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Power Guerra N, Bierkämper M, Pablik J, Hummel T, Witt M. Histochemical Evidence for Reduced Immune Response in Nasal Mucosa of Patients with COVID-19. Int J Mol Sci 2024; 25:4427. [PMID: 38674011 PMCID: PMC11050322 DOI: 10.3390/ijms25084427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
The primary entry point of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the nasal mucosa, where viral-induced inflammation occurs. When the immune response fails against SARS-CoV-2, understanding the altered response becomes crucial. This study aimed to compare SARS-CoV-2 immunological responses in the olfactory and respiratory mucosa by focusing on epithelia and nerves. Between 2020 and 2022, we obtained post mortem tissues from the olfactory cleft from 10 patients with histologically intact olfactory epithelia (OE) who died with or from COVID-19, along with four age-matched controls. These tissues were subjected to immunohistochemical reactions using antibodies against T cell antigens CD3, CD8, CD68, and SARS spike protein for viral evidence. Deceased patients with COVID-19 exhibited peripheral lymphopenia accompanied by a local decrease in CD3+ cells in the OE. However, SARS-CoV-2 spike protein was sparsely detectable in the OE. With regard to the involvement of nerve fibers, the present analysis suggested that SARS-CoV-2 did not significantly alter the immune response in olfactory or trigeminal fibers. On the other hand, SARS spike protein was detectable in both nerves. In summary, the post mortem investigation demonstrated a decreased T cell response in patients with COVID-19 and signs of SARS-CoV-2 presence in olfactory and trigeminal fibers.
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Affiliation(s)
- Nicole Power Guerra
- Smell & Taste Clinic, Department of Otorhinolaryngology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01309 Dresden, Germany; (N.P.G.); (M.B.); (T.H.)
| | - Martin Bierkämper
- Smell & Taste Clinic, Department of Otorhinolaryngology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01309 Dresden, Germany; (N.P.G.); (M.B.); (T.H.)
| | - Jessica Pablik
- Department of Pathology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01309 Dresden, Germany;
| | - Thomas Hummel
- Smell & Taste Clinic, Department of Otorhinolaryngology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01309 Dresden, Germany; (N.P.G.); (M.B.); (T.H.)
| | - Martin Witt
- Department of Anatomy, Institute of Biostructural Foundations of Medical Sciences, Poznań University of Medical Sciences, 61-781 Poznań, Poland
- Department of Anatomy, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01309 Dresden, Germany
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Weir EM, Exten C, Gerkin RC, Munger SD, Hayes JE. Transient loss and recovery of oral chemesthesis, taste and smell with COVID-19: a small case-control series. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.27.23287763. [PMID: 37034638 PMCID: PMC10081393 DOI: 10.1101/2023.03.27.23287763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Anosmia is common with respiratory virus infections, but loss of taste or chemesthesis is rare. Reports of true taste loss with COVID-19 were viewed skeptically until confirmed by multiple studies. Nasal menthol thresholds are elevated in some with prior COVID-19 infections, but data on oral chemesthesis are lacking. Many patients recover quickly, but precise timing and synchrony of recovery are unclear. Here, we collected broad sensory measures over 28 days, recruiting adults (18-45 years) who were COVID-19 positive or recently exposed (close contacts per U.S. CDC criteria at the time of the study) in the first half of 2021. Participants received nose clips, red commercial jellybeans (Sour Cherry and Cinnamon), and scratch-n-sniff cards (ScentCheckPro). Among COVID-19 cases who entered the study on or before Day 10 of infection, Gaussian Process Regression showed odor identification and odor intensity (two distinct measures of function) each declined relative to controls (close contacts who never developed COVID-19), but effects were larger for intensity than identification. To assess changes during early onset, we identified four COVID-19 cases who enrolled on or prior to Day 1 of their illness â€" this allowed for visualization of baseline ratings, loss, and recovery of function over time. Four controls were matched for age, gender, and race. Variables included sourness and sweetness (Sour Cherry jellybeans), oral burn (Cinnamon jellybeans), mean orthonasal intensity of four odors (ScentCheckPro), and perceived nasal blockage. Data were plotted over 28 days, creating panel plots for the eight cases and controls. Controls exhibited stable ratings over time. By contrast, COVID-19 cases showed sharp deviations over time. No single pattern of taste loss or recovery was apparent, implying different taste qualities might recover at different rates. Oral burn was transiently reduced for some before recovering quickly, suggesting acute loss may be missed in data collected after acute illness ends. Changes in odor intensity or odor identification were not explained by nasal blockage. Collectively, intensive daily testing shows orthonasal smell, oral chemesthesis and taste were each altered by acute COVID-19 infection, and this disruption was dyssynchronous for different modalities, with variable loss and recovery rates across modalities and individuals.
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Affiliation(s)
- Elisabeth M. Weir
- Sensory Evaluation Center, The Pennsylvania State University, University Park PA 16802
- Department of Food Science, College of Agricultural Sciences, The Pennsylvania State University, University Park PA 16802
| | - Cara Exten
- Ross and Carol Nese College of Nursing, the Pennsylvania State University, University Park PA 16802
| | | | - Steven D. Munger
- Department of Pharmacology and Therapeutics, University of Florida College of Medicine, Gainesville FL, 32610
- Center for Smell and Taste, University of Florida, Gainesville FL, 32610
- Department of Otolaryngology, University of Florida College of Medicine, Gainesville FL, 32610
| | - John E. Hayes
- Sensory Evaluation Center, The Pennsylvania State University, University Park PA 16802
- Department of Food Science, College of Agricultural Sciences, The Pennsylvania State University, University Park PA 16802
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Cosentino G, Maiorano E, Todisco M, Prunetti P, Antoniazzi E, Tammam G, Quartesan I, Lettieri S, De Icco R, Corsico AG, Benazzo M, Pisani A, Tassorelli C, Alfonsi E. Electrophysiological evidence of subclinical trigeminal dysfunction in patients with COVID-19 and smell impairment: A pilot study. Front Neurol 2022; 13:981888. [PMID: 36313508 PMCID: PMC9615421 DOI: 10.3389/fneur.2022.981888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background Smell and taste disturbances are among the most frequent neurological symptoms in patients with COVID-19. A concomitant impairment of the trigeminal nerve has been suggested in subjects with olfactory dysfunction, although it has not been confirmed with objective measurement techniques. In this study, we explored the trigeminal function and its correlations with clinical features in COVID-19 patients with impaired smell perception using electrophysiological testing. Methods We enrolled 16 consecutive patients with mild COVID-19 and smell impairment and 14 healthy controls (HCs). Olfactory and gustatory symptoms were assessed with self-reported questionnaires. Electrophysiological evaluation of the masseter inhibitory reflex (MIR) and blink reflex (BR) was carried out to test the trigeminal function and its connections within the brainstem. Results Masseter inhibitory reflex (MIR) analysis revealed higher latency of ipsilateral and contralateral early silent period in patients when compared with HCs. No significant differences between groups were detected as regards the duration of the early and late silent period. However, several patients showed a prolonged duration of the early silent period. BR evaluation disclosed only an increased amplitude of early components in patients. Conclusions Patients with COVID-19 and smell impairment show a subclinical trigeminal nerve impairment. Trigeminal alterations mainly involve the oligosynaptic pathway, as a result of either direct viral damage or secondary neuroinflammation of the peripheral trigeminal fibers, whereas the polysynaptic ponto-medullary circuits seem to be spared. The prolonged duration of the early silent period and the increased amplitude of early BR response might reflect a compensatory upregulation of the trigeminal function as a consequence of the olfactory dysfunction.
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Affiliation(s)
- Giuseppe Cosentino
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Eugenia Maiorano
- Department of Otolaryngology–Head and Neck Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimiliano Todisco
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Paolo Prunetti
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Elisa Antoniazzi
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Giulia Tammam
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Ilaria Quartesan
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Sara Lettieri
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto De Icco
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Angelo Guido Corsico
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Pneumology Unit, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Marco Benazzo
- Department of Otolaryngology–Head and Neck Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Antonio Pisani
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Movement Disorders Research Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Enrico Alfonsi
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Pavia, Italy
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Eitner L, Maier C, Brinkmann F, Schlegtendal A, Knoke L, Enax-Krumova E, Lücke T. Somatosensory abnormalities after infection with SARS-CoV-2 - A prospective case-control study in children and adolescents. Front Pediatr 2022; 10:977827. [PMID: 36263148 PMCID: PMC9574195 DOI: 10.3389/fped.2022.977827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Long-term neurological complaints after SARS-CoV-2 infection occur in 4-66% of children and adolescents. Controlled studies on the integrity of the peripheral nerve system are scarce. Therefore, we examined the somatosensory function in children and adolescents after SARS-CoV-2 infection in a case-control study compared with age-matched individuals. Materials and Methods Eighty-one subjects after SARS-CoV-2 infection (n = 44 female, 11.4 ± 3.5 years, n = 75 SARS-CoV-2 seropositive, n = 6 PCR positive during infection and SARS-CoV-2 seronegative at the time point of study inclusion, n = 47 asymptomatic infection) were compared to 38 controls without SARS-CoV-2 infection (26 female, 10.3 ± 3.4 years, n = 15 with other infection within last 6 months). After standardised interviews and neurological examinations, large fibre (tactile and vibration detection thresholds) and small fibre (cold and warm detection thresholds, paradoxical heat sensation) functions were assessed on both feet following a validated protocol. After z-transformation of all values, all participants were compared to published reference values regarding the number of abnormal results. Additionally, the mean for all sensory parameters values of both study groups were compared to an ideal healthy population (with z-value 0 ± 1), as well as with each other, as previously described. Statistical analyses: t-test, Chi-squared test, and binominal test. Findings None of the controls, but 27 of the 81 patients (33%, p < 0.001) reported persistent complaints 2.7 ± 1.9 (0.8-8.5) months after SARS-CoV-2 infection, most often reduced exercise capacity (16%), fatigue (13%), pain (9%), or paraesthesia (6%). Reflex deficits or paresis were missing, but somatosensory profiles showed significantly increased detection thresholds for thermal (especially warm) and vibration stimuli compared to controls. Approximately 36% of the patients after SARS-CoV-2, but none of the controls revealed an abnormal sensory loss in at least one parameter (p < 0.01). Sensory loss was characterised in 26% by large and 12% by small fibre dysfunction, the latter appearing more frequently in children with prior symptomatic SARS-CoV-2 infection. Myalgia/paraesthesia was indicative of somatosensory dysfunction. In all eight re-examined children, the nerve function recovered after 2-4 months. Interpretation This study provides evidence that in a subgroup of children and adolescents previously infected with SARS-CoV-2, regardless of their complaints, the function of large or small nerve fibres is presumably reversibly impaired.
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Affiliation(s)
- Lynn Eitner
- Department of Neuropediatrics, University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
- University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
| | - Christoph Maier
- University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
| | - Folke Brinkmann
- University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
| | - Anne Schlegtendal
- University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
| | - Leona Knoke
- University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
| | - Elena Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil gGmbH, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Lücke
- Department of Neuropediatrics, University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
- University Children’s Hospital, Ruhr University Bochum, Bochum, Germany
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Kay LM. COVID-19 and olfactory dysfunction: a looming wave of dementia? J Neurophysiol 2022; 128:436-444. [PMID: 35894511 PMCID: PMC9377782 DOI: 10.1152/jn.00255.2022] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
Olfactory dysfunction is a hallmark symptom of COVID-19 disease resulting from the SARS-CoV-2 virus. The cause of the sudden and usually temporary anosmia that most people suffer from COVID-19 is likely entirely peripheral-inflammation and other damage caused by the virus in the sensory epithelium inside the upper recesses of the nasal cavity can damage or prevent chemicals from properly activating the olfactory sensory neurons. However, persistent olfactory dysfunction from COVID-19, in the form of hyposmia and parosmia (decreased or altered smell) may affect as many as 15 million people worldwide. This epidemic of olfactory dysfunction is thus a continuing public health concern. Mounting evidence suggests that the SARS-CoV-2 virus itself or inflammation from the immune response in the nasal sensory epithelium may invade the olfactory bulb, likely via non-neuronal transmission. COVID-19-related long-term olfactory dysfunction and early damage to olfactory and limbic brain regions suggest a pattern of degeneration similar to that seen in early stages of Alzheimer's disease, Parkinson's disease, and Lewy body dementia. Thus, long-term olfactory dysfunction coupled with cognitive and emotional disturbance from COVID-19 may be the first signs of delayed onset dementia from neurodegeneration. Few treatments are known to be effective to prevent further degeneration, but the first line of defense against degeneration may be olfactory and environmental enrichment. There is a pressing need for more research on treatments for olfactory dysfunction and longitudinal studies including cognitive and olfactory function from patients who have recovered from even mild COVID-19.NEW & NOTEWORTHY More than 15 million people worldwide experience persistent COVID-19 olfactory dysfunction, possibly caused by olfactory bulb damage. SARS-CoV-2 can cause inflammation and viral invasion of the olfactory bulb, initiating a cascade of degeneration similar to Alzheimer's disease and Lewy body disease. People who have had even mild cases of COVID-19 show signs of degeneration in cortical areas connected with the olfactory system. These data suggest a wave of post-COVID dementia in the coming decades.
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Affiliation(s)
- Leslie M Kay
- Institute for Mind and Biology, Department of Psychology, The University of Chicago, Chicago, Illinois
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Melkumyan K, Shingala D, Simonyan S, Torossian H, Mkrtumyan K, Dilbaryan K, Davtyan G, Vardumyan E, Yenkoyan K. Assessment of Smell and Taste Disturbances among COVID-19 Convalescent Patients: A Cross-Sectional Study in Armenia. J Clin Med 2022; 11:3313. [PMID: 35743383 PMCID: PMC9224774 DOI: 10.3390/jcm11123313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/28/2022] [Accepted: 06/02/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Neurological manifestations of Coronavirus Disease 2019 (COVID-19) such as olfactory and gustatory disturbance have been reported among convalescent COVID-19 patients. However, scientific data on the prevalence of smell and taste disturbance are lacking. Therefore, we present findings on the degree of smell and taste disturbances among the Armenian population. METHODS Study participants were randomly recruited and then categorized into two groups based on their course of the disease. A cross-sectional study was performed to assess participants' sensitivity to smell triggered by the olfactory and the trigeminal nerves; their ability to differentiate between various odors; and to evaluate their gustatory perception. RESULTS The smell test revealed that the degree of olfactory nerve disturbance was different by 30.7% in those participants of the early group as compared to those of the late group, and the degree of trigeminal nerve disturbance was different by 71.3% in the early group as compared to the late group. A variation of the differentiating ability among the participants of the early and late groups was detected. Gustatory disturbances for all flavors were also found to be different in both the groups. A moderate positive correlation (0.51) was found between the overall sensitivity of smell and the ability to differentiate between various odors as cumulatively stimulated by both the olfactory and trigeminal nerves. Also, a moderate positive correlation (0.33) was found between headache and smell sensitivity through the olfactory nerve and a high negative correlation (-0.71) was found between headache and smell sensitivity through the trigeminal nerve. CONCLUSION Pathological changes in the olfactory and trigeminal perceptive abilities caused disturbances in smell sensation, with the trigeminal nerve being more affected. The capacity to differentiate fragrances did not improve with time and the disturbance severity of bitter taste perception was higher among the study participants.
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Affiliation(s)
- Karine Melkumyan
- Neuroscience Laboratory, COBRAIN Center, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (K.M.); (H.T.); (K.D.)
- Department of Physiology, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia
| | - Darshan Shingala
- General Medicine Faculty, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (D.S.); (S.S.); (G.D.); (E.V.)
- ClinChoice LLC., Yerevan 0033, Armenia
| | - Syuzanna Simonyan
- General Medicine Faculty, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (D.S.); (S.S.); (G.D.); (E.V.)
| | - Hrag Torossian
- Neuroscience Laboratory, COBRAIN Center, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (K.M.); (H.T.); (K.D.)
- General Medicine Faculty, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (D.S.); (S.S.); (G.D.); (E.V.)
| | | | - Karen Dilbaryan
- Neuroscience Laboratory, COBRAIN Center, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (K.M.); (H.T.); (K.D.)
- Department of Pharmacology, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia
| | - Garri Davtyan
- General Medicine Faculty, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (D.S.); (S.S.); (G.D.); (E.V.)
| | - Erik Vardumyan
- General Medicine Faculty, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (D.S.); (S.S.); (G.D.); (E.V.)
| | - Konstantin Yenkoyan
- Neuroscience Laboratory, COBRAIN Center, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia; (K.M.); (H.T.); (K.D.)
- Department of Bochemistry, Yerevan State Medical University after Mkhitar Heratsi, Yerevan 0025, Armenia
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Szewczyk AK, Skrobas U, Jamroz-Wiśniewska A, Mitosek-Szewczyk K, Rejdak K. Facial Diplegia-Complication or Manifestation of SARS-CoV-2 Infection? A Case Report and Systemic Literature Review. Healthcare (Basel) 2021; 9:healthcare9111492. [PMID: 34828542 PMCID: PMC8618007 DOI: 10.3390/healthcare9111492] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/24/2022] Open
Abstract
Since the outbreak of the new coronavirus, healthcare systems around the world have witnessed not only COVID-19 symptoms but also long-term complications of the aforementioned, including neurological problems. We report a clinical case of an adult patient with bilateral facial nerve palsy and progressive ascending paresis of the limbs after contracting the novel coronavirus (COVID-19). Additionally, the systematic review aimed to identify and summarize specific clinical features, outcomes and complications of the studies focusing on bilateral facial diplegia as a sequela of COVID-19 infection. The total number of analyzed patients was 15. Only one patient was diagnosed with isolated bilateral palsy; the rest had Guillain-Barré Syndrome (GBS). With one exception, all the presented cases had favorable outcomes, with facial palsy recovery from slight to almost complete. In patients with a confirmed COVID-19 diagnosis, bilateral facial palsy may be an isolated symptom as well as a variant of GBS. Symptoms of cranial nerve damage during a COVID-19 infection may explain the appearance of facial nerve damage. In order to clarify the spectrum of neurological manifestations and a causal relation between SARS-CoV-2, COVID-19 vaccination and neurological symptoms, direct attention towards the study of this virus is crucial. It seems reasonable to recognize human coronavirus as another potential GBS trigger.
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Affiliation(s)
- Anna K. Szewczyk
- Department of Neurology, Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland; (U.S.); (A.J.-W.); (K.R.)
- Correspondence:
| | - Urszula Skrobas
- Department of Neurology, Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland; (U.S.); (A.J.-W.); (K.R.)
| | - Anna Jamroz-Wiśniewska
- Department of Neurology, Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland; (U.S.); (A.J.-W.); (K.R.)
| | - Krystyna Mitosek-Szewczyk
- Department of Child Neurology, Medical University of Lublin, ul. Profesora Antoniego Gębali 6, 20-093 Lublin, Poland;
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland; (U.S.); (A.J.-W.); (K.R.)
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