Bell's palsy in a pediatric patient with hyper IgM syndrome and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Has Coranavirus Disease 2019 Changed the Incidence and Outcome of Bell's Palsy?

BACKGROUND

Objectives: (1) To determine whether the incidence of Bell's Palsy (BP) increased during the pandemic. (2) To investigate whether the outcomes of patients with BP and COVID-19 infection or vaccination differ from those in the pre-pandemic era.

METHODS

Patients with BP were studied in 2 periods retrospectively (March 2021-March 2022 and August 2018-August 2019). A prospective study from March 2021 to March 2022 was also performed. Primary outcome was grade ≤Ⅱ in the House-Brackmann (HB) and/or >70 in the Sunnybrook facial grading system (SFGS) scales at the 12-week visit. Reverse transcriptase polymerase chain reaction (PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and enzyme-linked immunosorbent assay-based SARS-CoV-2 immuonoglobulin G (IgG) test (blood) were measured.

RESULTS

About 162 and 196 patients with BP were identified between March 2021 and March 2022 and August 2018 and August 2019, respectively. Forty-seven patients (29%) entered the prospective study; 85% had HB grades I or II, while 92% had an SFGS score of 71-100 at the last visit. Only 3 patients (6.5%) had a positive PCR during the initial episode, whereas 35 patients (77%) had positive IgG SARS-CoV-2. There was no association between positive PCR and facial function outcomes. Of the 162 patients, 105 (67%) had received COVID-19 vaccine. In 23 of them (22%), the paralysis appeared within the first 30 days after a vaccine dose.

CONCLUSION

Coronavirus disease 2019 did not increase the incidence of BP. A direct association between the coronavirus and BP outcome cannot be established. The considerable number of patients developing BP within the first month suggests a possible association between COVID-19 vaccines and BP.

Examining the relationship between COVID-19 and Bell's palsy: Experience of a single tertiary care center

BACKGROUND

While the etiology of Bell's palsy (BP) is largely unknown, current evidence shows it may occur secondary to the immune response following a viral infection. Recently, BP has been reported as a clinical manifestation of coronavirus disease (COVID-19).

OBJECTIVES

To investigate an association between COVID-19 infection and BP. Additionally, to evaluate the need for COVID-19 testing in patients who present with BP.

METHODS

Hospital records of patients who presented to a single tertiary care center with BP in 2020 and 2021 were reviewed for presenting symptoms, demographics, COVID-19 infection and vaccination status.

RESULTS

There was no statistically significant difference between patients with BP who had a positive or negative COVID test in terms of sex, BMI, age, race, smoking history or alcohol use. All 7 patients with BP and a positive COVID test were unvaccinated. Of the total cohort of 94 patients, 82 % were unvaccinated at the time of the study. None of the 17 patients who were vaccinated had a positive COVID test. A history of BP showed no statistical significance (10.3 % vs 14.3 %, p-value 0.73).

CONCLUSION

We discovered a limited cohort of patients who underwent COVID-19 testing at the time of presentation for BP. Though there have been recent studies suggesting a COVID-19 and BP, we were unable to clearly identify a relationship between COVID-19 and BP. Interestingly, all patients with facial paralysis and COVID-19 were unvaccinated. To further study this relationship, we recommend consideration of a COVID-19 test for any patient that presents with facial paralysis.

Simultaneous Sudden Hearing Loss and Peripheral Facial Paralysis in a Patient With Covid-19

Although peripheral facial paralysis and sudden sensorineural hearing loss are not as common as anosmia, they are reported neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We present a 62-year-old, serologically COVID-19 positive woman with seventh and eighth nerve involvement showed electrophysiologically with Auditory Brainstem Response and electroneurography and radiologically with internal acoustic canal magnetic resonance imaging. This single case report suggests a possible association between the SARS-CoV-2 infection with simultaneous sudden sensorineural hearing loss and isolated facial paralysis. However, further studies are needed to determine whether this relationship is coincidental or occasional.

Neurological Manifestations of Coronavirus Disease 2019 and Mpox in Pediatric Patients and Their Management: A State-of-the-Art Systematic Review

BACKGROUND

There is an increasing number of cases being reported of neurological manifestations of Coronavirus disease 2019 (COVID-19) infection and Monkeypox (Mpox), both during the course of the infection and as a presenting symptom. We aim to review the neurological manifestations of COVID-19 and monkeypox in pediatric patients and their management.

METHODS

We conducted a systematic review that included cohort studies and case series or reports involving a pediatric population of patients with a confirmed COVID-19 or Mpox infection and their neurological manifestations. We searched the following electronic databases: PubMed, EMBASE, and Scopus.

RESULTS

From 1136 articles identified, 127 studies were included. Headache, stroke, Guillain-Barré syndrome, seizure, nerve palsies, and multisystem inflammatory syndrome in children were the most common neurological symptoms caused by COVID-19, whereas encephalitis was commonly seen in patients with Mpox. Rare neurological manifestations of COVID-19 included cerebral venous sinus thrombosis, plexopathies, demyelinating disorders, encephalitis, etc., and rare neurological manifestations of Mpox included headache.

CONCLUSIONS

Our review highlights the importance of investigating possible neurological manifestations and closely monitoring these patients to develop a better understanding of the treatment strategies that can be adopted.

Severity of SARS-CoV-2 infection in children with inborn errors of immunity (primary immunodeficiencies): a systematic review

BACKGROUND

Inborn errors of immunity (IEIs) are considered significant challenges for children with IEIs, their families, and their medical providers. Infections are the most common complication of IEIs and children can acquire coronavirus disease 2019 (COVID-19) even when protective measures are taken.

OBJECTIVES

To estimate the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children with IEIs and analyse the demographic parameters, clinical characteristics and treatment outcomes in children with IEIs with COVID-19 illness.

METHODS

For this systematic review, we searched ProQuest, Medline, Embase, PubMed, CINAHL, Wiley online library, Scopus and Nature through the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline for studies on the development of COVID-19 in children with IEIs, published from December 1, 2019 to February 28, 2023, with English language restriction.

RESULTS

Of the 1095 papers that were identified, 116 articles were included in the systematic review (73 case report, 38 cohort 4 case-series and 1 case-control studies). Studies involving 710 children with IEIs with confirmed COVID-19 were analyzed. Among all 710 IEIs pediatric cases who acquired SARS-CoV-2, some children were documented to be admitted to the intensive care unit (ICU) (n = 119, 16.8%), intubated and placed on mechanical ventilation (n = 87, 12.2%), suffered acute respiratory distress syndrome (n = 98, 13.8%) or died (n = 60, 8.4%). Overall, COVID-19 in children with different IEIs patents resulted in no or low severity of disease in more than 76% of all included cases (COVID-19 severity: asymptomatic = 105, mild = 351, or moderate = 88). The majority of children with IEIs received treatment for COVID-19 (n = 579, 81.5%). Multisystem inflammatory syndrome in children (MIS-C) due to COVID-19 in children with IEIs occurred in 103 (14.5%). Fatality in children with IEIs with COVID-19 was reported in any of the included IEIs categories for cellular and humoral immunodeficiencies (n = 19, 18.6%), immune dysregulatory diseases (n = 17, 17.9%), innate immunodeficiencies (n = 5, 10%), bone marrow failure (n = 1, 14.3%), complement deficiencies (n = 1, 9.1%), combined immunodeficiencies with associated or syndromic features (n = 7, 5.5%), phagocytic diseases (n = 3, 5.5%), autoinflammatory diseases (n = 2, 3%) and predominantly antibody deficiencies (n = 5, 2.5%). Mortality was COVID-19-related in a considerable number of children with IEIs (29/60, 48.3%). The highest ICU admission and fatality rates were observed in cases belonging to cellular and humoral immunodeficiencies (26.5% and 18.6%) and immune dysregulatory diseases (35.8% and 17.9%) groups, especially in children infected with SARS-CoV-2 who suffered severe combined immunodeficiency (28.6% and 23.8%), combined immunodeficiency (25% and 15%), familial hemophagocytic lymphohistiocytosis (40% and 20%), X-linked lymphoproliferative diseases-1 (75% and 75%) and X-linked lymphoproliferative diseases-2 (50% and 50%) compared to the other IEIs cases.

CONCLUSION

Children with IEIs infected with SARS-CoV-2 may experience higher rates of ICU admission and mortality in comparison with the immunocompetent pediatric populations. Underlying immune defects does seem to be independent risk factors for severe SARS-CoV-2 infection in children with IEIs, a number of children with SCID and CID were reported to have prolonged infections-though the number of patients is small-but especially immune dysregulation diseases (XLP1 and XLP2) and innate immunodeficiencies impairing type I interferon signalling (IFNAR1, IFNAR2 and TBK1).

Peripheral nervous system involvement in SARS-CoV-2 infection: a review of the current pediatric literature

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the pathogen responsible for the pandemic health emergency declared by the World Health Organization in March 2020. During the first part of the pandemic, adults showed mild to severe respiratory symptoms. Children seemed initially exempt, both from acute and subsequent complications. Hyposmia or anosmia were promptly identified as the main symptoms of acute infection, so neurotropism of SARS-CoV-2 was immediately suspected. (1, 2). As the emergency progressed, post infectious neurological complications were described also in pediatric population (3). Cases of cranial neuropathy in connection with acute SARS-CoV-2 infection have been reported in pediatric patients, as an isolate post infectious complication or in the context of the multisystem inflammatory syndrome in children (MIS-C) (4-6). Neuroinflammation is thought to be caused by several mechanisms, among which immune/autoimmune reactions (7), but so far, no specific autoantibody has been identified. SARS-CoV-2 can enter the central nervous system (CNS) directly and/or infect it retrogradely, through the peripheral nervous system (PNS), after replicating peripherally; several factors regulate invasion and subsequent neuroinflammation. Indeed, direct/secondary entry and replication can activate CNS-resident immune cells that, together with peripheral leukocytes, induce an immune response and promote neuroinflammation. In addition, as we will discuss in the following review, many cases of peripheral neuropathy (cranial and non-cranial) have been reported during or after SARS-CoV-2 infection. However, some authors have pointed out that the increase of cranial roots and ganglia in neurological imaging is not always observed in children with cranial neuropathy. (8). Even if a variety of case reports were published, opinions about an increased incidence of such neurologic diseases, linked to SARS-CoV-2 infection, are still controversial (9-11). Facial nerve palsy, ocular movements abnormalities and vestibular alterations are among the most reported issues in pediatric population (3-5). Moreover, an increased screen exposure imposed by social distancing led to acute oculomotion's disturbance in children, not primarily caused by neuritis (12, 13). The aim of this review is to suggest food for thought on the role of SARS-CoV-2 in neurological conditions, affecting the peripheral nervous system to optimize the management and care of pediatric patients.

A critical appraisal of neurological evidence on paediatric COVID-19 patients. A systematic literature review

Objective

The aim of our study was to assess the close direct relationship between the development of neurological manifestations and SARS-CoV-2 infection in paediatric patients, by a systematic review of the literature.

Methods

PubMed and Google Scholar were searched for publications from the start of the pandemic up to 31 December 2022. We included articles that described nervous system manifestations in patients aged 0-18 years with RT-PCR nasopharyngeal swab positivity for SARS-CoV-2.

Results

The initial search produced 3456 records, of which 37, involving a total of 48 paediatric patients, were included in our systematic review. The neurological complications were heterogeneous, due at least in part to the different age groups considered. In the literature, encephalitis was the most common diagnosis (20.83%). Clinical presentation, diagnostic support, treatment and outcome were analysed both in the literature and in our experience.

Conclusions

Neurological impairment can occur with the first clinical presentation of COVID-19, even in previously healthy children and with mild forms of the disease. The clinical presentations are heterogeneous in the different age groups. In most patients the outcome is good and neurological manifestations subside after discharge.

Eye damage in COVID-19. Part 2: posterior segment complications, neuro-ophthalmic manifestations, vaccination and risk factors

Posterior eye segment involvement in COVID-19 has varied manifestations: vascular, inflammatory, and neuronal. All of them are triggered by SARS-CoV-2 virus but they cannot be viewed as exclusively specific to COVID-19. According to the literature, the mean age of the patients varies from 17 to 75 with the median of 50 years. The median duration between the appearance of ophthalmic symptoms and the detection of COVID-19 was 12 days. The disease affects both men and women equally. Direct exposure to the virus, immune-mediated tissue damage, activation of the coagulation system, the prothrombotic state caused by a viral infection, concomitant diseases and medications used in the treatment contribute to the development of eye pathologies. Ophthalmologists should be aware of the possible relations of posterior eye segment pathologies, orbit and neuro-ophthalmic disorders with SARS-CoV-2, as well as the possible exacerbation of chronic forms of inflammatory eye diseases and autoimmune disorders due to anti-COVID-19 vaccination.

Facial palsy at the onset of SARS-CoV-2 infection. A case report

Introduction

SARS-CoV-2 infection has been associated with an increased number of deaths, due to severe respiratory damage, cardiovascular impairment, acute renal failure, and also neurological injury, including stroke, which is most commonly responsible for death. These are elements that determine patients to seek medical advice.

Case report

This is a case report of a female Caucasian patient, aged 65 years, with type 2 diabetes mellitus on metformin 1000 mg twice/day, and hypertension, who presented to the emergency department with one day history of left orbital hyperlacrimation and chewing and swallowing difficulty. On physical examination there was a decreased blink reflex, flattened nasolabial fold, and drooping left corner of the mouth, with left conjunctival hyperemia, and a present corneal reflex. Motion limited head CT and MRI revealed no pathological changes suggestive for the appearance of paresis. The patient was transferred to the Department of Infectious Diseases after laboratory confirmation of SARS-CoV-2 infection. Under treatment, improvement of paresis after three days was observed, with minimal asymmetry left five days after admission. A reassessment one month after discharge revealed complete recovery of the paresis, physical asthenia, and headache, in the context of long-COVID syndrome.

Conclusions

The appearance of paresis may be a consequence of the direct action of the virus on the nervous system, of hypercoagulability, or, later, of an immune mechanism. The case presented is judged as an early, direct action of the virus on the central nervous system, the respiratory symptoms were minimized by the patient at the time of presentation.

A review of the potential neurological adverse events of COVID-19 vaccines

Despite the advantages of getting access to the coronavirus disease 2019 (COVID-19) vaccines, their potential ability to induce severe adverse events (AEs) has been a significant concern. Neurological complications are significant among the various adverse events following immunization (AEFI) due to their likely durability and debilitating sequelae. Neurological AEs following COVID-19 vaccination can either exacerbate or induce new-onset neuro-immunologic diseases, such as myasthenia gravis (MG) and Guillain-Barre syndrome (GBS). The more severe spectrum of AEs post-COVID19 vaccines has included seizures, reactivation of the varicella-zoster virus, strokes, GBS, Bell's palsy, transverse myelitis (TM), and acute disseminated encephalomyelitis (ADEM). Here, we discuss each of these neurological adverse effects separately.

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.

Late peripheral facial paralysis after COVID-19: a rapid systematic review and two case reports

Peripheral facial paralysis (PFP) has been shown to be a neurological manifestation of COVID-19. The current study presents two cases of PFP after COVID-19, along with a rapid review of known cases in the literature. Both case reports were conducted following CARE guidelines. We also performed a systematic review of PFP cases temporally related to COVID-19 using PubMed, Embase, and Cochrane Library databases on August 30, 2021, using a rapid review methodology. The two patients experienced PFP 102 and 110 days after COVID-19 symptom onset. SARS-CoV-2 RNA was detected in nasal samples through reverse-transcription real-time polymerase chain reaction (RT-qPCR) testing. Anosmia was the only other neurological manifestation. PFP was treated with steroids in both cases, with complete subsequent recovery. In the rapid review, we identified 764 articles and included 43 studies. From those, 128 patients with PFP were analyzed, of whom 42.1% (54/128) were male, 39.06% (50/128) female, and in 23 cases the gender was not reported. The age range was 18 to 59 (54.68%). The median time between COVID-19 and PFP was three days (ranging from the first symptom of COVID-19 to 40 days after the acute phase of infection). Late PFP associated with COVID-19 presents mild symptoms and improves with time, with no identified predictors. Late PFP should be added to the spectrum of neurological manifestations associated with the long-term effects of SARS-CoV-2 infection as a post COVID-19 condition.

Facial Nerve Paralysis and COVID-19: A Systematic Review

Objective

Several cases of facial nerve paralysis (FNP) post‐COVID‐19 infection have been reported with varying presentations and management. This study aims to identify FNP clinical characteristics and recovery outcomes among patients acutely infected with COVID‐19. We hypothesize that FNP is a potentially unique sequalae associated with COVID‐19 infections.

Methods

A systematic review of PubMed‐Medline, OVID Embase, and Web of Science databases from inception to November 2021 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.

Results

This search identified 630 studies with 53 meeting inclusion criteria. This resulted in 72 patients, of which 30 (42%) were diagnosed with Guillain‐Barré Syndrome (GBS). Non‐GBS patients were on average younger (36 vs. 53 years) and more likely to present with unilateral FNP (88%) compared to GBS patients who presented predominantly with bilateral FNP (74%). Among non‐GBS patients, majority (70%) of FNP presented a median of 8 [IQR 10] days after the onset of initial COVID‐19 symptom(s). Treatment for non‐GBS patients consisted of steroids (60%), antivirals (29%), antibiotics (21%), and no treatment (21%). Complete FNP recovery in non‐GBS patients was achieved in 67% patients within a median of 11 [IQR 24] days.

Conclusion

FNP is a possible presentation post COVID‐19 infections, associated with both GBS and non‐GBS patients. Although no causation can be assumed, the clinical course of isolated FNP associated with COVID‐19 raises the possibility of a unique presentation differing from Bell's palsy, seen with higher proportion of patients developing bilateral FNP and a shorter duration to complete recovery. Laryngoscope, 2022

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.

A case of facial nerve palsy in a pediatric patient associated with Covid-19

Background

Pediatric facial nerve palsy is acute and mostly idiopathic; other causes are post-infectious forms.

Case presentation

We describe a rare case of facial nerve palsy associated with COVID-19 in a 5-year-old boy. The diagnosis of post-infectious COVID-19-related facial paralysis was made by serology positivity for a previous infection (IgG positive, IgM and IgA weakly positive), in the presence of a negative molecular nasopharyngeal swab and in the absence of other etiologies. Early treatment with steroids (1 mg/day for 7 days followed by tapering) and supportive care solved the problem.

Conclusion

In a child with facial paralysis, COVID-19 must be considered as the cause and both nasopharyngeal swab and serology must be performed.

Surge of Bell's Palsy in the era of COVID-19; Systematic review

BACKGROUND

With the progression of Coronavirus infectious disease-19 (COVID-19), various neurological manifestations have been noticed in these patients and Bell's palsy is one of the peripheral neuropathies among those. Bell's palsy has been associated with various other viral agents. Its evidence in patients with COVID-19 signifies the possibility of association between Bell's Palsy and Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2).

OBJECTIVE

To evaluate the number of published cases of Bell's palsy as the only major neurological manifestation in patients with COVID-19 from March 2020 to December 2021 and to investigate the association of SARS-CoV2 and Bell's palsy.

MATERIALS AND METHODS

A systematic review of the published English literature was performed using an electronic search in PubMed / Medline, Scopus, Research gate, Research square and Google Scholar databases, using keywords like 'COVID-19' OR/AND 'SARS-CoV-2', OR/AND 'Bell's palsy', OR/AND 'Facial nerve palsy', OR/AND 'Neurological', OR/AND 'Manifestation'.

RESULTS

Search strategy revealed 32 relevant publications with a total of 46 patients. Bell's palsy was the initial manifestation in 37% cases and in 63% cases it developed after COVID-19 symptoms. 71.7% cases showed complete recovery and 21.7% showed only partial relief from BP.

CONCLUSIONS

Although the number of documented cases in this research are not much, but evidence of Bell's palsy as the only major neurological manifestation in patients with COVID-19 signifies an important clinical finding and the possibility of another viral aetiology of BP. More evidence is needed to establish the exact co-relation between these two entities.

Cranial neuropathy in COVID-19: a case series and review of literature

Neurological presentation of COVID-19 is increasingly being recognised. Cranial neuropathy in COVID-19 is an uncommon and under-diagnosed entity. We report a case series of 4 patients who presented with trigeminal neuropathy (two cases) and facial nerve palsy (two cases) which recovered with conservative treatment along with the review of the literature.

Rehabilitation of peripheral facial palsy associated with COVID-19 in a child: A case report

COVID-19 has been associated with multiple neurological manifestations. Coronaviruses are known to have a neurotropic propensity, possibly leading to various neurological complications, including peripheral facial paralysis (PFP). However, the pathogenic mechanisms underlying neurological symptoms in COVID-19 are not completely understood. This report presents the first published case of facial palsy in an otherwise healthy child secondary to infection with the novel coronavirus SARS-Cov-2, with reflections on the natural course and the role of physical and rehabilitation medicine in this form of PFP. Thus, PFP may also be a manifestation of COVID-19 and in the current epidemiological context, physicians evaluating patients with facial palsy should exclude infection with SARS-Cov-2 to prevent diagnostic delays and further transmission of the disease. These patients may have a slower recovery and worse prognosis as compared with those with Bell's palsy. Thus, rehabilitation needs to be initiated promptly, and close follow-up must be assured to identify and address early complications.

Clinical case of peripheral facial palsy as first and single COVID-19 symptom in an immunized patient

SARS-CoV-2 virus affects the central as well as the peripheral nervous system. Peripheral facial palsy is possible as the first and single COVID-19 symptom. The author presents own clinical observation of a 58-year-old patient with peripheral facial palsy. It is known that the patient completed the vaccination 8 weeks ago and also had direct contact with the patient SARS-CoV-2 (the patient's son). Facial nerve palsy was the first and only symptom of coronavirus infection. In the blood there was a moderate lymphocytopenia, increased interleukin-6, C-reactive protein, seromukoids. MRI of the brain and CT of the temporal bones did not reveal focal and diffuse pathology. After treatment, there was a complete recovery on the ninth day of treatment. Treatment included antiviral drugs, vitamins, steroids, kinesiotaping of facial muscles. The author substantiates necessity and demonstrates the results of treatment with endothelioprotective therapy (combination of L-arginine and L-carnitine) , which is aimed at elimination of systemic inflammation, oxidative stress caused by SARS-CoV-2 virus. Conclusions. General practitioner need to be alert when examining patients, including those who have been vaccinated and those who have direct contact with patients with coronavirus infection. Pathogenesis of peripheral facial palsy in COVID-19 multidirectional: neuroinvasive and neurotropic effect of the virus on the nerve, hypercoagulation, ischemia of the peripheral nerve on the background of systemic inflammatory reaction, oxidative stress. Timely detection, careful monitoring and adequate treatment of pathology are necessary to prevent complications (persistent facial contractures, synkinesis). Further in-depth studies are needed on a larger sample of patients to identify the incidence of peripheral facial nerve palsy in COVID-19 and the possibility of a link to vaccination.

A cluster of children with facial nerve palsy in a high prevalence area for COVID-19

BACKGROUND

COVID-19 is a disease of varying presentation and neurological sequelae of the disease are being studied. Following a cluster of paediatric facial nerve palsy (FNP) cases in an area of South Wales with a high prevalence of COVID-19, we conducted an opportunistic study to determine whether there has been an increase of incidence of FNP and if there is an association between the FNP and COVID-19 in children.

METHODS

We performed a retrospective review of the incidence of FNP between 2015 and 2020 across two hospitals within the health board. The incidence was compared with that in 2020 including a cluster of six children in 14 weeks, presenting to Royal Glamorgan Hospital between June and October.

RESULTS

There were 48 cases of children with FNP across both hospital within the study years. Seven (7) cases in 2020. The incidence was not statistically different in comparison to other years. Five out of six of these children in 2020 had antibody testing for COVID-19. All serology testing (100%) returned negative for SARS-CoV- 2 antibodies.

CONCLUSIONS

In high prevalence area for COVID-19, cases of children with FNP have not shown a commensurate increase. we have found no causal link between COVID-19 and FNP in children. While this is a small study, larger cohort studies are needed to support this finding. As new strains of COVID-19 are being reported in UK, South Africa and Brazil, physicians need to continue to be vigilant for consistent pattern of signs and symptoms, especially in children.

Does the SARS-CoV-2 pandemic really increase the frequency of peripheral facial palsy?

PURPOSE

Publications about increased number of peripheral facial paralysis in the COVID-19 pandemic emerged in the literature. However, these studies comprised of an estimate rather than a broad analysis of exact numbers. In this study, we planned to investigate whether the pandemic really resulted in an increase in facial paralysis cases admitted to the hospital by evaluating the cases who applied to our hospital due to facial paralysis in the COVID-19 pandemic year and in the previous 4 years.

MATERIALS AND METHODS

Patients who applied to our hospital due to facial paralysis between March 2016-February 2017 (Group 1), between March 2017-February 2018 (Group 2), between March 2018-February 2019 (Group 3), between March 2019-February 2020 (Group 4), and between March 2020-February 2021 (Group 5) were investigated and detailed data were noted.

RESULTS

156, 164, 149, 172 and 157 patients were admitted to the hospital due to peripheral facial paralysis in Group 1, 2, 3, 4, and 5, respectively. Of these patients, 155, 164, 145, 169, and 153 were Bell's palsy, respectively. SARS-CoV-2 RT-PCR test was positive in only 2 of the 153 patients who were diagnosed in the year of the pandemic.

CONCLUSIONS

This study showed that the number of peripheral facial paralysis detected during the COVID-19 pandemic was similar to previous years. Very few number of positive SARS-CoV-2 RT-PCR test results may have been found incidentally in Bell's palsy patients. Theses stating that SARS-CoV-2 causes peripheral facial paralysis should be supported by laboratory studies and postmortem research.

A Systematic Review of Severe Neurological Manifestations in Pediatric Patients with Coexisting SARS-CoV-2 Infection

SARS-CoV-2 infection in children produces mild respiratory symptoms or no symptoms at all in most cases. Some pediatric patients develop a severe complication associated with high mortality, the multisystem inflammatory syndrome in children (MIS-C). In both scenarios, there are reports of neurological manifestations. This article aims to review the cases of pediatric patients with severe neurological issues and a coexisting positive SARS-CoV-2 test. A literature search was performed between March 2020 and May 2021. The results included the data from 41 studies, with 159 children with severe neurological manifestations, within an age range from 24 h to 17 years. The neurological disorders included 38 cases with stroke, 32 with encephalitis, 22 with encephalopathy, and 10 with Guillain–Barre syndrome. Sixty-five out of 159 cases with severe neurological manifestations were diagnosed with MIS-C. Direct neuroinvasion and the exaggerated immune response in some patients seem to be the most critical factors triggering these manifestations. Further research in the ongoing pandemic is needed to elucidate the precise mechanism.

A Cluster of Children with Facial Nerve Palsy in High Prevalence Area for COVID-19

OBJECTIVES

COVID-19 is a disease of varying presentation and neurological sequelae of the disease are being studied. Following a cluster of paediatric facial nerve palsy (FNP) cases in an area of South Wales with a high prevalence of COVID-19, we conducted an opportunistic study to determine whether there has been an increase in incidence of FNP and if there is an association between the FNP and COVID-19 in children.

STUDY DESIGN

A retrospective cohort study. Using the case series from 2020 and comparing it with previous years.

METHODS

We reviewed the incidence of FNP between 2015-2020 across two hospitals within the health board. The incidence was compared with that in 2020 including a cluster of six children in 14 weeks, presenting to the Royal Glamorgan Hospital between June and October.

RESULTS

There were 48 cases of children with FNP across both hospital within the study years. Seven (7) cases in 2020. The incidence was not statistically different in comparison to other years.Five out of six of these children in 2020 had antibody testing for COVID-19. All serology testing (100%) returned negative for SARS-CoV- 2 antibodies.In high prevalence area for COVID-19, cases of children with FNP have not shown a commensurate increase. we have found no causal link between COVID-19 and FNP in children. While this is a small study, larger cohort studies are needed to support this finding.

CONCLUSION

As new strains of COVID-19 are being reported in UK, South Africa and Brazil, physicians need to continue to be vigilant for consistent pattern of signs and symptoms, especially in children.

A systematic review of Bell's Palsy as the only major neurological manifestation in COVID-19 patients

BACKGROUND

Bell's palsy is an acute idiopathic paralysis of the facial nerve. The disease is caused by many viruses like Herpes simplex virus-1, Varicella zoster, Epstein-bar virus, Cytomegalovirus, Usutu virus, Human immunodeficiency virus, etc. Literature has reported few cases of COVID-19 patients with Bell's palsy as the only major neurological manifestation indicating the possible role of another virus in the etiopathogenesis of Bell's Palsy. This paper aims to evaluate the reported cases of COVID-19 positive patients, presented with Bell's palsy as the only major neurological manifestation from March 2020 to December 2020, and to investigate the association of SARS-CoV2 and Bell's palsy.

MATERIALS AND METHODS

A systematic review of the published literature was performed using an electronic search in PubMed/Medline, Science Direct, Web of Science, Embase, J- STAGE, Google Scholar, China National Knowledge Infrastructure (CKNI) and Scopus databases, from March 2020 to Dec 2020 using keywords like 'COVID-19', 'SARS-CoV-2', 'Coronavirus', 'Bell's palsy', 'Facial nerve', 'First', 'Only',' Neurological', 'Manifestation'. The studies reviewed were case series and case reports regarding the subject.

RESULTS

Search strategy revealed thirteen articles from March 2020 to Dec 2020 with a total of 20 cases of COVID-19 with Bell's palsy as the only major neurological manifestation.

CONCLUSION

Evidence of Bell's palsy as the only major neurological manifestation in COVID-19 patients signifies an important clinical finding but robust research is needed to investigate their association and the exact mechanisms by which SARS-CoV2 causes Bell's Palsy.

Neurological complications in pediatric patients with SARS-CoV-2 infection: a systematic review of the literature

OBJECTIVES

To describe clinical characteristics, laboratory tests, radiological data and outcome of pediatric cases with SARS-CoV-2 infection complicated by neurological involvement.

STUDY DESIGN

A computerized search was conducted using PubMed. An article was considered eligible if it reported data on pediatric patient(s) with neurological involvement related to SARS-CoV-2 infection. We also described a case of an acute disseminated encephalomyelitis (ADEM) in a 5-year-old girl with SARS-CoV-2 infection: this case was also included in the systematic review.

RESULTS

Forty-four articles reporting 59 cases of neurological manifestations in pediatric patients were included in our review. Most (32/59) cases occurred in the course of a multisystem inflammatory syndrome in children (MIS-C). Neurological disorders secondary to cerebrovascular involvement were reported in 10 cases: 4 children with an ischemic stroke, 3 with intracerebral hemorrhage, 1 with a cerebral sinus venous thrombosis, 1 with a subarachnoid hemorrhage, 1 with multiple diffuse microhemorrhages. Reversible splenial lesions were recognized in 9 cases, benign intracranial hypertension in 4 patients, meningoencephalitis in 4 cases, autoimmune encephalitis in 1 girl, cranial nerves impairment in 2 patients and transverse myelitis in 1 case. Five cases had Guillain-Barré syndrome (GBS) and two, including ours, had ADEM. Radiological investigations were performed in almost all cases (45/60): the most recurrent radiological finding was a signal change in the splenium of the corpus callosum. The presence of SARS-CoV-2 viral nucleic acid in the cerebrospinal fluid was proved only in 2 cases. The outcome was favorable in almost all, except in 5 cases.

CONCLUSIONS

Our research highlights the large range of neurological manifestations and their presumed pathogenic pathways associated with SARS-CoV-2 infection in children. Nervous system involvement could be isolated, developing during COVID-19 or after its recovery, or arise in the context of a MIS-C. The most reported neurological manifestations are cerebrovascular accidents, reversible splenial lesions, GBS, benign intracranial hypertension, meningoencephalitis; ADEM is also a possible complication, as we observed in our patient. Further studies are required to investigate all the neurological complications of SARS-CoV-2 infection and their underlying pathogenic mechanism.

COVID-19 as a rare cause of facial nerve neuritis in a pediatric patient

COVID-19 has been noted to present with neurological symptoms in nearly 30% of patients. While children are more likely to be asymptomatic, neurological involvement has been observed. We present the case of a 23-month-old previously healthy female who was brought to the emergency room for a new-onset facial droop. The patient tested positive for COVID-19 but was otherwise asymptomatic. Magnetic resonance imaging of the brain with and without contrast revealed abnormal enhancement along the canalicular segment of the right cranial VII extending to the first genu suggestive of cranial nerve neuritis. Given that our case involves a pediatric patient with no significant comorbidities presenting with facial drop, COVID-19 should be considered on the differential when evaluating causes of new onset peripheral nerve palsies.

Can COVID-19 Cause Peripheral Facial Nerve Palsy?

The aim of our study is to evaluate the relationship between peripheral facial paralysis and the patients who had a contact with a coronavirus disease 2019 (COVID-19) patient or had COVID-19. Patients with a history of contact with a COVID-19 patient or having COVID-19 disease, who were admitted to the emergency department for peripheral facial paralysis in the last 6 months, were included in the study. Facial paralysis grade at first presentation, treatment modality, treatment duration, post-treatment facial paralysis grade, and additional findings were analyzed. A total of 34 patients, 20 females and 14 males, were included into the study. Nasal-oropharyngeal reverse transcriptase-polymerase chain reaction (RT-PCR) was test taken from patients with a history of contact, and patients having COVID-19 disease were determined as positive in 5 and 3 patients, respectively. Peripheral facial paralysis was detected as an initial finding in 5 of these 8 patients, and paralysis developed in 7-12 days after the diagnosis of the COVID-19 disease in the remaining 3 patients. The grade of first admission paralysis did not change in one patient in the (+) group, while improvement was observed in all patients in the (−) group. Neuroinvasive potential of COVID-19 in the central and peripheral nervous system was reported in current literature. Our study indicates peripheral facial palsy can also be encountered during the clinical course of COVID-19 and should be considered a finding of this disease.

Coronavirus Infections in the Nervous System of Children: A Scoping Review Making the Case for Long-Term Neurodevelopmental Surveillance

BACKGROUND

The objective of this study was to describe the case literature of human coronavirus infections in the nervous system of children, including from SARS-CoV-2, and to provide guidance to pediatric providers for managing the potential long-term effects on neurodevelopment of human coronavirus infections in the nervous system.

METHODS

Using a structured strategy, the PubMed and Ovid:Embase databases were queried for articles about the clinical presentation and pathophysiology of coronavirus infections in the nervous system of children and young adults, aged 0 to 24 years.

RESULTS

Of 2302 articles reviewed, 31 described SARS-CoV-2 infections in the nervous system of children and 21 described other human coronaviruses: HCoV-229E, HCoV-NL63, HCoV-OC43, HCoV-HKU1, MERS-CoV, SARS-CoV-1. Excepting MERS-CoV, we found cases of neurological disease in children from each human coronavirus. Children with non-SARS-CoV-2 infections have suffered acute flaccid paralysis, acute disseminated encephalomyelitis, encephalitis, and seizures. In addition, cases of ischemic, hemorrhagic, and microvascular strokes have occurred in children with SARS-CoV-2. Patients with multisystem inflammatory syndrome in children have suffered encephalitis, stroke, pseudotumor cerebri syndrome, and cytotoxic lesions of deep brain structures. Despite these reports, few articles evaluated the impact of human coronavirus infections on long-term neurodevelopmental domains including cognitive, language, academic, motor, and psychosocial outcomes.

CONCLUSIONS

Neurological manifestations of human coronavirus infections can cause severe disease in children. The case literature suggests a critical gap in knowledge of the long-term effects on child neurodevelopment of these infections. As the current SARS-CoV-2 pandemic continues, this gap must be filled to facilitate optimal outcomes in recovering children.

Bell's Palsy as a Late Neurologic Manifestation of COVID-19 Infection

Bell's palsy is acute peripheral facial nerve palsy; its cause is often unknown but it can be triggered by acute viral infection. Coronavirus disease 2019 (COVID-19) infection commonly presents with respiratory symptoms, but neurologic complications have been reported. A few studies have reported the occurrence of facial nerve palsy during the COVID-19 pandemic. We present a case of Bell's palsy in a 36-year-old man with COVID-19 infection and a past medical history of nephrolithiasis. He presented to the emergency room with a day history of sudden right facial weakness and difficulty closing his right eye four weeks following a diagnosis of COVID-19 infection. Physical examination revealed right lower motor neuron facial nerve palsy (House-Brackmann grade IV). Serologic screen for Lyme disease, human immunodeficiency virus (HIV), and herpes simplex virus (HSV) 1 and 2 were negative for acute infection; however, neuroimaging with MRI confirmed Bell's palsy. He made remarkable improvement following treatment with a course of valacyclovir and methylprednisolone. This case adds to the growing body of literature on neurological complications that should be considered when managing patients with COVID-19 infection.

COVID-19 and Eye: A Review of Ophthalmic Manifestations of COVID-19

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had health implications of unprecedented magnitude. The infection can range from asymptomatic, mild to life threatening respiratory distress. It can affect almost every organ of the body. Ophthalmologists world over are reporting various manifestations of the infection in the eye. This review was undertaken to help ophthalmologists recognize the possible manifestations and the stage of the viral disease when they commonly appear. Literature search was performed for the publications on ophthalmic manifestations of coronavirus disease-19 (COVID-19) between January 1, 2020 and January 31, 2021. 46 case reports, 8 case series, 11 cross sectional/cohort observational studies, 5 prospective interventional studies, 3 animal models/autopsy studies and 6 reviews/meta-analysis were included. Conjunctivitis is the most common manifestation and can develop at any stage of the disease. Direct effect due to virus, immune mediated tissue damage, activation of the coagulation cascade and prothrombotic state induced by the viral infection, the associated comorbidities and drugs used in the management are responsible for the findings in the eye. The viral ribonucleic acid (RNA) has been isolated from ocular tissues but the role of eye as a route for infection is yet to be substantiated. Ophthalmic manifestations may be the presenting feature of COVID-19 infection or they may develop several weeks after recovery. Ophthalmologists should be aware of the possible associations of ocular diseases with SARS-CoV-2 in order to ask relevant history, look for specific signs, advise appropriate tests and thereby mitigate the spread of infection as well as diagnose and initiate early treatment for life and vision threatening complications.

Bell's Palsy Associated with SARS-CoV-2 Infection in a 2-Year-Old Child

Bell's palsy (BP) is an acute, unilateral facial nerve palsy (FNP) that is a diagnosis of exclusion, sometimes associated with infectious causes. In this article, we described a previously healthy 2-year-old child patient who presented with left-sided facial droop, positive severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) real-time reverse transcription polymerase chain reaction (RT-PCR), positive SARS-CoV-2 immunoglobulin (Ig)-G antibody, and negative cerebrospinal fluid (CSF) SARS-CoV-2 (PCR and serology). This is the second reported pediatric case of BP in the setting of SARS-CoV-2, and the first in a child without comorbidities. Due to the positive antibody test, we presented the idea that SARS-CoV-2 could be a triggering factor of the FNP, possibly occurring in the later stages of disease.

Case Report: Unilateral Sixth Cranial Nerve Palsy Associated With COVID-19 in a 2-year-old Child

Children have been described to show neurological symptoms in acute coronavirus disease 2019 (COVID-19) and multisystemic inflammatory syndrome in children (MIS-C). We present a 2-year-old boy's clinical course of unilateral acute sixth nerve palsy in the context of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Onset of the palsy in the otherwise healthy boy occurred seven days after symptoms attributed to acute infection had subsided respectively 3 weeks after onset of respiratory symptoms. SARS-CoV-2 specific IgG was detected in serum as well as in cerebrospinal fluid. The patient showed a prolonged but self-limiting course with a full recovery after three and a half months. This case illustrates in a detailed chronological sequence that sixth cranial nerve involvement may occur as post-infectious, self-limiting complication of pediatric SARS-CoV-2-infection thus expanding the neurological spectrum of symptoms for children with COVID-19. Clinicians should be aware of the possibility of post-infectious sixth nerve palsy related to SARS-CoV-2-infection particularly in view of recent respiratory tract infection or confirmed cases of SARS-CoV-2-infection amongst the patient's close contacts.