COVID-19-associated polyneuritis cranialis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Javaria Anwer M.D.[2]

Synonyms and keywords:

Overview

Polyneuritis cranialis literally means inflammation of the cranial nerves. It is a rare neurological disorder characterised by multiple cranial nerve palsies sparing the spinal cord.[1] The novel coronavirus is also emerging as a neurotropic virus. The disease is a Guillain-Barré syndrome-Miller Fisher syndrome interface. The pathogenesis of polyneuritis cranials is characterized by demyelination of lower cranial nerves. COVID-19-associated polyneuritis cranials must be differentiated from other diseases that cause bulbar weakness, facial weakness, and ophthalmoparesis. The diagnosis of PNC is clinical and confirmed by NCS. Fixation nystagmus, bilateral abducens palsy, impaired visual acuity and gaze palsy abnormality and loss of deep tendon reflexes has been observed with no gait pathology. Treatment with acetaminophen caused complete recovery within 2 weeks. The disease itself is associated with COVID-19 infection as believed to be an immune response so prevention of the infection itself is the most promising primary prevention strategy at the moment.

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating COVID-19-associated polyneuritis cranialis from other Diseases

COVID-19-associated polyneuritis cranials must be differentiated from other diseases that cause bulbar weakness, facial weakness, and ophthalmoparesis:

Epidemiology and Demographics

A single case report of COVID-19 associated PNC ensures a very low incidence of this rare disease.

Age

The median age at the diagnosis of PNC is 40 years. COVID-19 associated PNC was reported in a 39-year-old patient.[2][5]

Race

There is no racial predilection to COVID-19 associated with PNC.

Gender

The patient with COVID-19 associated PNC was a male. Data regarding gender distribution for PNC, in general, is not available.

Risk Factors

  • In general more severe patients are likely to have neurologic symptoms.[4]
  • There are no established risk factors for COVID-19-associated polyneuritis cranials (PNC).

Screening

  • Currently, there are no recommended guidelines in place for the routine screening for COVID-19-associated polyneuritis cranials or coronavirus disease 2019 (COVID-19). Some countries use temperature monitoring as a screening tool. Certain companies have launched the Screening Tool but there are no formal guidelines. Click here for more information on COVID-19 screening. [15]

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

The diagnosis of GBS and MFS is confirmed by Nerve conduction studies (NCS). A decreased amplitude shows nerve conduction pathology. Although other reports mention decreased nerve conduction in PNC patients, COVID-19 associated PNC report did not show NCS studies.

History and Symptoms

Physical Examination

Laboratory Findings

  • A positive qualitative real-time oropharyngeal swab RT PCR COVID-19 test.[5]
  • Cerebrospinal fluid (CSF) examination reveals:[5][17]
    1. Opening pressure is normal (normal range 8-15 mm Hg).
    2. WBC count was reported normal with all monocytes (normal range 0 - 5 WBCs all monocytes).
    3. CSF protein was a little high i.e, 62 mg/dl (normal range 15 to 60 mg/dl). CSF protein can be normal as in other cases of polyneuritis cranialis (PNC) due t other etiologies.[12][13] A high CSF protein and normal cell counts can be described as albuminocytologic dissociation and is seen in 67% PNC cases.[6][2]
    4. CSF glucose is normal (normal range 50-80 mg/dl).
    5. CSF cytology was normal.
    6. CSF cultures and serology were sterile and negative respectively.
    7. CSF RT PCR for COVID-19 was found negative in the patient.
  • Anti-ganglioside GM-1 IgM and IgG antibody levels ( antiganglioside GQ1b and GD1b) should be checked.[2] The COVID-19 associated PNC patient reported could not get the planned laboratory tests done due to hospital saturation.
  • CBC and differential, ESR, CRP, Basic Metabolic Panel, cardiac enzymes were all normal expect leukopenia was observed.[13]

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

  • There are no CT scan findings associated with COVID-19-associated polyneuritis cranialis.[5]
  • Chest CT scan may be helpful in suggesting other organ involvement in the COVID-19 which is a multi-organ disease. click here to see the CT scan findings in COVID-19.

MRI

  • There are no MRI findings associated with COVID-19-associated polyneuritis cranialis.[6]
  • MRI may be helpful in suggesting other organ involvement in the COVID-19 which is a multi-organ disease.
  • The MRI findings in COVID-19 can be viewed by clicking here.

Other Imaging Findings

There are no other imaging findings associated with COVID-19-associated polyneuritis cranialis.

Other Diagnostic Studies

There diagnostic studies associated with COVID-19-associated polyneuritis cranialis (PNC) that can help in the diagnosis include:

Treatment

Medical Therapy

Surgery

Surgical intervention is not recommended for the management of COVID-19-associated polyneuritis cranialis.

Primary Prevention

  • The disease itself is associated with COVID-19 infection as believed to be an immune response so prevention of the infection itself is the most promising primary prevention strategy at the moment.
  • There have been rigorous efforts in order to develop a vaccine for novel coronavirus and several vaccines are in the later phases of trials.[19]
  • The only prevention for COVID-19 associated abdominal pain is the prevention and early diagnosis of the coronavirus-19 infection itself. According to the CDC, the measures include:[20]
    • Frequent handwashing with soap and water for at least 20 seconds or using a alcohol based hand sanitizer with at least 60% alcohol.
    • Staying at least 6 feet (about 2 arms’ length) from other people who do not live with you.
    • Covering your mouth and nose with a cloth face cover when around others and covering sneezes and coughs.
    • Cleaning and disinfecting.

References

  1. Pavone, Piero; Incorpora, Gemma; Romantshika, Olga; Ruggieri, Martino (2007). "Polyneuritis Cranialis: Full Recovery after Intravenous Immunoglobulins". Pediatric Neurology. 37 (3): 209–211. doi:10.1016/j.pediatrneurol.2007.05.002. ISSN 0887-8994.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Wakerley, Benjamin R.; Yuki, Nobuhiro (2015). "Polyneuritis cranialis—subtype of Guillain–Barré syndrome?". Nature Reviews Neurology. 11 (11): 664–664. doi:10.1038/nrneurol.2015.115. ISSN 1759-4758.
  3. "WHO Timeline - COVID-19".
  4. 4.0 4.1 Mao, Ling; Wang, Mengdie; Chen, Shanghai; He, Quanwei; Chang, Jiang; Hong, Candong; Zhou, Yifan; Wang, David; Li, Yanan; Jin, Huijuan; Hu, Bo (2020). doi:10.1101/2020.02.22.20026500. Missing or empty |title= (help)
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Gutiérrez-Ortiz, Consuelo; Méndez, Antonio; Rodrigo-Rey, Sara; San Pedro-Murillo, Eduardo; Bermejo-Guerrero, Laura; Gordo-Mañas, Ricardo; de Aragón-Gómez, Fernando; Benito-León, Julián (2020). "Miller Fisher Syndrome and polyneuritis cranialis in COVID-19". Neurology: 10.1212/WNL.0000000000009619. doi:10.1212/WNL.0000000000009619. ISSN 0028-3878.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Polo A, Manganotti P, Zanette G, De Grandis D (May 1992). "Polyneuritis cranialis: clinical and electrophysiological findings". J. Neurol. Neurosurg. Psychiatry. 55 (5): 398–400. doi:10.1136/jnnp.55.5.398. PMC 489084. PMID 1318358.
  7. "www.who.int" (PDF).
  8. Vavougios GD (July 2020). "Potentially irreversible olfactory and gustatory impairments in COVID-19: Indolent vs. fulminant SARS-CoV-2 neuroinfection". Brain Behav. Immun. 87: 107–108. doi:10.1016/j.bbi.2020.04.071. PMC 7185018 Check |pmc= value (help). PMID 32353521 Check |pmid= value (help).
  9. Wu Y, Xu X, Chen Z, Duan J, Hashimoto K, Yang L, Liu C, Yang C (July 2020). "Nervous system involvement after infection with COVID-19 and other coronaviruses". Brain Behav. Immun. 87: 18–22. doi:10.1016/j.bbi.2020.03.031. PMC 7146689 Check |pmc= value (help). PMID 32240762 Check |pmid= value (help).
  10. Bohmwald, Karen; Gálvez, Nicolás M. S.; Ríos, Mariana; Kalergis, Alexis M. (2018). "Neurologic Alterations Due to Respiratory Virus Infections". Frontiers in Cellular Neuroscience. 12. doi:10.3389/fncel.2018.00386. ISSN 1662-5102.
  11. 11.0 11.1 Bohmwald K, Gálvez N, Ríos M, Kalergis AM (2018). "Neurologic Alterations Due to Respiratory Virus Infections". Front Cell Neurosci. 12: 386. doi:10.3389/fncel.2018.00386. PMC 6212673. PMID 30416428. Vancouver style error: initials (help)
  12. 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 Kasundra GM, Bhargava AN, Bhushan B, Shubhakaran K, Sood I (2015). "Polyneuritis cranialis with generalized hyperreflexia as a presenting manifestation of thyrotoxicosis". Ann Indian Acad Neurol. 18 (2): 240–2. doi:10.4103/0972-2327.150625. PMC 4445207. PMID 26019429.
  13. 13.0 13.1 13.2 Torres, Alcy R; Salvador, Carla; Mora, Mauricio; Mirchandani, Sharam; Chavez, Wilson (2019). "Idiopathic Recurrent Polyneuritis Cranialis: A Rare Entity". Cureus. doi:10.7759/cureus.4488. ISSN 2168-8184.
  14. Willison HJ, Jacobs BC, van Doorn PA (August 2016). "Guillain-Barré syndrome". Lancet. 388 (10045): 717–27. doi:10.1016/S0140-6736(16)00339-1. PMID 26948435.
  15. "Coronavirus (COVID-19) - Apple and CDC".
  16. Wakerley BR, Yuki N (September 2015). "Polyneuritis cranialis: oculopharyngeal subtype of Guillain-Barré syndrome". J. Neurol. 262 (9): 2001–12. doi:10.1007/s00415-015-7678-7. PMID 25712542.
  17. "Cerebral spinal fluid (CSF) collection: MedlinePlus Medical Encyclopedia".
  18. Capuano A, Scavone C, Racagni G, Scaglione F (July 2020). "NSAIDs in patients with viral infections, including Covid-19: Victims or perpetrators?". Pharmacol. Res. 157: 104849. doi:10.1016/j.phrs.2020.104849. PMC 7189871 Check |pmc= value (help). PMID 32360482 Check |pmid= value (help).
  19. "NIH clinical trial of investigational vaccine for COVID-19 begins | National Institutes of Health (NIH)".
  20. "How to Protect Yourself & Others | CDC".


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