18FDG-PET/CT Assessment of COVID-19-Induced Bell's Palsy

Bell's Palsy and COVID-19: Insights from a Population-Based Analysis

Background: Coronavirus disease 2019 (COVID-19) has been linked to Bell's palsy and facial paralysis. Studies have also shown increased risk of Bell's palsy in unvaccinated COVID-19 patients. Objective: To compare the relationship between Bell's palsy and COVID-19 infection and vaccination. Design: This is a retrospective longitudinal study. Methods: The COVID-19 research network was used to identify patients with facial palsy presenting to 70 health care organizations in the United States. The incidence of Bell's palsy was measured within an 8-week window after COVID-19 test or vaccination event in identified patients. Results: Incidence of facial palsy diagnosis (0.99%) was higher than the background rate within 2 months of COVID-19 infection. When compared with their negative counterparts, patients with COVID-19 infection had significantly higher risk of Bell's palsy (risk ratio [RR] = 1.77, p < 0.01) and facial weakness (RR = 2.28, p < 0.01). Risk ratio was also amplified when evaluating Bell's palsy (RR = 12.57, p < 0.01) and facial palsy (RR = 44.43; p < 0.01) in COVID-19-infected patients against patients who received COVID-19 vaccination. Conclusion: In our patient population, there is a higher risk of developing facial palsy within 2 months of COVID-19 infection versus vaccination. Vaccinated patients are not at higher risk of developing facial palsy.

Facial nerve palsy: An early sign of COVID-19

Introduction

Bell's palsy is a peripheral lower motor neuron (LMN) facial nerve palsy, characterized by the acute onset (72 hours or less) of unilateral peripheral facial paresis without other neurologic signs. Bell's palsy has been described at three clinical junctures of COVID-19 infection: as the unique initial signal of COVID-19, as an accompanying feature during the acute phase of COVID-19 when respiratory and systemic symptoms predominate, or during the recuperative phase beginning 2-3 weeks after resolution of respiratory and systemic covid symptoms.

Case report

We present a unique case of a COVID-19-related facial nerve palsy that occurred 3 weeks prior to the onset of pneumonia caused by COVID-19.

Conclusions

This case report suggests an association between early COVID-19 presenting as facial nerve palsy and alerts physicians about the ways in which COVID-19 may cause this phenomenon.

F-18 FDG PET/CT as a One-Stop Shop Imaging Modality for Assessment of Neurologic and Pulmonary Manifestations of COVID-19

Neurologic manifestations are now being increasingly encountered in patients who are admitted for respiratory symptoms of COVID-19. A 67-year-old male with a recent history of Wernicke's aphasia was referred to the nuclear medicine department for risk stratification of malignancy in pulmonary nodule by 18F-FDG PET-CT scan. PET-CT revealed decreased metabolic activity in the left temporoparietal lobe of the brain consistent with recent CVA and excluded malignancy in the pulmonary nodule with low-grade metabolic activity. Incidentally noted, new bilateral pulmonary hypermetabolic ground glass opacities rising suspicious for covid-19 infection which was confirmed by PCR of nasopharyngeal mucosa sample. These findings highlight the value of 18FFDG PET-CT in the assessment of COVID-19 infection especially in non-pulmonary presentations like early neurologic manifestation.

Facial palsy as a manifestation of COVID-19: A systematic review of cases

Background and Aims

Facial palsy is a rare complication of the COVID-19 infection. Herein, we conducted a systematic review of all published cases of facial palsy post-COVID-19 infection in an attempt to educate the general population and medical practitioners regarding the likely occurrence of facial palsy in COVID-19 patients, its detection, effective treatment plan, and prognosis of the condition.

Methods

We searched PubMed, Google Scholar, and Directory of Open Access Journals (DOAJ) from December 1, 2019 to September 21, 2021.

Results

We included 49 studies bearing accounts of 75 cases who had facial palsy. The mean age of patients was 42.9 ± 19.59 years, with a male-to-female ratio of 8:7. The majority of the cases were reported from Brazil (n = 14), USA (n = 9), Turkey (n = 9), and Spain (n = 9). Noticeably, 30.14% of COVID-19 patients were diagnosed with Guillain-Barré syndrome. In total, 22.97% of patients complained of bilateral facial paralysis (n = 17), whereas ipsilateral paralysis was observed in 77.03% (n = 57). These were common complaints of Lagophthalmos, otalgia, facial drooping, dysarthria, and compromised forehead wrinkling. The treatment regimen mainly included the use of corticosteroids (n = 51) (69.86%), antivirals (n = 23) (31.51%), IVIG (n = 18) (24.66%), antibiotics (n = 13) (17.81%), antiretroviral (n = 9) (12.33%), and antimalarial (n = 8) (10.96%) medications. In all, 35.62% of patients (n = 26) adhered to a combination of antiviral and corticosteroid-based therapy. Positive treatment outcomes were observed in 83.58% (n = 56) of cases. In contrast, 10 patients (14.93%) showed nonsignificant recovery, out of which 3 (4.48%) died from the disease.

Conclusion

The association of facial palsy with COVID-19 is controversial and therefore requires further investigation and published work to confirm a causal relationship. However, physicians should not overlook the likelihood of facial palsy post-COVID-19 infection and treat it accordingly.

Epidemiology, clinical features, and treatment modalities of facial nerve palsy in COVID-19 patients: a systematic review

Background

Coronavirus disease 2019 (COVID-19) is responsible for a wide variety of multi-system clinical features. Facial nerve palsy (FNP) is identified as one of the neurological complications of the virus. This work aims to systematically review the clinical picture, laboratory/imaging findings, treatment options, and prognostic factors of FNP in COVID-19 patients.

Methods

Using six online databases, a search was conducted to include all articles with patients infected with COVID-19 and presenting with unilateral or bilateral FNP. Screening for eligibility and data extraction were done by three and four independent reviewers, respectively. Descriptive analyses and data visualizations were done using Google Sheets. Survival analysis and Kaplan–Meier plotting were done by R software.

Results

The data from 22 studies included 32 patients who were infected with COVID-19 and presented with clinical features of FNP. Fourteen patients were male while 18 were female. FNP affected 29 patients unilaterally and 3 patients bilaterally. The imaging findings confirmed that complications of FNP were COVID-19 related. Additionally, antivirals combined with steroids had the lowest median time (21, IQR = 8) to clinical improvement compared to steroid-only (30, IQR = 15) and antiviral-only (33, IQR = 3.5) treatments.

Conclusion

This study has shown a potential correlation between the increased incidence of FNP and COVID-19. We have also found that combining antivirals with steroids may have better outcomes in patients with FNP and COVID-19 although the evidence to support this claim is not strong enough. Further studies are required to assess the extent of linkage between the two conditions and how to properly manage FNP when encountered in COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13760-022-02026-8.

Molecular imaging findings on acute and long-term effects of COVID-19 on the brain: A systematic review

Molecular imaging techniques such as PET and SPECT have been used to shed light on how coronavirus disease 2019 (COVID-19) affects the human brain. We provide a systematic review that summarizes the current literature according to 5 predominant topics. First, a few case reports have suggested reversible cortical and subcortical metabolic alterations in rare cases with concomitant para- or postinfectious encephalitis. Second, imaging findings in single patients with the first manifestations of parkinsonism in the context of COVID-19 resemble those in neurodegenerative parkinsonism (loss of nigrostriatal integrity), but scarceness of data and a lack of follow-up preclude further etiologic conclusions (e.g., unmasking/hastening of neurodegeneration vs. infectious or parainfectious parkinsonism). Third, several case reports and a few systematic studies have addressed focal symptoms and lesions, most notably hyposmia. The results have been variable, although some studies found regional hypometabolism of regions related to olfaction (e.g., orbitofrontal and mesiotemporal). Fourth, a case series and systematic studies in inpatients with COVID-19–related encephalopathy (acute to subacute stage) consistently found a frontoparietal-dominant neocortical dysfunction (on imaging and clinically) that proved to be grossly reversible in most cases until 6 mo. Fifth, studies on post–COVID-19 syndrome have provided controversial results. In patients with a high level of self-reported complaints (e.g., fatigue, memory impairment, hyposmia, and dyspnea), some authors found extensive areas of limbic and subcortical hypometabolism, whereas others found no metabolic alterations on PET and only minor cognitive impairments (if any) on neuropsychologic assessment. Furthermore, we provide a critical appraisal of studies with regard to frequent methodologic issues and current pathophysiologic concepts. Finally, we devised possible applications of PET and SPECT in the clinical work-up of diagnostic questions related to COVID-19.

FDG-PET/CT of COVID-19 and Other Lung Infections

While not conventionally used as the first-line modality, [¹⁸F]-2-fluoro-2-deoxy-D-glucose (FDG) - positron emission tomography/computed tomography (PET/CT) can identify infection and inflammation both earlier and with higher sensitivity than anatomic imaging modalities [including chest X-ray (CXR), computed tomography (CT), and magnetic resonance imaging (MRI)]. The extent of inflammation and, conversely, recovery within the lungs, can be roughly quantified on FDG-PET/CT using maximum standardized uptake value (SUVmax) values. The Coronavirus disease 2019 (COVID-19) pandemic has highlighted the value of FDG-PET/CT in diagnosis, elucidation of acute pulmonary and extrapulmonary manifestations, and long-term follow up. Similarly, many other pulmonary infections such as previously documented coronaviruses, aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, histoplasmosis, mucormycosis, and typical/atypical mycobacterial infections have all been identified and characterized using FDG-PET/CT imaging. The goal of this review is to summarize the actual and potential benefits of FDG-PET/CT in the imaging of COVID-19 and other lung infections. Further research is necessary to determine the best indications and clinical applications of FDG-PET/CT, improve its specificity, and ultimately ascertain how this modality can best be utilized in the diagnostic work up of infectious pathologies.