Case report BMJ Case Rep: first published as 10.1136/bcr-2021-242330 on 24 May 2021. Downloaded from Polyneuropathy following COVID-19 infection: the rehabilitation approach Ahmad Saif ,1,2 Anton Pick2 1Rehabilitation Medicine, SUMMARY Throughout his intensive care admission, he had Buckinghamshire Healthcare A range of neurological manifestations associated with multiple SARS- CoV-2 RNA PCR tests from nasal NHS Trust, Aylesbury, UK and throat swabs and broncheoalveolar lavage 2 COVID-19 have been reported in the literature, but the Rehabilitation Medicine, Oxford pathogenesis of these have yet to be fully explained. The samples that were negative but was treated as Centre for Enablement, Oxford, majority of cases of peripheral nervous system disease suspected COVID-19 based on what was deemed UK published thus far have shown a symmetrical pattern. to be a typical clinical presentation. He developed several complications including Correspondence to In contrast, we describe the case of a patient with Dr Ahmad Saif; asymmetrical predominantly upper-limb sensorimotor ventilator- associated pneumonia, gastrointestinal ahmad. saif2@ nhs. net polyneuropathy following COVID-19 infection, likely due bleed, acute kidney injury requiring a period of to a multifactorial pathological process involving critical haemodialysis and bilateral pulmonary embolisms. Accepted 22 April 2021 illness neuropathy, mechanical injury and inflammatory Nerve conduction studies (NCS) were carried out on disease. His presentation, management and recovery day 29 of his intensive care unit admission showing contribute to the understanding of this complex evidence of widespread and severe sensory and motor condition and informs rehabilitation approaches. axonal dysfunction, in keeping with critical care polyneuropathy. The patient was extubated and discharged from intensive care after 55 days. He was found to have BACKGROUND generalised weakness most prominently in the upper As the coronavirus pandemic progresses, so does our limbs and associated neuropathic pain. He was then understanding of the natural history, transmission transferred to a specialist multidisciplinary neurore- and clinical presentation.1 Although patients most habilitation unit for ongoing treatment. Examination commonly present with respiratory and gastrointes- findings for the upper limbs on admission to the reha- tinal symptoms, a diverse range of symptoms have been bilitation unit are shown in table 1. In the lower limbs, reported. Descriptions of neurological manifestations there was 5/5 power throughout. Sensation to light include reports of encephalopathies, central nervous touch was reduced in areas consistent with C8 and T1 system vasculitides, cerebrovascular events and periph- http://casereports.bmj.com/ dermatomes on the right, and T1 dermatome on the eral nervous system disease in particular Guillain-Barré left. He was found to have reduced proprioception syndrome (GBS) and its variants.2 in fourth and fifth digits on the right hand. Sensation, The pathogenesis of these manifestations is including proprioception, was grossly normal in his yet to be fully elucidated. Evidence from other lower limbs. Tone was normal in the lower limbs. similar viruses suggests mechanisms may include Repeat NCS (table 2) were carried out 83 days direct effects of the virus on the nervous system, following initial admission. The study showed parainfections or postinfection immune- mediated evidence for a peripheral neuropathy which may in disease as well as neurological complications of part have been due to a length-dependent sensory the systemic effects of COVID-19 and critical care motor axonal neuropathy; however, the striking on September 29, 2021 by guest. Protected copyright. admission.2 Here, we describe the case of a patient aspect was the distribution, with profound dener- who developed asymmetrical predominantly upper- vation of both upper limbs and relative preserva- limb sensorimotor polyneuropathy following tion of lower limb strength including distally with COVID-19 infection.3 minimal axonal loss. This pattern was not typical for a critical illness CASE PRESENTATION myopathy but rather raised the possibility of pref- The patient is a man in his 60s who first presented erential sensory motor peripheral nerve fibre loss with severe shortness of breath. His symptoms either affecting the lower aspect of the brachial started 12 days prior with dry cough, mild short- plexus bilaterally or possibly a combination of ness of breath, fever and chest tightness. Following a sensory neuropathy, in addition to perhaps a advice from his general practitioner, he had been localised cervical spinal cause at the C7–T1 levels. self- isolating and had been commenced on Amox- Further investigation with MRI brachial plexus and C- spine, however, showed no focal injury or © BMJ Publishing Group icillin for suspected community- acquired pneu- Limited 2021. No commercial monia 1 day prior. On admission, he was in severe inflammation to the brachial plexus either side with re- use. See rights and respiratory distress with saturations of 91% on minor degenerative change in the lower cervical permissions. Published by BMJ. 12 L of oxygen, respiratory rate 34 breaths/min, spine only. To cite: Saif A, Pick A. BMJ temperature 37.6°C, heart rate 101 beats/min and Case Rep 2021;14:e242330. blood pressure 163/89 mm Hg. He had a prolonged doi:10.1136/bcr-2021- admission on intensive care requiring intubation 242330 and ventilation and later tracheostomy formation. Saif A, Pick A. BMJ Case Rep 2021;14:e242330. doi:10.1136/bcr-2021-242330 1 Case report BMJ Case Rep: first published as 10.1136/bcr-2021-242330 on 24 May 2021. Downloaded from Brachial plexus injury due to compression or stretch from Table 1 Upper limb examination findings proning has been reported, with the majority of cases recov- Power (MRC grade) 4 5 Movement ering well. This likely played a contributing role to the clin- Left Right ical picture in the current case, the patient having been proned Shoulder abduction (C5) 2 2 in intensive care. However, MRI showed no features to suggest Elbow flexion (C5, C6) 0 4 focal injury or inflammation of either brachial plexus; that is, no Elbow extension (C7) 3 1 pseudomeningocele to suggest traumatic nerve root avulsion, no Wrist extension (C6) 3 3 focal collection or haematoma and no inflammatory change or Wrist flexion (C8) 2 1 thickening of the brachial plexus elements on either side. Local- Finger extension (C7) 2 0 ised cervical spine injury at the C7–T1 levels was also considered Finger flexion (C8) 0 0 but imaging showed only minor degenerative change with no Finger abduction (T1) 0 0 nerve root impingement. MRC, Medical Research Council. There has been an association of asymmetric neuropathies with other viruses in particular cytomegalovirus, HIV and hepa- titis C.6–8 However, viral screen in this case was negative and DIFFERENTIAL DIAGNOSIS there were no other abnormal blood tests or signs suggestive of Critical illness neuropathy was the proposed diagnosis to explain these. the initial findings in intensive care. However, repeat NCS were Cases of GBS associated with COVID-19 have also been 2 carried out following the acute COVID-19 infection given the reported. Differentiating the axonal variants of GBS from crit- asymmetry of presentation. The clinical and neurophysiological ical illness polyneuropathy can be difficult. The major clinical picture was atypical for this diagnosis alone with the dispropor- distinction is that the critical illness polyneuropathy occurs tionate upper-limb involvement suggesting an additional patho- during the period of severe illness and stay in intensive care logical process. while GBS often occurs after the acute illness and leads to an Table 2 Nerve conduction study results taken 83 days following initial admission Sensory NCS Nerve /sites Rec. site Onset latency (ms) PP amplitude (µV) Velocity (m/s) R Median, ulnar—median ulnar orthodromic Median Dig II Wrist NR NR NR Ulnar Dig V Wrist NR NR NR L Median, ulnar—median ulnar orthodromic http://casereports.bmj.com/ Median Dig III Wrist NR NR NR Ulnar Dig V Wrist NR NR NR R Radial—anatomical snuff box (forearm) Forearm Wrist NR NR NR L Radial—anatomical snuff box (forearm) Forearm Wrist NR NR NR L Sural, superficial peroneal Sural calf Ankle NR NR NR Superficial peroneal calf Ankle NR NR NR on September 29, 2021 by guest. Protected copyright. Motor NCS Nerve /sites Muscle Latency (ms) Amplitude (mV) PP amplitude (mV) Relative amplitude (%) Duration (ms) Velocity (m/s) L Median—APB Wrist APB NR NR NR NR NR Elbow APB NR NR NR NR NR R Median—APB Wrist APB NR NR NR NR NR L Ulnar—ADM Wrist ADM NR NR NR NR NR R Ulnar—ADM Wrist ADM NR NR NR NR NR R Peroneal—EDB Ankle EDB 5.68 1.2 1.6 100 24.9 Fib head EDB 12.81 0.9 1.2 78.8 24.53 42 Pop fossa EDB 14.53 0.6 0.9 53.1 24.64 40.7 R Tibial—AH Ankle AH 4.17 5.2 7.7 100 22.24 ADM, abductor digiti minimi; AH, abductor hallucis; APB, abductor pollicis brevis; EDB, extensor digitorum brevis; NCS, nerve conduction studies. 2 Saif A, Pick A. BMJ Case Rep 2021;14:e242330. doi:10.1136/bcr-2021-242330 Case report BMJ Case Rep: first published as 10.1136/bcr-2021-242330 on 24 May 2021. Downloaded from intensive care admission.9–11 Furthermore, GBS more often role of rehabilitation medicine in managing patients following involves the cranial nerves. Without cerebrospinal fluid (CSF) COVID-19 infection. Table 3 shows the multiple functional results or serum immunological markers in this case, GBS cannot impairments in this patient and the holistic programme to be ruled out. However, a recent epidemiological study found an manage each aspect. overall reduction in incidence of GBS during the pandemic and He showed improvement in impairment, activity and partic- while a link could not be ruled out, no epidemiological clues ipation, following a period of intensive cardiopulmonary and of SARS- CoV-2 causing GBS have been identified.12 Given the neurorehabilitation.