Physiotherapy results of a patient with critical illness polyneuropathy due to COVID-19: A case report

The aim of this study is to examine the results of physiotherapy in a patient with critical illness polyneuropathy (CIP) due to coronavirus disease 2019 (CO-VID-19). The 48-year-old male patient with CIP due to COVID-19 was enrolled in a physiotherapy program for 3 months with 5 sessions/week. Pain intensity, motor skills, daily living activities, fatigue level, cognitive status, and decubitus ulcer were evaluated with a visual analogue scale, the Medical Research Coun-cil-Sum Score, the Functional Independence Scale, the Fatigue Severity Scale, the Standardized Mini-Mental Test, and pressure wound staging, respectively. Positive improvements were achieved in functional level, fatigue, pain, and pressure sores with the physiotherapy program for this patient with CIP due to COVID-19. This report provides an idea about the effects of physiotherapy programs for COVID-19-related CIP to academics and clinicians working in this field.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Super Slow Conduction Velocitiesin Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)

Objective: NA Background: Chronic inflammatory demyelinating polyneuropathy (CIDP) is characterized on nerve conduction study (NCS) by prolonged distal latencies, slowed conduction velocities, prolonged late responses, conduction blocks, and temporal dispersion. Unmyelinated fibers typically conduct action potentials at speeds of 0.5-10 m/s;myelinated fibers conduct an order of magnitude faster, e.g. 50-70 m/s. While very slow conduction velocities < 25 m/s are typically associated with the genetic neuropathies as in the Charcot-Marie Tooth neuropathies, CIDP can manifest with slow conduction velocities. Prompt recognition of CIDP is crucial for the timely initiation of immunotherapy. Design/Methods: NA Results: This case series of three CIDP patients demonstrates very slow conduction velocities and prolonged distal latencies. An 81-year-old woman with history of multiple sclerosis and chronic myelogenous leukemia presented with inability to walk over a few months with diffuse sensory loss. NCS showed absent motor responses in the leg, partial conduction blocks in the arm, prolonged ulnar motor distal latency 7.9 ms (normal ≤3.4ms), and very slow conduction velocities < 15 m/s. A 50-year-old woman with prior history of COVID-19 presented with diffuse weakness. NCS showed ulnar motor distal latency of 23.2 ms, slowed motor conduction velocities < 30 m/s. After treatment initiation with intravenous immunoglobulin, sensory responses improved, and conduction velocities increased to > 30 m/s. A 49-year-old woman presented with 3 months of bilateral weakness and sensory symptoms two weeks after a COVID-19 vaccination. NCS showed ulnar motor distal latency of 14 ms and slowed motor conduction velocities < 30 m/s. Conclusions: Very slow conduction velocities are a feature not just of the genetic neuropathies but also of acquired demyelination as seen in CIDP, and the latter is distinguished by abnormal temporal dispersion and conduction blocks. Astute electrophysiologists should modify sweep speed and gain to increase sensitivity for delayed or dispersed responses.

COVID-19 associated myositis with severe proximal and bulbar weakness

Objective: NA Background: Here we report a patient with COVID-19 associated inflammatory myopathy, presenting with facial, bulbar and proximal limb weakness. A 58-year-old woman presented with cough, dyspnea, and myalgia. Vital signs and her physical exam was unremarkable. Initial PCR testing for SARS-CoV-2 was negative and the patient was discharged home. She returned three weeks later with more severe dyspnea, cough, dysarthria, dysphagia, odynophagia and severe generalized weakness with inability to ambulate. She had no sensory symptoms or bowel or bladder dysfunction. Physical examination was significant for tachycardia and oxygen saturation of 88% on room air. She had bilateral ptosis, facial weakness, hypernasal dysarthria and profound symmetric proximal limb weakness. Reflexes were symmetrically diminished. Repeated SARS-CoV-2 PCR was positive. MRI of the entire neuroaxis showed no central or peripheral nervous system involvement, but demonstrated diffuse muscle edema and enhancement, with a region of myonecrosis Motor nerve conduction studies were unremarkable, needle electromyography revealed sparse fibrillation potentials;On admission, CK was elevated to 700 U/L. Anti-Sjögren's-syndrome-related antigen and anti-small ubiquitinlike modifier-1 activating enzyme antibodies were both strongly positive and Ku antibody was weakly positive. Muscle biopsy showed perivascular inflammatory infiltration with endomysial extension, regenerating fibers and upregulation of HLA Class ABC expression on non-necrotic fibers. Our presumptive diagnosis was COVID-19 associated myositis and a five-day course of 1000 mg intravenous methylprednisolone was administered. Over two weeks, her CK levels normalized and she recovered the ability to raise her arms and legs from the bed and showed slow improvement in bulbar function. Design/Methods: NA Results: Viral infection is a well-known cause of myositis. The severe immune activation known to occur in COVID-19 patients likely plays a major pathophysiologic role. The finding of multiple serologic autoimmune antibodies is intriguing suggesting an epiphenomenon rather than activation or unmasking of a specific immune response directed to the muscles. Conclusions: NA.

Atypical Pharyngo-Cervico-Brachial Variant of GBS Associated with Covid-19 Antibodies

Objective: Neurological manifestations are common with Covid-19 illness. Many unusual neurological manifestations have been described and we herewith report one such case. Background: COVID-19 is predominantly a respiratory pathogen but can cause multi system involvement. Many studies have shown significant neurological manifestations associated with Covid-19 infection. Some of these neurological manifestations are quite specific like GuillainBarre syndrome. But, many uncommon manifestations have been described like the following case. Design/Methods: A 35-year old woman with no prior history of fever or any other illness presented with insidious onset, gradually progressive weakness of bulbar and bilateral facial weakness along with asymmetrical weakness of both upper limbs of one and half months duration. She was evaluated and investigated accordingly. Results: On neurological examination, the patient had dysphonia, dysphagia, bilateral lower motor neuron facial palsy. Along with weakness of neck flexors and grossly asymmetrical weakness of upper limbs. The motor power on right is MRC 2/5 and MRC 4/5 in left upper limb with diffuse hypotonia. Motor power was normal in lower limbs. There was diffuse hyporeflexia in all the four limbs. Nerve conduction studies showed absent SNAPS with decreased motor nerve conduction velocities and increased CMAP latencies in both upper and lower limbs. CSF examination showed albumin-cytological dissociation. MRI Brain and Cervical Spine were normal. Serum ANA and Serum Ganglioside antibodies were negative. She was tested for total Covid-19 antibodies which was significantly positive with 55.25 COI. Patient was treated initially with IV Methylprednisolone with no significant response. So, followed with intravenous immunoglobulins and showed some improvement. Conclusions: Atypical Pharyngo-cervico-brachial variant of GB Syndrome with gross asymmetrical upper limb weakness and progressed over six weeks associated with positive SARS Cov-2 antibodies. During the pandemic, unusual neurological manifestations should be evaluated for possibility of SARS-CoV-2 associated antibodies as neuropathogenesis has shown both vascular and post infectious demyelinating disorders.