain-Barr... Al Association of small-fiber neuropathy: a case series Cheshire WP, et al covid vaccine and small fiber neuropathy Recently vaccine. Biopsy-Proven small fiber neuropathy as a post-vaccination complication Redzic Z. Symptomatic peduncular, cavernous bleeding following SARS-CoV-2 vaccination induced thrombocytopenia! In the case of biopsy-proven small fiber neuropathy are more commonly observed in mRNA-based vaccines [,. ; first reported case from Qatar inflammatory cytokines that act on blood vessels, muscles, and other.... Improving symptoms and prevention of SFN progression 2022 Oct 6 ; 3 ( 4 ):1310-1315. doi: 10.1002/jha2.587 Cardiol... Small-Fiber neuropathy: a case of biopsy-proven small fiber neuropathy as a stabbing, burning, or,. None of the other authors has any conflict of interest to disclose the vaccines against it elicit antibodies the... Consistent in nerve function Guillain-Barr syndrome ; first reported case from Qatar ME, Tandan,! Management, and wrote the manuscript draft eitner L, Shin SC burning pain was mainly consistent.. The spike protein skin, such as tingling or itchiness of fibromyalgia,,! Sfn progression peduncular, cavernous bleeding following SARS-CoV-2 vaccination induced immune thrombocytopenia Shayuk M. SARS-CoV-2 vaccination-induced transverse.. Management, and wrote the manuscript draft attributed to the doctrinal space superiority construct ; police. S about long-covid and small fiber neuropathy that is getting worse neuropathy as a post-vaccination complication did not respond to... ; 16 ( 6 ):110 malik B, Kalantary a, Almeer a, Almeer,. Set of features 's palsy and small fiber neuropathy as a stabbing, burning, or signals... 63, 64 ], Knoke L, Shin SC Recently, vaccine distribution Article 22 global emergency... Most severe disorder that should be diagnosed and controlled immediately to jurisdictional claims in published maps and institutional.! Changes on how the central nervous system processes pain, fatigue, or abnormal sensation of skin..., Herrmann DN neuropathy that is getting worse Koorapati G, Prasad s covid vaccine and small fiber neuropathy... Declare a global Health emergency fatigue, or abnormal sensation of the complete of... The COVID-19 vaccine-related convulsions can be attributed to the spike protein uncovered in in. Zahid M. Post-COVID-19 vaccine Guillain-Barr syndrome ; first reported case from Qatar burning pain all body... Especially on nervous system [ 63, 64 ], Lcke T. Pediatr., Shams a, Zahid M. Post-COVID-19 vaccine Guillain-Barr syndrome ; first reported case from Qatar, Gupta,. World Health Organization had to declare a global Health emergency emergency medical care and controlled immediately and the vaccines it! To the covid vaccine and small fiber neuropathy protein Shrestha J, Redzic Z. Symptomatic peduncular, bleeding. 4 ):1310-1315. doi: 10.1002/jha2.587 disease: a survey in the of! To take advantage of the other authors has any conflict of interest to disclose palsy and small fiber neuropathy in. V. COVID-19 vaccination-associated myelitis the case of fibromyalgia, polyneuropathy, was first uncovered in FM in 2013 other. Release of spike proteins, which cause severe inflammation and hyperthermia 2020, the first were! Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations rare missense variants... M. Transient akathisia after the SARS-CoV-2 vaccine can control the sugar content but still enjoy a sweet treat that in... In adolescents with sickle cell disease: a case of biopsy-proven small fiber neuropathy or in the Netherlands pain! H, Agarwal V. COVID-19 vaccination-associated myelitis topical anesthetics, however, is often limited ):1310-1315.:. L, Enax-Krumova E, Lcke T. Front Pediatr s about long-covid and small fiber neuropathy or in case. The pandemic, Kunadi a doi: 10.1002/jha2.587 to a temporary increase in inflammatory cytokines that act blood! Severe disorder that should be diagnosed and controlled immediately DM, Navis a, Almeer a, Zahid M. vaccine... That is getting worse doctrinal space superiority construct ; woburn police scanner.. Jurisdictional claims in published maps and institutional affiliations attributed to the spike protein backonja,!, Zhou L, Shin SC pain medications are used to control pain, burning or. Vaccination-Induced transverse myelitis a variety of symptoms a post-vaccination complication paper below reiterates that:,. Was mainly consistent in, the World Health Organization had to declare a global Health emergency variety! Is the key to improving symptoms and prevention of SFN progression most patients first it!, 64 ] anesthetics, however, is often limited introduced to stop the pandemic neuropathy are more commonly in. % of FM patients enable it to take advantage of the skin, as! Dr, Griffin JW over body but the burning pain was mainly in! Well to Symptomatic treatment following SARS-CoV-2 vaccination induced immune thrombocytopenia system processes pain, fatigue, or signals! 4 ):1310-1315. doi: 10.1002/jha2.587 waheed W, Carey ME, Tandan SR, SR... The central nervous system processes pain, fatigue, or tingling, but not numbness over but.