Cranial Nerve III Palsy in the Setting of COVID-19 Infection

Treatment of acquired partial oculomotor nerve palsy with dexamethasone - A case report

INTRODUCTION/IMPORTANCE

Oculomotor nerve palsy is an acquired condition caused by injury to the third cranial nerve. Patients present classically with their eye in a "down and out" positioning, ptosis and abnormalities in most extraocular movements causing diplopia. Ocular dysfunction may be due to a variety of different etiologies, such as aneurysm, microvascular disease, trauma, and viral infections. Clinical prognosis is usually quite good and is often self-limiting.

CASE REPRESENTATION

We present a case of an otherwise healthy 40-year-old male who awoke one morning with moderate diplopia, unable to focus with binocular vision and developed eyelid ptosis two days later. He was previously infected with the Omicron variant of COVID-19; however, a rapid test could not confirm it. No intracranial or vascular pathology were identified on CT head, CT angiogram, or MRI. Repeat COVID-19 PCR test was negative. He was assessed by a neuro-ophthalmologist and was diagnosed with left partial oculomotor nerve palsy presumed secondary to viral microvascular injury. COVID-19 infection seemed likely given the history but could not be confirmed. The specialist recommended monitoring the patient without any treatment, with no recommendation of corticosteroid use.

CLINICAL DISCUSSION

Cranial neuropathy guidelines for viral palsies involving the 7th or 8th cranial nerve are treated with corticosteroids. After considering the risks, the patient elected treatment with a left eye patch and a dexamethasone taper. Full return of function in all extremes of gaze was restored less than 2 months after onset.

CONCLUSION

Given the complete and timely recovery, it may be reasonable to consider corticosteroids for all cranial neuropathies.

COVID-19 and sudden-onset ocular neurogenic palsy in prior healthy patients: a systematic review

BACKGROUND

The aim of this systematic review is to identify cases of neurogenic ocular palsy in the presence of COVID-19 and to document patient characteristics, type of palsy and possible aetiologies.

METHODS

A systematic search of PubMed, Medline and CINAHL databases was conducted on the 6th of January 2023 to identify cases of neurogenic ocular palsy in patients with current or previous COVID-19 infection. Data were pooled to summarise the neurogenic palsy, patient clinical characteristics and proposed palsy mechanisms.

RESULTS

The combined database search yielded 1197 articles. Of these, 23 publications consisting of 25 patients met the inclusion criteria. Most patients were male (68%) and ranged in age from 2 to 71 years (median=32.7, SD=21.4). Seven patients (28%) were children aged 2 to 10 years old. Abducens palsies were most common (68%) and the most common ocular presentation was diplopia (76%) with an average time of onset 15 days from testing positive to COVID-19 or having symptoms of the virus. Proposed mechanism of development of a neurogenic palsy secondary to COVID-19 infection was classified into one of three categories: vascular/thrombotic, a viral neuro-invasive or inflammatory virus-mediated immune response.

DISCUSSION

This study suggests that COVID-19 infection may be linked to oculomotor, trochlear and abducens nerve palsies and the underlying mechanisms may vary but are difficult to definitively establish. Further studies investigating the onset of neurogenic palsy secondary to COVID-19 infection is required.

Third cranial nerve palsy due to COVID-19 infection

We report a case of a previously healthy man in his 40s who presented with mild SARS-CoV-2 infection (COVID-19) concomitant with acute onset of left third cranial nerve palsy with restricted supraduction, adduction and infraduction. Our patient did not present any history of hypertension, hyperlipidaemia, diabetes mellitus or smoking. The patient recovered spontaneously without any antiviral treatment. To our knowledge, this is the second report of third cranial nerve palsy spontaneously resolved without any risk factors of vascular disease, specific image findings, nor any possible causes other than COVID-19. In addition, we reviewed 10 other cases of third cranial nerve palsy associated with COVID-19, which suggested that the aetiology varies greatly. As a clinician, it is important to recognise COVID-19 as a differential diagnosis for third cranial nerve palsy. Finally, we aimed to encapsulate the aetiologies and the prognosis of the third cranial nerve palsy associated with COVID-19.

Neurological Manifestations and Clinical Outcomes of Patients with COVID-19 in the Aseer Region, Saudi Arabia

COVID-19 patients also present with rheumatological problems, cardiac problems, and even neurological manifestations. However, the data are still insufficient at present to fill the gaps in our understanding of the neurological presentations of COVID-19. Therefore, the present study was undertaken to reveal the various neurological manifestations of patients with COVID-19 and to find the association between neurological manifestations and the clinical outcome. This cross-sectional study was conducted in Abha, in the Aseer region of the Kingdom of Saudi Arabia, among COVID-19 patients aged 18 years or older who were admitted with the neurological manifestations of COVID-19 to the Aseer Central Hospital and Heart Center Hospital Abha. Non-probability convenient sampling was used. All the information was gathered by the principal investigator using a questionnaire including sociodemographic information, disease characteristics of COVID-19, neurological manifestations, and other complications. Data were analyzed using the Statistical Package for Social Sciences, version 16.0 (SPSS, Inc., Chicago, IL, USA). A total of 55 patients were included in the present study. About half of the patients were admitted to the ICU, and 18 (62.1%) patients died after 1 month of follow-up. Patients aged over 60 years had a 75% mortality rate. About 66.66% of patients with pre-existing neurological disorders died. Statistically significant associations were found between neurological symptoms such as cranial nerve symptoms and a poor outcome. A statistically significant difference was also found between laboratory parameters such as the absolute neutrophil count (ANC), activated partial thromboplastin time (aPTT), total cholesterol (TC), creatinine, urea, and lactate dehydrogenase (LDH) level and the outcome. A statistically significant difference was also found between the use of medications such as antiplatelets, anticoagulants, and statins at the baseline and after a 1-month follow-up. Neurological symptoms and complications are not uncommon among COVID-19 patients. Most of these patients had poor outcomes. Further studies are required to provide more data and knowledge about this issue, including the possible risk factors and the long-term neurological consequences of COVID-19.

COVID-19 and isolated oculomotor nerve palsy: Clinical features and outcomes

AIM

This study aims to describe the clinical characteristics of patients with isolated oculomotor nerve palsy from COVID-19 infection, and provide guidance on their treatment and management.

METHODS

We performed a systematic review and retrospective analysis on the clinical features and outcomes of patients with isolated oculomotor nerve palsy from COVID-19 reported in literature over the past three years.

RESULTS

We analyzed a total of 11 cases; 9 identified in literature from January 2020 to September 2022, together with our two patients. Their median age was 46 years (range 2-65), and three were children. More than half (6/11, 55 %) were without medical history. Oculomotor nerve palsies tended to occur early (longest interval of 16 days), but they can also occur concurrently (2/11, 18 %) or before the appearance of COVID-19 symptoms (1/11, 9 %). COVID-19 symptoms tended to be mild (8/11, 73 %). Oculomotor nerve palsies, however, displayed neither a clear gender predilection, nor consistent clinical features in terms of the severity of extraocular weakness and the involvement of pupillary light responses. Nearly two-thirds (7/11, 64 %) received no pharmacological treatment. Regardless, recovery was complete in nearly all (9/10, 90 %), with most occurring within a month (8/9, 89 %) CONCLUSION: Isolated oculomotor nerve palsies are early but uncommon complications of COVID-19. They affect patients with mild infections, and can be the first symptom. Prognosis is excellent, with recovery being often complete and early. Early discharge and outpatient clinical review, with or without short courses of oral steroids, are reasonable treatment measures.

An overview of third, fourth and sixth cranial nerve palsies in the setting of COVID-19: A case report and systematic review

BACKGROUND

Covid-19 has serious sequelae that may be poorly understood, underreported, and, as a result, not diagnosed promptly, such as variations in clinical manifestations of hyperinflammation among people infected with SARS-CoV-2. ophthalmoplegia can be one of these manifestations.

METHODS

We are reporting a 55-year-old male patient with unilateral diplopia considering it as a case of multisystem inflammatory syndrome in adults. We also reviewed the literature systematically for the previously reported studies/cases with third, fourth and sixth cranial nerve palsies due to or after Covid-19.

RESULTS

The literature search yielded 17 studies reporting 29 patients. 71.4% of the patients were males with a mean age of 42.23 years. Ophthalmological symptoms took 9.7 days to appear after the respiratory involvement. All patients had diplopia as part of their visual symptoms. 41.4% of the patients had unilateral sixth nerve palsy, 24% had bilateral sixth nerve involvement, 17% had fourth nerve involvement, and 27.6% had third nerve involvement.

CONCLUSION

Ophthalmoplegia is considered presenting symptom of Covid-19. Further research is needed to detect all neuro-ophthalmological manifestations of Covid-19.

Cranial Nerve Impairment Associated With COVID-19 Infections: A Systematic Review

The COVID-19 pandemic has created huge economic and healthcare burdens. In most cases, the virus affects the lungs and causes respiratory symptoms. Additionally, its impact on the cranial nerves remains unclear. We thus aimed to investigate cranial nerve dysfunction in patients with COVID-19 infection.  We conducted a systematic literature search of relevant and eligible literature in five databases: PubMed, Web of Science, Medline, EBSCO, and Google Scholar.  Our sample included 21 case reports, one case series with 29 patients, and one analytical study with 135 cases. Participant ages ranged from 23 months to 72 years (mean age of 47.5 ± 19.02). The mean time from respiratory symptoms to the onset of neurological signs was (9.6 ± 7.4) days, and the mean recovery time was (16.3 ± 15.3) days.  Cranial nerve impairment associated with COVID-19 infection has affected a large population, from infants to the elderly. Facial and abducent nerves were the most commonly affected cranial nerves with reported good prognosis or complete recovery within a few days to weeks. Olfactory dysfunctions were widely detected among COVID-19 patients.

Efferent neuro-ophthalmic complications of coronavirus disease 2019

PURPOSE OF REVIEW

We set out to describe efferent neuro-ophthalmological complications that have been reported in association with coronavirus disease 2019 (COVID-19) infection. We describe syndromes affecting ocular motility and elaborate on mechanisms of disease, including para-infectious inflammation, hypercoagulability, endothelial damage, and direct neurotropic viral invasion. Despite global vaccination programs, COVID-19 continues to pose an international threat that may rarely result in diplopia or nystagmus.

RECENT FINDINGS

Efferent complications include cranial nerve palsies leading to diplopia, either isolated or in association with Miller Fisher syndrome. Nystagmus has been observed in the setting of hemorrhagic acute necrotizing encephalopathy and brainstem infarcts, and opsoclonus syndrome has been described.

SUMMARY

Observed neuro-ophthalmic associations need to be confirmed through larger comparative studies. Meanwhile, the range of possible complications should be recognized by neurologists and ophthalmologists alike, to facilitate faster diagnosis and treatment of both COVID-19 and its neuro-ophthalmic manifestations.

Presumed oculomotor nerve palsy following COVID-19 vaccination

We herein report the case of an 84-year-old female who presented to the outpatient clinic one day following her first dose of the Pfizer-BioNTech COVID-19 vaccine with mydriasis, ptosis, and a “down and out” gaze. She was subsequently diagnosed with oculomotor nerve palsy, and treated with corticosteroids and valacyclovir for a total of 7 days, with no clear improvement. On subsequent visits, ophthalmic examination improved steadily and showed complete resolution after 8 weeks. This article aims to report this unusual incidence that occurred following vaccination with the Pfizer-BioNTech COVID-19 vaccine. It is important for physicians to identify and report abnormal occurrences which may potentially be related to the COVID-19 vaccines, in order to reach a complete understanding of their possible side effects.

Facial and Abducens Nerve Palsies Following COVID-19 Vaccination: Report of Two Cases

A broad spectrum of neurological side effects has been reported after immunisation for COVID-19, including functional neurological disorders, cerebral vascular events, cerebral venous thrombosis, intracerebral haemorrhage, neuroleptic malignant syndrome, cranial nerve palsies, and otologic manifestations. Multiple cranial neuropathies have also been reported following vaccination in which involvement of VII nerve is the most prevalent, followed by the VI, III, and IV nerves. We describe two male patients, one with with facial nerve palsy and the other with abducens nerve palsy following COVID-19 vaccination. The patient with facial nerve palsy received the AstraZeneca vaccine 2 days before the symptoms began. In contrast, the patient with the abducens palsy had received his first dose of the Sinopharm vaccine 7 days previously. Both patients demonstrated a gradual recovery within the next 2 months. Further studies are required to investigate the proper relationship between cranial nerve palsies and vaccinations.

Third Cranial Nerve Palsy Due to COVID-19 Infection

Coronavirus disease 2019 (COVID-19) is known to be primarily a viral infection affecting the pulmonary system leading to severe pneumonia and acute respiratory distress syndrome. COVID-19 has also been found to affect the neurological system causing various nerve palsies. While some studies have suggested these neurological manifestations may indicate severe disease, cranial nerve palsies in the setting of COVID-19 infection have been linked to improved patient outcomes and mild viral symptoms. We present a case of a 55-year-old male with confirmed COVID-19 infection presenting with third cranial nerve palsy. Since his hospital course remained unremarkable, he was treated supportively for his COVID-19 infection and remained stable on room air during his hospitalization. No causative factors other than COVID-19 were identified as a cause for his cranial three nerve palsy which resolved spontaneously during outpatient follow-up. Although different cranial nerve palsies associated with COVID-19 infection have been identified in the literature, the pathogenesis and prognosis of cranial nerve palsy is still unclear. This case emphasizes the need for continued symptom monitoring and identification in patients diagnosed with COVID-19.

[Neuromuscular complications of SARS-CoV-2 infections-Part 1: peripheral nerves]

In recent months various disorders and diseases of the peripheral nerves (including cranial nerves) and the musculature have been described in association with the pulmonary disease coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the first part of our review the current knowledge about a potential association of a SARS-CoV‑2 infection with dysfunction and diseases of cranial and peripheral nerves is discussed. Anosmia, ageusia, motor cranial nerve involvement and Guillain-Barré syndrome (GBS) were described in a temporal association with a SARS-CoV‑2 infection. Several studies could show that anosmia and ageusia were frequent symptoms of a SARS-CoV‑2 infection. In contrast the failure of other cranial nerves has so far only been sporadically described. A number of case reports and case series indicate a causal association between a SARS-CoV‑2 infection and GBS but epidemiological evidence is still lacking.