Two rare neurologic conditions in patients with COVID-19

A 50-year-old man developed Miller Fisher syndrome and a 39-year-old man developed polyneuritis cranialis.

Both are variants of Guillain-Barré syndrome (GBS), which physicians in China and Italy also linked to COVID-19 infection.

In both cases, physicians made the diagnoses based on abnormal eye examinations. The two patients responded to treatment and improved over 2 weeks, with only the 50-year-old featuring residual symptoms of anosmia and ageusia.

The 50-year-old man was admitted to an emergency room with a temperature of 99.9°F (37.7°C). He reported two days of vertical diplopia, perioral paresthesias, and gait instability. His neurologic examination showed intact cognitive function and language.

Five days earlier he developed a cough, malaise, headache, low back pain, fever, anosmia, and ageusia.

His neuro-ophthalmologic examination showed right hypertropia in all fields of gaze, severe limitations to the adduction and downgaze movements of his right eye, and left eye nystagmus on left gaze. These findings were consistent with right internuclear ophthalmoparesis and right fascicular oculomotor palsy.

He responded to intravenous (IV) immunoglobulin therapy and was discharged home 2 weeks after admission.

The 39-year-old man was admitted to the emergency room with acute onset diplopia and ageusia. Three days earlier he had presented with diarrhea, a low-grade fever and in generally poor condition, without any headache, respiratory symptoms, or dyspnea.

He showed esotropia of 10 prism diopters at distance and 4 prism diopters at near, severe abduction deficits in both eyes, and fixation nystagmus, with the upper gaze more impaired, all consistent with bilateral abducens palsy.

The patient was discharged home and treated symptomatically with acetaminophen and telemedicine monitoring "due to a complete hospital saturation with COVID-19 patients," write the researchers, led by Consuelo Gutiérrez-Ortiz, MD, PhD, Hospital Universitario Príncipe de Asturias, Madrid, Spain, write.

Two weeks later, he had made a complete neurologic recovery with no ageusia, complete eye movements, and normal deep tendon reflexes.