A Case of Ocular Myasthenia Gravis Seen by Rheumatology as Suspected Mononeuritis Multiplex in an Adult Male Shortly after Pfizerbiontech Sars-Cov-2 Vaccination

Background/Aims Myasthenia gravis (MG) is an antibody-mediated autoimmune disease targeting proteins at the postsynaptic membrane of the neuromuscular junction. MG is thought to occur in genetically susceptible individuals following an environmental trigger. SARS-CoV-2 infection has been associated with new-onset autoimmune disease, new-onset MG, and exacerbations of pre-existing MG, with molecular mimicry between SARS-CoV-2 epitopes and autoantigen-induced autoreactivity thought to be part of the underlying mechanism. We report a case of newonset ocular MG following first dose Pfizer-BioNTech BNT162b2 SARS-COV2 vaccination which was referred to rheumatology as suspected mononeuritis multiplex. Methods A 53-year-old man of East Asian ethnicity presented to the emergency department (ED) with sudden onset diplopia and left lateral gaze restriction 7 days after receiving his first dose of the Pfizer-BioNTech BNT162b2 SARS-COV2 vaccination. He had longstanding myopia and dry eyes but no other medical history, no regular medications or significant family history. He was a current smoker, with a 50-pack year history. He did not drink alcohol or use any recreational drugs. He was found to have an isolated left VI cranial nerve (CN) palsy with an otherwise normal ocular and physical examination. Blood tests were unremarkable apart from raised cholesterol, and he was discharged with a suspected self-limiting microvascular CN lesion. Three weeks later he presented to ED with worsening diplopia, increasingly restricted eye movements, headache, nausea, vomiting and blurred vision. Ophthalmology assessment noted new right sided CN III and VI palsy, persistent left CN VI palsy, and vertical diplopia in all fields of gaze. Neurological and physical examination were normal. Bloods including an autoimmune screen were unremarkable. SARS-CoV-2 Spike antibodies were positive consistent with SARS-CoV-2 vaccination but not infection. Intracranial and thoracic imaging were unremarkable. He was referred to and seen by both rheumatology and neurology as a case of suspected mononeuritis multiplex. Results A diagnosis of ocular MG was confirmed with positive serum acetylcholine receptor antibodies, and he was started on prednisolone, and pyridostigmine to good effect. Daily forced vital capacity (FVC) showed no respiratory muscle involvement, and nerve conduction studies and electromyography were normal, excluding secondary generalisation. Conclusion A review of the literature found 14 reported cases of new-onset MG all within 4 weeks following SARS-CoV-2 vaccine. Whilst these cases provide interesting insights into the pathogenesis of autoimmune conditions such as MG, they are not epidemiological studies to inform vaccine safety. Ultimately, current evidence suggests that the risks of SARS-COV-2 infection outweigh the risk of vaccine-related adverse events, therefore we suggest clinicians should be aware of potential new-onset autoimmune conditions, but support the safety of SARSCOV2 vaccination. Further, research into possible immunological mechanisms behind this phenomenon, including identifying potential epitopes inducing molecular mimicry, could help establish the likelihood of a causative link.

Acute abducens nerve palsy with acute disseminated encephalomyelitis-like presentation following COVID-19 vaccination.

We report two adult cases of abducens nerve palsy presenting immediately (within weeks) after they received the first dose of Covishield vaccination. Magnetic resonance imaging (MRI) of the brain obtained after the onset of diplopia demonstrated demyelinating changes. The patients had associated systemic symptoms. Post-vaccination demyelination typically known as acute disseminated encephalomyelitis (ADEM) associated with several vaccines is more common in children. Although the mechanism of the nerve palsy remains unclear, it is suspected to be related to the post-vaccine neuroinflammatory syndrome. Cranial nerve palsies and ADEM-like presentations may represent part of the neurologic spectrum following COVID-vaccination in adults, and ophthalmologists should be aware of these sequelae. Although cases of sixth nerve palsy following COVID vaccination are already reported, associated MRI changes have not been reported from India.

Mild Encephalitis/Encephalopathy with a Reversible Lesion in The Splenium.

Mild encephalitis/encephalopathy with a reversible lesion in the splenium (MERS) is a clinico-radiological syndrome with mild central nervous system symptoms and a reversible lesion in the splenium of the corpus callosum. It is mainly associated with a number of viral and bacterial infections, including Coronavirus disease 2019 (COVID-19). In this paper, we report four MERS patients. One had a mumps infection, the second had aseptic meningitis, the third had Marchiafava-Bignami disease, and the fourth had atypical pneumonia associated with COVID-19 infection.

COVID‐19 vaccination and vision loss in three older male individuals homoplasmic for m.14484T>C mutation in the ND6 gene

Purpose: To report three older male individuals, all homoplasmic for m.14484 T > C mutation in the ND6 gene, presenting onset of vision loss weeks‐months after covid vaccination. None reported a history of covid‐19 infection.Methods: All clinical data was extracted and reported here as a Case Series.Results: A 68 years old man (A) had a 3rd dose of BioNTech/Pfizer COVID‐19 vaccination on 1st Nov 2021. 10 days later his vision was 6/6 OD and 6/60 OS. By Dec 2021 VA was 6/36 OD and 6/60 OS. His nephew lost vision age of 18 years with LHON. In March 2022, visual acuities were HM OD and HM OS. In May 2022 visual acuity was HM OD, PL OS. He started on idebenone 300 mg tds.A 55 years old man (B) had a 1st dose Astra Zeneca COVID‐19 vaccination in mid Feb 2021. 12 days later, March 2021 he developed a Bell's Palsy and sensory neuropathy at the top of his legs, feet and upper arms, with difficulty walking. MRI showed enhanced optic nerves and enhanced lesions at C2. In April 2021, he lost vision in his right eye, followed by left eye in June 2021. By September 2021 vision was CF BEs. He started on idebenone 300 mg po tds. In May 2022 he was LogMAR @ 2 m 1.34 OD and MH OS.A 72 years old man (C) had his 2nd dose of BioNTech/Pfizer COVID‐19 vaccination in April 2021. In Sept 2021 he reported loss of vision in both eyes but could not date onset. He was the maternal cousin of individual B. In May 2022 vision was 3/60 OD CF OS. He started on idebenone 300 mg po tds.Conclusions: Adverse ocular events related to COVID‐19 vaccines are remarkable rare. There are >20 published case reports (~89 patients) of adverse ocular events within 28 days of COVID‐19 vaccination, with all three vaccines (Pfizer, AstraZeneca and Moderna). Reports incl. conjunctivitis, facial and abducens nerve palsy, CSR, uveitis, MEWDS, VKH, Graves' Disease, endothelial graft rejection, AAION and AZOOR. The role of vaccination in subsequent vision loss in those with underlying mitochondrial mutation is not clear.

An Unusual Case Presentation of MOG-Positive Acute Disseminated Encephalomyelitis (ADEM) in a Preschool Child

Introduction: An unusual case presentation of MOG-positive Acute Disseminated Encephalomyelitis (ADEM) in a preschool child following meta-pneumo viral infection responded to the combination of immune modulatory treatment with a favourable outcome. Material: Three-year-old female child presented with acute encephalopathy, high fever, vomiting, starring episodes, floppiness, and left abducent nerve palsy with rapid deteriorating GCS necessitating intubation and ventilation. Two weeks earlier, she was treated for suspected CNS infection with 10 days of antibiotics in the PICU with a positive meta-pneumo-virus. On admission, she had a GCS score of 6 with left-sided increased tone, bilateral hyperreflexia, and bilateral extensor response and on Day 14 demonstrated hyperkinetic movements of the upper and lower limbs. Method(s): Serum MOG antibody positive, CSF MOG low positive, metabolic investigations, Mycoplasma, EBV, Influenza, corona PCR, SARS-COV-2 Antibody, viral CSF panel unremarkable. MRI brain demonstrated T2 hyperintense signal in bilateral medial thalami and brain stem with a normal spine. Progressive changes were shown on repeated MRI Brains on day 4 and day 14 suggestive of multifocal changes involving deep cortical and subcortical white matter bilaterally with a new short segment of the spinal lesion at the T8 level. Repeated EEG and ambulatory EEG showed a diffusely slow background with intermittent slow runs of slow waves suggestive of generalized cerebral dysfunction. Result(s): After receiving the combination of high pulse steroids with a taper over 10 weeks, IVIG and 10 cycles of plasmapheresis she demonstrated gradual and remarkable clinical improvement over 10-12 weeks with a minimal focal neurological deficit. Conclusion(s): Initial differentiating CNS infection, metabolic disease and ADEM may be clinically challenging. Her clinical presentation, investigations and imaging were in keeping with the diagnosis of MOG-positive ADEM. Previous CNS infection may be related. MOG-positive ADEM treated with the early combination of immunomodulation may lead to positive clinical outcomes.

Multi-System and Cavernous Sinus Inflammatory Syndrome Presenting with Evolving Multiple Cranial Neuropathies Following Zoledronate Infusion

Case report - Introduction: Bisphosphonates are known to rarely cause multi-system inflammation, including multiple cranial neuropathies. This is possibly via provoking transient cytokine storm. The literature reports bisphosphonate-associated orbital inflammatory syndrome, and one case of retrobulbar optic neuritis following zoledronate. Bisphosphonate manufacturers report conjunctivitis, blurred vision, scleritis, orbital inflammation, uveitis and episcleritis as ocular side effects. Separately, neurological sequalae, including cranial neuropathies, are reported following COVID-19 infection and vaccination. Here, we report the first case of cavernous sinus inflammation temporally related to both zoledronate infusion, and more remotely, to Pfizer- BioNTech COVID-19 vaccination. Case report - Case description: A 76-year-old white man developed fever, bony leg pain - which rendered him unable to walk - and frontal headache, within 8 hours of his first zoledronate infusion for osteoporosis. A few weeks earlier he received his first Pfizer-BioNTech COVID-19 vaccine. His General Practitioner commenced a short course of lowdose oral prednisolone for the episode. One week later, off prednisolone, the headache localised around the left eye. He developed horizontal diplopia associated with abduction deficit. He was diagnosed with left VIth nerve palsy. He was started on high-dose steroids and clopidogrel (with PPI) with neuroimaging to exclude stroke or venous sinus thrombosis. Two weeks later, the diplopia worsened over 4 days, with new left adduction deficit (-2 limitation), left ptosis 1-2mm and anisocoria 0.5-1mm R>L suggestive of partial third nerve palsy and early Horner's syndrome. Ocular and neurological examinations were otherwise normal. He wore varifocals and had migraines, osteoporosis, and asthma, for which he used inhalers. He worked in visual arts and was an ex-smoker (>50 years) with moderate alcohol intake. Blood results revealed CRP 38mg/L, but otherwise normal inflammation/ vasculitis/infection screen;anti-thyroglobulin antibodies were >4000 U/ml;GQ1P, Creatinine Kinase, anti-ganglioside, and Anti- AChR/MuSK antibodies were normal. CT head and Optical Coherence Tomography were unremarkable. An enhanced MRI of the brain and orbits revealed abnormal thickening and T2 hyper-intensity of the left oculomotor nerve, most notably involving the left canalicular portion. The left cavernous sinus also appeared asymmetrically bulky with a rind of abnormal enhancing soft tissue in the left cavernous sinus. Subtle STIR hyper-intensity was also observed in the ipsilateral CN IIIinnervated extra-ocular muscles. After a 6-week course of tapering prednisolone, the vertical diplopia and leg swelling persisted;the horizontal diplopia and headaches had resolved. By 3months, there was resolution with mild residual visual changes. Case report - Discussion: We report a constellation of symptoms relating to multi-system inflammatory syndrome involving the cavernous sinus. There is a lack of epidemiological data on the incidence of this rare presentation in the population. This case has close temporal association to bisphosphonate infusion (<12h) and weaker association to coronavirus vaccination (<3wk). It is difficult to determine whether this is a rare presentation of a known drug reaction, a more delayed presentation of a vaccine reaction or whether these events were coincidental. A further possibility in this case is a combined predisposition resulting from both vaccination and bisphosphonate infusion. This case highlights a wider issue relating to the challenging possibility of ascertainment bias and increased 'Yellow Card' reporting of rare presentations during this historic global coronavirus pandemic, which may or may not have any true causal association to vaccination. There is difficulty in disentangling a true vaccine reaction from an unrelated presentation of a rare condition with an unknown baseline incidence rate. This is especially topical given that the majority of the population are receiving the coronavirus ccination at this time. We also question what a plausible cut-off point would be to propose a temporal relationship for an adverse reaction;in the literature, adverse reactions have been postulated to develop beyond 1 month after the provoking agent. Case report - Key learning points: . This case highlights the need for urgent assessment, investigations including neurological imaging and consultant input in patients with evolving cranial neuropathy. The priority is to rule out thrombotic, compressive, inflammatory and infectious pathology in the cavernous sinus, venous sinus, orbit and orbital apex. . Pathology of the cavernous sinus presents with variable involvement of CN III, IV, V and VI and Horner's syndrome. A differential for this case would be superior orbital fissure syndrome, which also presents with multiple oculomotor cranial neuropathies;it involves these cranial nerves and the ophthalmic branch of CN V. Orbital apex syndrome is SOF with a loss of vision due to additional CNII involvement. . The neuro-radiology differential included inflammatory, infiltrative, granulomatous and neoplastic aetiologies and that there was sufficient existing evidence to exclude brainstem pathology. . Through communication between specialties, the temporal relationship was established, and clinical examination and extensive investigation further honed the differential to either inflammatory or vascular. Since it was temporally related to the zolendronate infusion, it seemed plausible it was related. We demonstrate the need for multi-disciplinary collaboration for these patients between rheumatology, ophthalmology and neuro-radiology.

Visual Impairment Secondary to Right Sigmoid and Transverse Sinus Thrombosis in Setting of COVID- 19 Viral Infection: A Case Report

Case Diagnosis: 23-year-old female with past medical history significant for morbid obesity and prior oral contraceptive use diagnosed with right sigmoid and transverse sinus thrombosis resulting in visual impairment nineteen days after testing positive for COVID-19 infection. Case Description or Program Description: Patient initially presented to the emergency department for evaluation of worsening dyspnea and chest tightness eight days after diagnosis of COVID-19 infection. At that time a diagnosis of right lower lobe pulmonary embolism was established. She was discharged home with warfarin for anticoagulation. Prior to discharge, the patient did not have visual disturbance or focal neurological deficits. Five days after discharge and nineteen days after COVID-19 diagnosis patient returned to the emergency department for evaluation of new onset blurry vision and tinnitus. Setting(s): Tertiary care hospital Assessment/Results: Physical examination revealed bilateral mydriasis, abducens palsy, and papilledema. Patient with a therapeutic INR at time of admission. Full neurological workup was performed including MRI/MRV of brain which revealed extensive venous sinus thrombosis involving the right transverse and sigmoid sinuses and significant bilateral optic nerve head edema. Patient underwent left optic nerve sheath fenestration followed by thrombectomy of right sigmoid sinus with angioplasty. Serial lumbar punctures were performed for cerebrospinal fluid pressure reduction. Despite treatment the patient was left with permanent vision loss and was admitted to an inpatient rehabilitation facility (IRF) for three weeks prior to discharge home. Discussion (relevance): The inflammatory response related to COVID-19 infection places patients in a hypercoagulable state and those who have pre-existing risk factors for venous thrombosis should be monitored closely for complications related to acute thrombosis. Conclusion(s): This case brings awareness to possible neurological deficits seen following the acute phase of a COVID-19 infection. It is important for physiatrists to be mindful of these complications as they may present following acute phase of infection within an IRF to assist with early detection and improved outcomes.

Ulnar Neuropathy During COVID-19 Infection: A Case Report

Case Diagnosis: Ulnar Mononeuropathy following COVID-19 infection. Case Description or Program Description: A 44-year-old male with history of morbid obesity presented with coronavirus disease 2019 (COVID-19) infection resulting in a prolonged hospitalization of 37 days. While admitted he was largely proned, however never required intubation. While hospitalized, he developed numbness, tingling, and weakness in digits 4-5 of his left hand exacerbated by pressure on the elbow. No symptoms were present in the contralateral arm. Setting(s): Academic Acute Care Hospital Assessment/Results: Magnetic resonance imaging of the brain and cervical spine were unremarkable. Physical examination of digits 4-5 in the left hand revealed reduced sensation to light touch, an inability to fully extend the digits, and 4/5 strength with abduction. Electrodiagnostic testing demonstrated absent left ulnar sensory nerve action potential when recorded from the left 5th digit and reduced motor conduction velocity across the elbow (39m/s) compared to the below-elbow segment (53m/s) when recorded from the left ulnar abductor digiti minimi, consistent with conduction block. He declined needle electromyography due to potential pain. His hemoglobin A1c was 7.3%. Discussion (relevance): Peripheral nerve injuries (PNIs) may occur in up to 14.5% of patients with COVID-19 who undergo prone positioning, and the ulnar nerve is the most frequently affected. We present a case of ulnar mononeuropathy during COVID-19 hospitalization. Etiology is likely multifactorial, with prone positioning, similar risk factors, or direct pathogenicity contributing. Compressive injuries of the ulnar nerve have been associated with improper prone positioning. Additionally, PNI shares risk factors with severe COVID-19, namely obesity and diabetes in this patient. The hyperinflammatory state associated with COVID- 19 also increases the risk of PNI. Lastly, COVID-19 invades cells by binding angiotensinogen converting enzyme-2 receptors, which are present in the nervous system. Conclusion(s): COVID-19 infection may be associated with an increased risk of peripheral nerve injuries through a multifactorial mechanism. Further research is needed to establish the association.

Left Ventricular Non-Compaction: An Uncommon Cause of Cardoembolic Stroke

Introduction: Left ventricular non-compaction (LVNC) is a rare, usually congenital or hereditary cardiomyopathy. The formation of deep trabecular recesses increases the likelihood of a thrombus entering the systemic vasculature which may cause cardioembolic stroke. Clinical manifestations of LVNC range from asymptomatic to severe heart failure, thromboembolic events, and sudden death. In adults, individuals with LVNC have a 21 - 38% chance of developing a cardioembolic stroke. Case Presentation: We present a case of a 29-year-old African American female, six weeks postpartum with a history of cleft palate, right sixth nerve palsy, and recent Covid-19 infection who developed stroke-like symptoms of left side numbness and weakness, left side facial droop and slurred speech upon awakening. On initial examination, the patient displayed 4/5 strength and decreased sensation to pinprick in left upper and lower extremities as well as left lower facial palsy and dysarthria. CT head without contrast revealed a large infarct in the right middle cerebral artery (MCA) territory. A brain MRI confirmed the right MCA infarct but did not reveal acute infarct in other vascular territory. CTA head/neck reported right MCA proximal M2 segment occlusion. During admission, stroke work-up included a normal EKG. A transthoracic echocardiography (TTE) with bubble study was obtained which reported no patent foramen ovale but with severely reduced systolic function with a LVEF estimated 15-20%;questionable right ventricle apical thrombus was also suspected. Cardiology was consulted for acute systolic heart failure with plans to initiate goal directed medical therapy. A cardiac MRI was recommended which revealed left ventricle increased trabeculations meeting MRI criteria for LVNC, but no cardiac thrombus was detected. Patient was started on warfarin with enoxaparin bridging for secondary stroke prevention. Discussion(s): Given our case's young age of onset of stroke and the history of postpartum and recent COVID-19 infection, cardioembolic stroke due to other more common etiologies such as hypercoagulable disorders, postpartum cardiomyopathy or COVID-19 associated cardiomyopathy were initially suspected based on the initial TTE findings. Subsequent cardiac MRI revealed LVNC as an unusual cause of her cardioembolic stroke. This case illustrates the importance of thoroughly investigating the potential managementchanging causes of stroke, including congenital structural cardiac abnormalities, in patients with young age of onset.

A Case of Beriberi After MIS-C

Introduction: As of June 2021, 4 million children have tested positive for COVID-19 in the US. In contrast to adults, children are often hospitalized with gastrointestinal symptoms including persistent vomiting. Pancreatitis has also been seen in MISC, which can lead to malnutrition. Most physician learn about thiamine deficiency and Wernicke Encephalopathy in patients with severe alcoholism or in low-income settings. We cared for a child with Wernicke Encephalopathy due to subacute malnutrition and weight loss after pancreatitis secondary to MISC in the US. Case Description: A 13-year-old female presented to Levine Children's Hospital with weight loss. She was diagnosed with COVID on 1/23/21 with 1 week of URI symptoms, with baseline weight 165 pounds (BMI 31.1). She was seen in an Emergency Department (ED) on 3/1/21 for vomiting with lipase 350u/L;she received fluids and was discharged. She represented on 3/7/21 with persistent symptoms weighing 135.5 pounds (BMI 25.6) with lipase 790u/L. She was discharged after three days with a diagnosis of post-COVID pancreatitis and lipase 600u/L. After discharge, she continued losing weight despite ondansetron. She followed up with GI on 3/15, weighing 130 pounds (BMI 24.5). An abdominal MRI and endoscopy were normal. She was started on omeprazole and cyproheptadine. She presented to Levine Children's Hospital on 3/24/21 for a second opinion. Upon admission, her serum lipase was 895u/L and she weighed 115 pounds (BMI 21.7). She was started on dextrose-containing fluids and developed seizures on 3/27/21. MRI brain was normal. Ophthalmology noted bilateral abducens nerve palsy. She developed worsening mental status and respiratory failure, so was intubated. A repeat MRI brain revealed posterior reversible encephalopathy syndrome and findings specific for Wernicke Encephalopathy. Thiamine level was low, and empiric thiamine was initiated. She was started on feeds and clinically improved. She was then extubated and showed improvements in her motor function and ability to follow commands. She transferred to inpatient rehab and continues to make progress. Discussion: Identification of the degree of malnutrition for this patient was difficult to obtain due to non-communicating EMRs. This limited the providers' ability to accurately quantify the degree of weight loss and the potential for Thiamine deficiency. The combination of limited body storage and short half-life can result in total depletion of thiamine stores within 2 weeks leading to altered mental status. Unfortunately, stigmatization of obesity in children has been well documented and malnutrition may be overlooked due to a normal BMI. Conclusion: Obtaining growth charts for patients presenting with weight loss is important as they provide objective data and help prevent obesity bias. If a child has a history of weight loss and develops altered mental status, vitamin B deficiencies should be considered in the differential. Pancreatitis associated with MIS-C can cause significant malnutrition leading to Wernicke Encephalopathy.

COVID-19 and abducens nerve palsy in a 9-year-old girl-case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Although many reports have detailed a range of neurological symptoms in SARS-CoV-2-infected patients, studies of neuro-ophthalmological manifestations are still scarce. CASE PRESENTATION: We report a 9-year-old girl with abducens nerve palsy after COVID-19 with no evidence of other neurological disease on neuroimaging. At 2-month follow-up clinical conditions were improved. CONCLUSIONS: The palsy may have occurred due to a possible post-infectious immune-mediated mechanism underlying the neuropathy, as opposed to direct viral infiltration. Despite being rare, this complication must be taken into account.

The Immediate Onset of Isolated and Unilateral Abducens Nerve Palsy Associated with COVID-19 Infection: A Case Report and Literature Review.

Cranial nerve palsy associated with coronavirus disease 2019 (COVID-19) is rare. We herein report the first Asian case of the immediate onset of isolated and unilateral abducens nerve palsy (ANP) accompanied with COVID-19 infection. A 25-year-old man developed diplopia one day after the COVID-19 symptom onset. Neurological examination revealed limitation of left eye abduction without ataxia and hyporeflexia. Negative anti-ganglioside antibody results and mild albuminocytological dissociation were noted. The patient was diagnosed with left ANP accompanied by COVID-19 infection. The ANP spontaneously recovered without treatment. ANP can develop during the early phase of COVID-19 infection and adversely affect patients' quality of life.

Epochs Of Sternutation Induced By Coronavirus 19

Objective: To understand that COVID-19 can cause epochs of sneezing. Background: While Coronavirus 19 has been reported to inhibit sternutation (Mattu, 2021), Coronavirus-induced epochs of sternutation has not henceforth been described. Case Study: 38-year-old right-handed nasute woman, seven months prior to presentation, experienced an acute onset of loss of smell and taste, with a positive nasopharyngeal swab for SARS COV-2. Since then there has been no improvement in her chemosensory complaints and has developed periods of sternutation, whereby she sneezes 18 times in a row every morning. Results: Abnormalities of physical examination: Neurological Examination: Motor Examination: Drift testing: Left pronator drift with left abductor digiti minimi sign. Cerebellar examination: dysmetria in both upper extremities, left more than right. High frequency low amplitude tremor on extension of both upper extremities. Reflexes: 3+ biceps and brachioradialis and absent ankle jerks bilaterally. Bilateral Hoffman reflexes. Chemosensory testing: Alcohol Sniff Test: 0 (anosmia). Olfactory Retronasal Smell Test Index: 0 (anosmia). Gustatory testing: Propylthioruacil Disk Taste Test: 0 (ageusia). Conclusions: The neuroanatomy of the sneeze reflex suggests that it occurs through the afferent pathway from the trigeminal nerve to the rostral dorsolateral medullary sneezing center where the efferent discharge of the autonomic nervous system occurs through the nervous intermedius to the greater superficial petrosal nerve and to the sphenopalatine ganglion. In any of these afferent or efferent pathways or in the central nervous system itself, COVID may have acted to cause intermittent irritation and thus epochs of sneezing (Songu, 2009;Herman, 1983). The common experience of sneezing occurring in threes may be centrally mediated and this occurred with eighteen sneezes may just be a prolonged variant of such a chronobiological reflex. In those who present with COVID-19, query as to epochs of sternutation may be revealing.

COVID-19 pansinusitis with abducens paralysis

Increasing numbers of the papers indicate that SARS-CoV-2 also causes neurological symptoms;the underlying mechanism has not been elucidated yet. Hypothetic mechanisms to explain the CNS involvement of SARSCoV-2 include the neurotropic mechanisms and the cytokine storm developing during the disease process. A middle age female patient applied to the emergency department with complaints of eye pain, a double, foggy, and blurred vision and a severe throbbing headache. The outward gaze was found to be limited in her right eye. Nasopharyngeal swab for SARS-CoV-2 RNA was positive, radiological findings were supported the COVID pneumonia and diffuse sinonasal inflammation. Cranial imaging showed thickening and contrast involvement in the cavernous sinus in the postcontrast series. While shortness of breath improved, and the headache was completely resolved on the 10th day of treatment the right eye outward gaze restriction was continued. The control MRI reveals a significant reduction in cavernous thickening and contrast enhancement and complete resolution in dural thickening. In our case of COVID, cranial nerve involvement and pansinusitis developed without cytokine storm findings suggests that the virus has spread to the cavernous sinuses and dura by regional neighborhood. Neurological symptoms may appear as the first symptom of COVID.

Acute abducens nerve palsy after COVID-19 vaccination in a young adult.

We present the case of a 23-year-old young man with left-eye abducens nerve palsy following the COVID-19 vaccination. Given the temporal relationship between vaccination and the onset of symptoms, the lack of systemic history, and unremarkable magnetic resonance imaging, the patient's abducens nerve palsy was related to his vaccination. The ophthalmologist should be aware of this neurotropic sequela of COVID-19 vaccination in young adults.

Isolated abducens nerve palsy in a patient with asymptomatic SARS-CoV-2 infection.

The neuro-ophthalmological complications of SARS-CoV-2 infection are emerging but the spectrum of presentations and pathophysiological mechanism underpinning the association remains to be fully determined. We describe the case of a 44-year-old female who presented with a 12-hour history of diplopia preceded by a mild headache and found to have an isolated right abducens nerve palsy. Initial vital signs were normal but she developed a fever and nasopharyngeal swab confirmed SARS-CoV-2 infection by RT-PCR. All other investigations returned normal including blood tests, chest X-ray, MRI brain and cerebrospinal fluid analysis. She remained systemically well, and there was complete resolution of the abducens palsy and diplopia at two week follow up. In the absence of an alternative underlying cause or risk factors identified, the aetiology was presumed to be microvascular and potentially related to the viral infection. We add to the evolving literature of neuro-ophthalmological associations of SARS-CoV-2, discuss possible causal mechanisms and suggest considering asymptomatic SARS-CoV-2 infection in cases of isolated abducens palsy without clear risk factors.