Impact of the Coronavirus Disease 2019 Pandemic on the Patient Profile Evaluated in the Electromyography Laboratory

Objective: The objective of this study was to evaluate how the coronavirus disease 2019 pandemic affected the profile of patients admitted to the electromyography (EMG) laboratory and the types of neurophysiologic evaluations. Method(s): We included patients who were admitted to our EMG laboratory in the first 6 months of the pandemic period (Period 1) and the same 6 months of the previous year (Period 2). In view of changes in health-care strategies, lockdown, and disease awareness during the pandemic, each group was divided into 3-month periods (early and late). Demographic and clinical characteristics and electrophysiologic data were evaluated retrospectively and compared between the groups. Result(s): In Period 1, there were 1872 studies of 1829 patients, and in Period 2, there were 625 studies of 607 patients. Electrodiagnoses for cranial neuropathies were more frequent during the pandemic when compared with before the pandemic (P = 0.018). The subgroup analysis revealed that the ratio of segmental anterior horn involvement decreased in the early pandemic period (P = 0.003), myopathies decreased in the late pandemic period (P = 0.001), and cranial neuropathies increased in the late pandemic period (P = 0.005) compared with the same periods in the previous year. Conclusion(s): During the pandemic, there have been changes in clinical practice approaches in the electrophysiology laboratory. More cranial neuropathies seemed to be diagnosed in the EMG laboratory during the pandemic, including new-onset facial neuropathies, which was the most significant finding of our study.Copyright © 2023 AVES. All rights reserved.

Peripheral nervous system manifestations associated with COVID-19

A novel severe acute respiratory syndrome coronavirus 2 has been identified. The disease caused by this virus was termed Coronavirus disease 2019 (COVID-19). The most common reported symptoms include fever, cough, headache, and fatigue. Vast central nervous system and peripheral nervous system complications associated with SARS-CoV-2 have been recently reported. The main mechanism of SARS-CoV-2 and neuroinvasion is hypothesized to be related to angiotensin converting enzyme-2 receptor. Damage to nervous system is mainly by hyperactivation of the immune system with overproduction of inflammatory mediators and producing autoantibodies. Here we review the peripheral nervous system manifestations and complications associated with COVID-19 and highlight its immune-mediated mechanism of pathology. Common neurological complications in COVID-19 include Guillain-Barré syndrome, myasthenia gravis, Cranial neuropathy, and myopathy. Our aim is to update the physicians working with suspected cases of COVID-19 about the possible neurological complication. © 2023 Elsevier Inc. All rights reserved.

CASPR-2 Antibody Associated Autoimmunity in the Setting of COVID-19 (Infection, Vaccination, or Both?) and Chronic Lymphocytic Leukemia: Case Report and Review of the Literature

Objective To report a case of Anti-Contactin-Associated Protein-like2 (CASPR-2) autoimmunity in a patient with low-grade Chronic Lymphocytic Leukemia (CLL) following COVID-19 vaccination and infection. Background Anti-CASPR2 antibody disorder has been associated with neoplastic disorders like thymoma. Recent reports enlist COVID-19 as apotential trigger of CASPR2 autoimmunity. While the clinical presentations are similar, management differs based on the underlying etiology. Design/Methods We review a case of anti-CASPR2-antibody associated disorder with concurrent low grade CLL and recent history of COVID-19 vaccination and infection. Additionally, we review the literature and discuss the therapeutic challenges. Results A 73-years old male presented with five months of progressive fatigue, weight loss, diffuse sweating, muscle cramps, and neuropathic pain. He eventually developed bilateral upper and lower facial weakness. Patient contracted a mild COVID-19 infection two months prior and COVID- 19 vaccination one month prior to his symptom onset. His exam was remarkable for bilateral facial weakness, diffuse fasciculations and sensory neuropathy on his trunk and extremities. His diagnostic work up including bone marrow biopsy was consistent with a chronic lymphocytic leukemia (CLL)-like immunophenotype. Cerebrospinal fluid (CSF) analysis was remarkable for five WBC (lymph-dominant) and protein of 74 mg/dl. Serum paraneoplastic panel revealed positive CASPR2 antibody with a titer of 1:100. Magnetic Resonance Imaging (MRI) of the brain showed enhancement of bilateral cranial nerve VII. After lack of clinical response to IV methylprednisone (1 gram for 5 days), patient was treated with a single cycle of IV immunoglobulin (IVIG). He had complete recovery of his symptoms except for residual facial weakness. He remains stable at his six months post-treatment follow-up. Conclusions Anti-CASPR2 associated autoimmunity following COVID-19 infection or in the setting of CLL has previously been reported. However, cranial neuropathy in association with CASPR2 antibody has never been. A trial of IVIG could be beneficial in patients with viral-spike protein-induced autoimmunity and CLL who do not otherwise meet the criteria for CLL treatment.

A case report of unilateral cervical lymphadenopathy and multiple cranial neuropathies following mRNA-COVID-19 vaccination.

BACKGROUND: We report a rare case of ipsilateral multiple cranial neuropathy and ipsilateral lymphadenopathy following mRNA-COVID-19 vaccination. CASE PRESENTATION: A 41-year-old male visited our emergency room complaining of dysphagia and hoarseness that started a week after receiving COVID19 mRNA vaccination (in his right arm). During his hospitalization, he also complained of right side hearing loss and diplopia. Neurological examination depicted a right IV nerve palsy, ipsilateral facial paresthesia and peripheral facial paresis. Otorinolaryngological examination revealed right vocal cord paralysis. A brain magnetic resonance imaging showed enhancement of the right VII and VIII cranial nerves in the auditory canal. The lumbar puncture revealed increased protein concentration and lymphocytic pleocytosis in the cerebrospinal fluid (CSF). Additionally, a neck computed tomography (CT) scan showed a swollen right supraclavicular lymph node. We hypothesize that the ipsilateral cranial neuropathies of IV, VI, VII, VIII and X, associated with cervical lymphadenopathy, was possible caused by a post-vaccination immune-mediated reaction. The patient was treated with a 5-day course of intravenous methylprednisolone (1000 mg/day), and a gradual improvement was observed. CONCLUSIONS: Similarly, to other vaccines, it is possibly that also mRNA vaccines may act as triggers of non-specific autoimmune neurological syndromes.

COVID-19 associated multiple cranial neuropathies

The polymorphism of the clinical manifestations of coronavirus infection often creates great diagnostic difficulties for the practitioners, especially in patients with a predominance of neurological symptoms. Of the latter, cranial neuropathies take a particular place, as they may be either one of the first symptoms or appear during the disease progression. Impairment of smell and taste is considered an early manifestation of SARS-CoV-2 infection. Similar to the involvement of the olfactory bulb, multiple cranial nerves involvement (for example, VII, VI, and III) has been described. Patients with COVID-19 associated multiple cranial neuropathies are more likely to experience partial recovery of impaired function. We present and discuss a rare case of COVID-19 associated multiple cranial neuropathies with a sequential involvement of the olfactory (I), right visual (II), frontal branch of the trigeminal (V), facial (VII), and hypoglossal (XII) nerves. Data on clinical manifestations and diagnostic criteria for this form of pathology are presented.

Refractory Rhombencephalitis Secondary to SARS-CoV-2 Infection: A Case Report

Objective: To describe a case of rhombencephalitis secondary to severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) Background: Rhombencephalitis is an inflammation of the brainstem and cerebellum. Etiologies include infectious, inflammatory, and autoimmune causes. Rhombencephalitis has varied presentations but frequently includes encephalopathy, cranial neuropathies, long tract signs and cerebellar dysfunction. To date, SARS-CoV-2 has been reported as the cause of rhombencephalitis in 4 cases. Design/Methods: Authors searched PubMed and Google Scholar for articles using the keywords: “COVID-19”, SARS-CoV-2', “Rhomboencephalitis”, “Rhombencephalitis”. Results: 30-year-old African American man with poorly controlled type 1 diabetes mellitus presented with dysgeusia, slurred speech, night sweats, left-sided hypoesthesia, paresthesias, ataxic gait, and light-headedness. Exam was notable for, left-sided hypoesthesia of the face and left upper extremity weakness as well as ataxia. MRI brain revealed diffuse pontine edema and central areas of diffusion restriction. COVID-19 nasal PCR and COVID-19 IgG antibodies were positive. Extensive infectious, autoimmune and paraneoplastic workup was unrevealing. Pulse-dose steroids resulted in improvement of edema and patient was discharged with diagnosis of a monophasic infectious rhombencephalitis due to COVID-19. Patient re-presented 8 days following discharge with acute left-sided headache and vomiting. Exam was notable for mild cranial nerve seven palsy and ataxia in all extremities. MRI brain displayed increased edema, mass effect and enhancement throughout the brainstem extending superiorly to include optic tracts and hypothalamus. CSF studies were remarkable for leukocytosis and increased protein. Repeat infectious, autoimmune and paraneoplastic studies again negative. Re-treatment with pulse-dose steroids followed by prolonged taper resulted in clinical and radiographic improvement at 1 month follow-up. Conclusions: The complete picture of neurological sequelae from COVID-19 is developing as the pandemic continues. Our case adds to the literature of SARS-CoV-2 associated rhombencephalitis and highlights the need for close monitoring and slow titration of immunotherapies such as steroids to minimize the potentially devasting effects of rhombencephalitis.

Acute Neurological Inflammatory Diseases in Colombia: A Multi-center Observational Study from Zika outbreak to SARS-CoV-2 pandemic

Objective: To evaluate clinical, laboratory, and epidemiological features of acute neuroinflammatory disorders (ANIDs) that followed the 2016 Zika epidemic in Colombia. Background: The outbreak of Zika virus infection in Colombia in 2015-2016, produced an increased incidence of Guillain-Barré Syndrome (GBS) and other ANID cases. The Neuroviruses Emerging in the Americas Study (NEAS) network was established in 2016 as a multicenter-based observatory of ANIDs to investigate the role of emerging pathogens in neuroinflammatory diseases. Design/Methods: NEAS serves as a multi-center study based on 13 hospitals in 7 cities in Colombia which study all newly diagnosed patients who fulfill established criteria for GBS, encephalitis, myelitis, meningoencephalitis, or cranial nerve disorders as part of an observational cohort. We analyzed the clinical and epidemiological features of all cases evaluated between January 2016 and September 2021. Results: An observational cohort of 825 patients with ANIDs were recruited during the study period. 58.8% of cases were male with a median age of 43 (IQR 25-58) years. The most frequent ANIDs were GBS (46.1%) and facial nerve palsy (28.7%). The diagnosis of encephalitis (9.5%), myelitis (6.5%), and optic neuritis (5.9%) were less frequent. Patients with GBS were predominantly male (70.6%) and had a median age of 49 (IQR 32-60) years. Interestingly, there was an increase incidence of GBS in 2019. Conclusions: The outbreak of Zika in Colombia produced a marked increase in the incidence of GBS in 2016. Although cases of GBS and other ANIDs continued to emerge after the incidence of Zika infection decreased in July 2016, the recent SARS-CoV-2 pandemic has not produced any significant increase in the incidence of GBS in Colombia.

Multiple Cranial Neuropathies After COVID-19 Vaccination

Objective: To present a patient with acute-onset of multiple cranial neuropathies associated with recent COVID-19 vaccination. Background: Vaccine-associated neurologic adverse effects have been well-described over the decades;the influenza vaccine as well as others have been thought to precede Guillain-BarréSyndrome (GBS), Miller-Fisher Syndrome (MFS), and similar processes. Hyper-inflammatory responses have been frequently reported with SARS-CoV-2 infection and immunization, along with various neurologic pathologies. In this case report we describe a cranial polyneuropathy (3, 6, 7 and 12) associated with the COVID-19 vaccine. Design/Methods: Case Report with Video/Photos Results: A 52-year-old R-handed female presented with acute-onset, rapidly progressive deficits including left upper lid ptosis, left eye ophthalmoplegia, leftward tongue deviation, left facial paresis and dysarthria. History includes congenital left eye cataract s/p lens exchange, remote strabismus surgery and slight ptosis at baseline. She denied recent illness or injuries, though had completed single-dose vaccination for SARSCoV-2 11 days prior to symptom onset. Exam revealed new L eye esotropia with restriction in abduction and supraduction. Also noted was worsening of baseline ptosis, weak tongue protrusion with right-sided fasciculations and leftward deviation. Patient endorsed dysphagia and dysarthria. Workup consisted of three unexplanatory MRIs during week of symptom onset, lumbar puncture, evaluation by ENT and neuro-ophthalmology as well as other serum and CSF studies to investigate other autoimmune causes. Consent-obtained videos and photographs were taken for documentation/educational purposes. Follow-up visits revealed slow improvement starting three months after symptom onset. Conclusions: We outline a case of a female patient who presented with progressive, multiple cranial neuropathies with onset 11 days after single-dose SARS-CoV-2 vaccination. This constellation of symptoms in the setting of COVID-19 vaccination suggests propensity towards autoimmune neurologic processes. Further investigation is needed to determine the true incidence of similar polyneuropathies with the COVID-19 vaccine and to guide providers and patients to make informed decisions.

Neurosarcoidosis after infection with COVID-19, a case report and review of the literature

Objective: N/A Background: The full scope of the mid- and long-term effects of SARS-CoV2 infection is currently being reported. The immune response might contribute not only to the development of ARDS, but also to other systemic complications after the acute setting. Some disorders, including those of autoimmune or presumed autoimmune etiology, have been reported to be triggered, exacerbated, or unmasked during the COVID-19 pandemic. Sarcoidosis is a multi-systemic inflammatory disorder believed to occur due to an exaggerated immune response to unknown antigens in the setting of genetic susceptibility. We present a case of neuro-sarcoidosis after COVID-19. Design/Methods: Descriptive study, case report. Results: A 51-year-old right-handed female presented with multiple cranial neuropathies and paresthesia after a mild case of COVID-19. Her symptoms included vertigo, hypoacusis, balance issues, left facial palsy, and paresthesia in her upper extremities. Her brain MRI with contrast showed bilateral enhancement of the VII and VIII cranial nerves. CSF analysis showed mild protein elevation and elevated CD4:CD8 ratio. Serum sIL-2R was also elevated. Her chest CT scan was abnormal, prompting a lymph node biopsy that was consistent with non-caseating granulomas. A diagnosis of probable neuro-sarcoidosis was made and she showed improvement with steroids. She was later started on methotrexate as a steroid sparing agent in the outpatient setting. Conclusions: To our knowledge, neuro-sarcoidosis has not been previously described in temporal association with COVID-19. It might be that this infection acts as one of the triggers for sarcoidosis. Some common pathways shared by these conditions could explain the possibility of such a trigger. These pathways include the ACE2 receptor, the TMRPPS gene, and certain cytokines. When aberrant, causing incomplete clearance of an antigen, these pathways might lead to the formation of granulomas. Further research surrounding the non-immediate effects of the novel coronavirus is needed to better delineate possible autoimmune consequences of this serious infection.

A CASE REPORT OF THE EMERGENCE OF NEUROSARCOIDOSIS AFTER COVID-19 INFECTION

Introduction Sarcoidosis is a granulomatous disease with protean manifestations. The aetiology is not fully understood. Infectious agents are considered to potentially contribute to its pathogenesis. This case report highlights the emergence of neurosarcoidosis after COVID-19 infection. Case: A 48 year old female developed cough, myalgia and fatigue and was diagnosed with COVID-19 based on serological testing in April 2020. Post-infection, she developed a reactive arthritis, then presented in June with left facial lower motor neuron weakness, initially treated as a Bell's palsy with a significant neuralgic component. This pain resolved with steroid treatment. One month later she developed multiple cranial neuropathies and bilateral leg weakness. MRI brain showed bilateral enhancement of the trigeminal and facial nerves. CSF was abnormal (CSF protein 0.95g/L, WCC 9/uL). Leg power rapidly improved with intravenous immunoglobulins, and FDG-PET identified mediastinal and axillary hilar lymphadenopathy. A neck node showed non-necrotising granulomatous inflammation. CSF angiotensin converting enzyme was elevated (2.07umol/min/L). She has since commenced high dose steroids for probable neurosarcoidosis. Discussion This case suggests a possible association between COVID-19 and the emergence of sarcoidosis. At present the strength of any association is uncertain and putative mechanisms remain to be determined.

Primary Presentation of Neurosarcoidosis as a Pituitary Mass with Sinonasal Involvement

Objective: Sarcoidosis is a systemic granulomatous disease identified by noncaseating granulomas that can have central nervous system (CNS) involvement but rarely presents with primary CNS involvement. Neurosarcoidosis can present with or without systemic disease and can present with mass effect, endocrinopathies, and neuropathic symptoms. We report on an unusual case of neurosarcoidosis involving a pituitary adenoma. Case report: A 45-year-old African American man presented to ophthalmology clinic with a chief complaint of worsening field of vision. Magnetic resonance imaging (MRI) showed a 3.8-cm macroadenoma containing cystic and calcified components with optic chiasm compression, near-complete opacification of the maxillary sinuses, and mucosal thickening in the frontal sinuses. Due to the COVID-19 pandemic, follow-up was delayed for 4 months while the vision loss progressed to near blindness in his right eye. After thorough evaluation, the patient was found to have near-complete right sided blindness, diffuse lymphadenopathy. After interdisciplinary discussions surgery was recommended. The patient underwent endoscopic transsphenoidal resection of the pituitary tumor and concurrent endoscopic sinus surgery. During the approach sinus mucosa was grossly inflamed. Frozen section of the sinus mucosa revealed granulomatous disease. The suprasellar mass had both soft contents which could be suctioned and fibrotic tumor with dense septations. Final pathology showed a pituitary adenoma with non-necrotizing granulomas within in the pituitary adenoma. Post-operatively, the patient was started on steroids and reported gradual improvement in his visual fields. At 3-months post-operative, MRI showed significant reduction in macroadenoma with a 1.5 cm residual tumor remaining in the sella and a decompressed optic chiasm which retracted inferiorly without any evidence of other intercranial anomalies. Literature review: Sarcoidosis occurs mostly in African Americans and Northern European women in their 3rd and 4th decades and can affect any part of the body such as the lymphatic systems, skin, lungs, and liver. Sarcoidosis is estimated to be prevalent in up to 80 per 100,000 people. CNS involvement occurs in 5 to 15% of patients with systemic sarcoidosis and can present with cranial neuropathy such as 7th nerve palsy, anticonvulsant refractory seizures, visual changes, and headaches. Pituitary involvement occurs 0.5% of patients with sarcoidosis and can present with endocrine and water metabolism dysfunction while sinonasal sarcoidosis can occur in up to 4%. Sinonasal sarcoidosis most usually presents as chronic crusting rhinitis, nasal obstruction, anosmia, and epistaxis and can show clinically as mucosal hypertrophy and external nose deformity in ~10% of these patients. Discussion and Conclusion: Symptomatic pituitary mass as the initial presentation of sarcoidosis is extremely rare. This case of primary neurosarcoidosis is unusual with its initial presentation mimicking non-functional pituitary macroadenoma with optic chiasm compression and associated vision loss. Primary presentation of neurosarcoidosis as a pituitary mass is rare but should be included in the differential diagnosis of a patient presenting with a combination of a macroadenoma, chronic sinusitis, and lymphadenopathy.

Cardiovascular, pulmonary and neuromuscular involvement in covid-19 and its management

Regarding the most critical health threat in 21st century, caused by the coronavirus, identifying its controlling methods and treatments is the first priority of the medical society. Up-to-date methods are required for identifying and controlling coronavirus, due to its raising pervalence and mutations. In this presentation, we discuss cardiac, pulmonary, and musculoskeletal side effects of coronavirus. While COVID-19 may affect multiple organ systems, symptoms are most often located in the respiratory tract. Approximately 80% of symptomatic patients present with mild disease: symptoms of fever, runny nose, sore throat or dry cough. Moderate to severe disease is characterized by pneumonia. Underlying CVD and/or development of acute cardiac injury are associated with significantly worse outcome in these patient, Information about other cardiovascular manifestations is very limited at patients with coronavirus disease 2019 (COVID-19) have underlying cardiovascular (CV) disease or develop acute cardiac injury during the course of the illness. Adequate understanding of the interplay between COVID-19 and CV disease is required for optimum management of these patients. COVID-19 is primarily a respiratory illness but cardiovascular involvement can occur through several mechanism Acute cardiac injury is the most reported cardiovascular abnormality in COVID-19, with average incidence 8-12%. Recently research about musculoskeletal disorders in COVID-19 represent, COVID-19 that has an affinity for neural tissue. There are reports of encephalitis, encephalopathy, cranial neuropathy, Guillain-Barrè syndrome, and myositis/rhabdomyolysis in patients with COVID-19. Moreover, Rehabilitation methods, especially exercise therapy, are discussed as supporting treatments for COVID-19. Considering cardiac side effects, like Myocarditis, and other pulmonary side effects, especially pneumonia, as well as identifying musculoskeletal side effects of COVID-19, including Neuropathy, have great importance. Furthermore, secondary side effects, caused by this disease due to deconditioning;results in a decrease in cardiac, respirational, and mobility performance of the patients after an acute period;however, by using an exact, scientific rehabilitation program, the recovery process can become shorter, and the patients can return to their normal lives cycles in a quicker way.

COVID-19 and the peripheral nervous system. A 2-year review from the pandemic to the vaccine era.

Increasing literature has linked COVID-19 to peripheral nervous system (PNS) diseases. In addition, as we move from the pandemic to the vaccination era, literature interest is shifting towards the potential association between COVID-19 vaccines and PNS manifestations. We reviewed published literature on COVID-19, COVID-19 vaccines and PNS manifestations between 1 January 2020 and 1 December 2021. For Guillain-Barré syndrome (GBS), isolated cranial neuropathy (ICN) and myositis associated with COVID-19, the demographic, clinical, laboratory, electrophysiological and imaging features were included in a narrative synthesis. We identified 169 studies on COVID-19-associated complications, including 63 papers (92 patients) on GBS, 29 papers (37 patients) on ICN and 11 papers (18 patients) on myositis. Additional clinical phenotypes included chronic inflammatory demyelinating polyneuropathy, vasculitic neuropathies, neuralgic amyotrophy, critical care-related complications, and myasthenia gravis. PNS complications secondary to COVID-19 vaccines have been reported during randomized clinical trials, in real-world case reports, and during large-scale surveillance programs. These mainly include cases of GBS, Bell's palsy, and cases of neuralgic amyotrophy. Based on our extensive review of the literature, any conclusion about a pathophysiological correlation between COVID-19 and PNS disorders remains premature, and solely supported by their temporal association, while epidemiological and pathological data are insufficient. The occurrence of PNS complications after COVID-19 vaccines seems limited to a possible higher risk of facial nerve palsy and GBS, to a degree that widespread access to the ongoing vaccination campaign should not be discouraged, while awaiting for more definitive data from large-scale surveillance studies.

The emergency neurology literature 2020.

Managing neurological emergencies is an essential element of emergency physicians' armamentarium, irrelevant of the specific nature of their practice. The combination of evolving literature and advances in imaging fuel the rapidly changing standards of care, especially in high-stakes diagnoses such as stroke. Navigating the emergency neurology literature to stay abreast of the current updates is becoming more challenging with the sheer volume of publications, combined with the recent dominance of COVID-19 on the literature and media attention. This review article summarizes emergency neurology literature updates that can help you improve your care of these high-risk presentations; articles covering stroke, dizziness, intracerebral hemorrhage, head trauma imaging, headache, seizures, and COVID-19 are reviewed.

Early reversible leukoencephalopathy and unilateral sixth cranial nerve palsy in mild COVID-19 infection.

OBJECTIVES: To provide new insights into neurological manifestations of COVID-19. We describe a patient with mild COVID-19 associated with diplopia from right sixth cranial nerve palsy and early diffuse leukoencephalopathy, successfully treated with intravenous methylprednisolone. METHODS: The patient was evaluated for diplopia that occurred 1 day after the onset of fever, myalgia, and headache. A complete neurological workup, including neurological examination, cerebrospinal fluid (CSF) analysis with viral polymerase chain reaction (PCR), serum autoimmune encephalitis, and anti-nerve antibodies and brain magnetic resonance imaging (MRI), was performed. RESULTS: Clinical examination revealed incomplete right sixth cranial nerve palsy. Brain MRI showed diffuse confluent fluid-attenuated inversion recovery (FLAIR) hyperintense white matter abnormalities, while CSF analysis showed mild hyperproteinorrachia (61 mg/dL) without pleocytosis. The patients were treated with high-dose intravenous methylprednisolone with rapid improvement of neurological symptoms and resolution of CSF and MRI abnormalities. DISCUSSION: Our report shows that COVID-19 may predominantly present with neurological symptoms; furthermore, it argues the notion of leukoencephalopathy as a typical feature of a severe case of the disease. Mechanisms underpinning neurological symptoms in COVID-19 still need to be elucidated; nonetheless, early recognition and prompt management may ensure their improvement or even complete recovery and are therefore recommended.

Neurological Complications with COVID-19: A Contemporaneous Review.

The COVID-19 pandemic is raging across the world, affecting 212 Countries and Territories around the world. It has infected more than 3.7 million people with a mortality rate of around 7%. Although the causative virus, the SARS-CoV-2 is primarily a respiratory pathogen, recent observational studies have documented a high rate of neurological complications associated with COVID-19. We searched PubMed databases from December 01, 2019 to June 9, 2020 for articles published on "COVID 19" OR "coronavirus" with targeted search words. We also search preprint servers for neurological complications of COVID-19. Neurological manifestations are seen in around 36%-45% of patients with COVID-19 and can involve almost every part of the central nervous system (CNS) from the hemispheres, cranial or peripheral nerves, spinal cord, and muscle. The mechanisms vary from direct viral invasion of the CNS, to a dysregulated host immune response to molecular mimicry to multiorgan dysfunction. In many patients, neurological manifestations preceded other systemic features or the diagnosis of COVID-19. Sick patients with COVID-19 will require ICU care and many patients may present first to the neurocritical care ICU and receive a diagnosis of COVID-19 later. Hence, it is important for all healthcare personnel to be aware of the myriad neurological manifestations of this infection, so as to initiate appropriate infection control practices and refine investigation and treatment protocols.

Multiple cranial nerve palsies in malignant external otitis: A rare presentation of a rare condition.

Malignant external otitis (MEO) is a rare inflammatory and infectious condition, typically caused by Pseudomonas aeruginosa, that mainly affects diabetic or immunocompromised elderly patients and is associated with severe morbidity and mortality. It begins in the external auditory canal and rapidly progresses through the skull base, leading to osteomyelitis and may result in cranial neuropathy, especially of the facial nerve. Here we describe a rare neurological presentation of MEO in a 65-year old diabetic man, who presented with an 8-month progressing left otitis externa and evolved with ipsilateral proptosis, ophthalmoplegia, blindness, facial palsy, hearing loss and contralateral evolvement of the temporal bone with hearing impairment. He was initially treated with oral ciprofloxacin and after one week was transferred to our tertiary hospital, where antibiotic therapy was switched to meropenem and vancomycin due to the severity of the case and to the hospital's microbiological profile. The patient underwent left canal wall-up mastoidectomy with insertion of ear ventilation tube bilaterally, with good recovery of right ear hearing capacity, but with no improvements of neurological deficits nor left hearing function. All microbiological tests performed were negative, and this was interpreted as a possible consequence of the early use of antibiotics. Unfortunately, the patient was infected by Sars-CoV-2 during hospitalization and passed away after ten days of COVID-19 intensive care unit internment.