Extended Neuralgic Amyotrophy Syndrome in a Confirmed COVID-19 Patient After Intensive Care Unit and Inpatient Rehabilitation Stay

Abstract

The cause of neuralgic amyotrophy is often unknown but is commonly associated with a recent upper respiratory viral tract infection. Since the beginning of the COVID-19 pandemic, there has been a tireless effort to understand the sequelae of the virus. A 46-yr-old woman who presented after a COVID-19 hospitalization complicated by hypoxic respiratory failure requiring intubation and mechanical ventilation for 23 days was subsequently found to have lower limb sensorium changes as well as upper limb weakness. Left shoulder abduction and extension were both 3/5 in motor strength, and left hip flexion strength was 4/5 with diminished sensation to crude touch in the left lateral thigh. Nerve conduction studies and electromyography findings included a mild left median neuropathy at the wrist and motor unit recruitment pattern consistent with a chronic left upper trunk plexopathy with reinnervation. The case presented describes an extended neuralgic amyotrophy syndrome from an atraumatic mechanism in a previously diagnosed COVID-19 patient. An extended neuralgic amyotrophy syndrome has at least three immune mediated etiologies postulated (1) direct neuropathogenicity, (2) molecular mimicry, and (3) direct cytotoxic effects on peripheral nerves. As COVID-19 survivors continue to be seen in outpatient settings, practitioners should remain aware of diffuse neurological complications as sequelae of the virus persist.

Parsonage-Turner Syndrome Following COVID-19 Vaccination: Clinical and Electromyographic Findings in 6 Patients

“…PTS is a clinical diagnosis and depends on an accurate history and neurological examination. The differential diagnosis includes several conditions including cervical radiculopathy; cervical myelopathy; adhesive capsulitis, rotator cuff, or labral tear of the shoulder; and glenohumeral osteoarthritis [ 2 , 3 , 11 ]. A vague and unreliable history and confusing findings on physical examination may lead to misdiagnosis.…”

“…Very few case reports/series have been published in the literature describing PTS as a sequelae of COVID-19 infection or vaccination (Table 2 ) [ 2 , 3 , 7 , 8 , 9 , 10 , 11 , 12 , 18 , 19 , 20 ]. In 5 of these articles, patients had contracted COVID-19, after which they developed shoulder and/or arm pain followed subsequently by arm/hand paresthesia and weakness [ 2 , 7 , 9 , 11 , 12 ]. Five case reports/series featured similar presenting symptoms after receiving the COVID-19 vaccine [ 3 , 10 , 18 , 19 , 20 ].…”

“…Initially described in 1948, Parsonage-Turner syndrome (PTS) refers to the acute onset of shoulder pain followed by progressive motor weakness, dysesthesia, and numbness of the upper extremities [ 1 ]. Also known as acute brachial plexus neuropathy or neuralgic amyotrophy, this condition is usually unilateral and has an incidence of 1.64 cases per 100,000 individuals (although may be as high as 20–30/100,000 due to missed cases or misdiagnosis) [ 1 , 2 , 3 ]. While the etiology is unknown in many cases, several causes have been reported, including prior viral infections, vaccination, surgery, and trauma [ 1 , 4 ].…”

“…Numerous short- and long-term side effects of the peripheral nervous system from the COVID-19 infection have been reported, including nerve pain and skeletal muscle injury, Guillain-Barrė syndrome, Bell's palsy, tinnitus, cranial polyneuritis, neuro-ophthalmological disorders, neurosensory hearing loss, neuromuscular junction disorders, and dysautonomia [ 7 ]. Rare cases of PTS following COVID-19 infection or vaccination have been described [ 2 , 3 , 7 , 8 , 9 , 10 , 11 , 12 ]. It has been suggested that peripheral nervous system abnormalities may be attributed to dysregulation of the systemic immune response due to COVID-19 [ 12 ].…”

“…It has been suggested that peripheral nervous system abnormalities may be attributed to dysregulation of the systemic immune response due to COVID-19 [ 12 ]. In this manner, COVID-19 infection results in an increased number of antibodies against peripheral nerve myelin leading to inflammation with macrophage activation [ 2 ].…”