Cranial neuropathy soon after COVID-19 onset

This study describes 2 patients who developed cranial neuropathies within days of presenting with SARS-CoV-2-related respiratory symptoms.

Observations

The first patient was a 36-year-old man who presented with left partial pupil involving third nerve palsy and bilateral sixth nerve palsy, with lower extremity hyporeflexia and hypesthesia, and gait ataxia. Four days earlier, he had symptoms of fever, cough and myalgia that resolved before ocular presentation. Nasal swabs tested positive for SARS-CoV-2 and MRI revealed enhancement, T2 hyperintensity and enlargement of the left oculomotor nerve. Presumed to have Miller Fisher syndrome, he was treated with intravenous immunoglobulin (2 g/kg for 3 days) along with hydroxychloroquine for COVID-19 (600 mg twice in 1 day, then 400 mg daily for 4 days). He partially improved 3 days after admission.

The second patient was a 71-year-old hypertensive woman with painless diplopia and who could not abduct her right eye; the rest of her neuro-ophthalmic exam was normal. She had a cough and fever for several days and was sent to the emergency, where she had a fever, hypoxemia and lymphocytosis. She had enhancement of the optic nerve sheaths and posterior tenon capsules on MRI; lumbar puncture and chest x-rays were normal. Nasal swabs tested positive for SARS-CoV-2. She received hydroxychloroquine for her COVID-19 pneumonia. Her abduction palsy gradually improved 2 weeks after discharge.

In the first case, the combination of ophthalmoparesis, lower limb paresthesia and areflexia suggests an acute demyelinating inflammatory polyneuropathy secondary to a virus-mediated immune response. However, the rapid onset of symptoms after the onset of COVID-19 disease may point to a direct infectious process. In the second case, the presence of enhancement of the optic nerve sheaths, although nonspecific, suggests a viral leptomeningeal process. Both cases exhibited rapid onset of symptoms after COVID-19 diagnosis, coupled with neuro-imaging findings and improvements that paralleled recovery from COVID-19, suggesting there may be an association between neuro-ophthalmic manifestation and COVID-19.

Limitations

Since the second case was an older patient with hypertension, an ischemic etiology cannot be excluded, particularly in the absence of sixth nerve enhancement on the MRI. However, both cases had presentation of symptoms within days of COVID-19 symptoms, suggesting that even patients with mild symptoms and signs of COVID-19 should be considered for possible SARS-CoV-2 infection. It is unclear whether hydroxychloroquine was beneficial.

Clinical significance

These cases highlight the benefit of having ophthalmologists at the frontline with COVID-19 patients presenting with neuro-ophthalmic manifestation. In the current pandemic, ophthalmologists should screen for COVID-19 in all neuro-ophthalmic cases. Screening for COVID-19 could even be considered in the work-up of patients with neuro-ophthalmic manifestations who are asymptomatic and who have no clear etiology for their manifestations.