New Onset Vertigo After COVID-19 Infection. A Case Report

Vestibular Decompensation Following COVID-19 Infection in a Person With Compensated Unilateral Vestibular Loss: A Rehabilitation Case Study

BACKGROUND AND PURPOSE

Surgical removal of a vestibular schwannoma (vestibular schwannoma resection; VSR) results in a unilateral vestibular hypofunction with complaints of dizziness and imbalance. Although the anatomic lesion is permanent, recovery of balance and diminution of dizziness occurs through central neurophysiologic compensation. Compensation of the system is maintained through daily activity. Unfortunately, interruption of stimulus, such as decreased activities due to illness, can cause decompensation. Decompensation is described as the return of symptoms consistent with that experienced during the initial insult/injury (eg, dizziness, oscillopsia, balance difficulty). This case study describes a reoccurrence of vestibular dysfunction in a person with a history of VSR following hospitalization and protracted recovery from a COVID-19 infection. It further documents her recovery that may be a result of vestibular rehabilitation.

CASE DESCRIPTION

A 49-year-old woman (M.W.) with a surgical history of VSR (10 years prior) and a medical history of significant COVID-19 infection, resulting in an intensive care unit stay and prolonged use of supplemental oxygen, presented to physical therapy with persistent dizziness and imbalance. The video head impulse test confirmed unilateral vestibular hypofunction.

INTERVENTION

M.W. attended biweekly vestibular rehabilitation for 6 weeks and completed daily home exercises.

OUTCOMES

At discharge, M.W. demonstrated improvements in patient-reported outcomes (Dizziness Handicap Inventory), functional testing (MiniBEST, 2-Minute Walk Test), and gaze stability measures (video head impulse testing, dynamic visual acuity).

DISCUSSION

Vestibular decompensation preluded by a COVID-19 infection caused a significant decrease in functional mobility. Vestibular rehabilitation targeted at gaze and postural stability effectively reduced symptoms and facilitated recovery to M.W.'s pre-COVID-19 level of function. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A458 ).

[Cochleovestibular manifestations in coronavirus infection]

One of the main causes of the of the inner ear pathology is a viral infection including SARS-CoV-2 virus. On the other hand the psycho-emotional state of patients also affects patients with hearing loss, tinnitus and dizziness, and an increase in depression and anxiety was revealed during the period of self-isolation. Goal of our study was to analyze cochleovestibular pathology in patients with COVID-19. The study involved 84 patients and the leading complaint was hearing loss - in 70 patients, tinnitus - in 54 patients, dizziness - in 50 patients. In addition, an increased anxiety background was found in patients, as well as signs of depression. Thus, the 2020 pandemic period was a high risk period for patients with inner ear pathology, which may be associated not only with the actual pathological effect of the virus on the auditory and vestibular system, but also with changes in the psycho-emotional status of patients.

Acute Vertigo in a Patient Following COVID-19 Infection: A Case Report and Literature Review

COVID-19 has infected millions of people worldwide causing millions of deaths. COVID-19 has many serious effects on organs of the body especially the respiratory system causing pneumonia and acute respiratory distress syndrome (ARDS). The disease also has severe complications on other different organs; kidneys and liver which may end in multi-organ failure. Most common symptoms that have been detected in large section of patients were fever, cough and loss of taste or smell and less commonly sore throat, headache and muscle pain. The incidence of vertigo or dizziness is a rare symptom of COVID-19. In this case report, we introduce a 59-year-old male patient suffering from acute vertigo attack after COVID-19 infection. The patient had negative medical history of vertigo and any ear diseases. The patient received REGEN-COV (casirivimab and imdevimab) for COVID-19 and meclizine for vertigo. Vertigo attacks lasted for the two weeks follow up after disappearance of COVID-19 symptoms despite receiving vertigo medication. In conclusion, vertigo may be the sole neurological manifestation of COVID-19. More observational studies should address this symptom and researchers should also focus on identifying the origin of developing vertigo and the direct or indirect mechanisms that SARS-CoV-2 triggers to develop dizziness in general. This research should deliver a clear message, especially to ER physicians to consider proper referral of these patients without underestimating the risk of developing more serious COVID-19 symptoms as ARDS and multi-organ failure if no proper testing and follow-up are provided.

Vertigo in the Setting of COVID-19 Infection: A Case Report

Extensive research has been conducted on the pathophysiological sequelae of the SARS-CoV-2 virus. Newer symptoms pertaining to cardiovascular, gastrointestinal, and neurological systems, apart from the recognized respiratory system, are constantly being reported. We report a case of a 22-year-old female with a seven-day history of COVID-19 who presented to the emergency department with an acute vertigo attack associated with nausea and vomiting for three hours. Physical examination and audiometry showed no neurological and auditory deficits; she was diagnosed with vestibular neuritis. The patient was managed with betahistine hydrochloride and an antihistamine. There was a complete resolution of symptoms after seven days. There have been reports of new-onset vertigo associated with SARS-CoV-2 infection, but more well-designed studies are needed to establish an association between COVID-19 and vertigo.

Therapeutic Approaches to the Neurologic Manifestations of COVID-19

As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.

Neuro-otological Symptoms: An Atypical Aspect of COVID-19 Disease

This study aimed to evaluate the various neuro-otological symptoms experienced by patients with COVID-19 disease. This is a retrospective study conducted from September 2020 to August 2021. Patients with positive RTPCR tests for COVID-19, aged between 18 and 60 years were included in the study. The patients were assessed for neuro-otological symptoms, the type, frequency, and character of these symptoms, their relation with age, gender and COVID-19 disease. Of the 286 patients, 64 (22.3%) had neuro-otological symptoms. The mean age of the patients was 36.3 ± 8.1 years. The frequency of neuro-otological symptoms was higher in females than males and was more frequent in the age group of 18–30 years as compared with other age groups. Of these 64 patients, 29 had vertigo (10.1%), 21 (7.3%) tinnitus, 16 (5.5%) experienced hearing loss. Like many viral diseases, apart from its typical prodromal symptoms, COVID-19 can also cause symptoms like tinnitus, hearing loss, and vertigo.

Vestibular Cochlear Manifestations in COVID-19 Cases

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a high transmissible infectious disease that primarily impacts the respiratory system and leads to death as it worsens. Ever since the World Health Organization declared the disease as a global pandemic, the pathophysiology, clinical manifestations, and disease prognosis has been discussed in various literature. In addition to impaired respiratory health, the symptoms also indicated the involvement of the cardiovascular and neurological system after SARS-CoV-2 infection. Despite the pulmonary, cardiovascular, and neurological complications, many reports also revealed the prevalence of vestibulocochlear symptoms like dizziness, vertigo, vestibular neuritis, sudden sensorineural hearing loss, and tinnitus. Though many clinical reports and scientific reviews reported the vestibular and cochlear impairments associated with coronavirus disease 2019 (COVID-19) infection, the underlying pathological mechanisms are still unclear and unexplored. In this review, we discussed the published clinical reports, research articles, and literature reviews related to vestibulocochlear manifestations following SARS-CoV-2 infections. We also summarized the current knowledge about the prevalence, epidemiological and clinical features, and potential pathological mechanisms related to vestibular and cochlear manifestations resulting from COVID-19 infections.

Vestibular neuritis after COVID-19 vaccination

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 and presents with pneumonia as the most frequent and serious manifestation. COVID-19 vaccination is an important and urgent interest globally due to COVID-19's rapid spread and high rates of mortality and morbidity. Vestibular neuritis (VN) is an acute vestibular syndrome that causes acute and spontaneous vertigo due to unilateral vestibular deafferentiation, leading to nausea or vomiting and unsteadiness that can last from days to weeks. Reactivation of latent type 1 herpes simplex virus, autoimmune disorders, and microvascular ischemia are hypothesized to be etiologies. Herein, the case of a 54-year-old man who developed VN within three days after COVID-19 vaccination is presented. There have been no reports of VN after vaccination for COVID-19 or other viral diseases. Although the association between VN and COVID-19 vaccination remains unclear, clinicians should be aware that VN may occur as an adverse event of COVID-19 vaccination.