Post COVID-19 syndrome associated with orthostatic cerebral hypoperfusion syndrome, small fiber neuropathy and benefit of immunotherapy: a case report

Abstract

Coronavirus disease (COVID-19) is a novel highly contagious infectious disease caused by the coronavirus SARS-CoV2. The virus affects the human respiratory and other systems, and presents mostly as acute respiratory syndrome with fever, fatigue, dry cough, myalgia and dyspnea. The clinical manifestations vary from no symptoms to multiple organ failure. Majority of patients fully recover. Several postinfectious presumably autoimmune complications of COVID-19 affecting the brain or peripheral large nerve fibers have been reported. This report describes a post COVID-19 patient who developed chronic fatigue, orthostatic dizziness and brain fog consistent with orthostatic hypoperfusion syndrome (OCHOS), a form of orthostatic intolerance, and painful small fiber neuropathy (SFN). Initially, the patient was diagnosed with. OCHOS (detected by the tilt test with transcranial Doppler monitoring) and SFN (confirmed by skin biopsy), and both OCHOS/SFN were attributed to Post Treatment Lyme Disease Syndrome of presumed autoimmune etiology. Patient recovered on symptomatic therapy. COVID-19 triggered exacerbation of OCHOS/SFN responded to immunotherapy with intravenous immunoglobulins. This case suggests that post COVID-19 syndrome may present as an autoimmune OCHOS/SFN and that early immunotherapy may be effective. Further studies are necessary to confirm the link between OCHOS/SFN and COVID-19 disease as well as to confirm the benefit of immunotherapy.

Post-acute COVID-19 syndrome

“…Post-COVID brain fog in critically ill patients with COVID-19 may evolve from mechanisms such as deconditioning or PTSD 141 . However, reports of COVID-19 brain fog after mild COVID-19 suggest that dysautonomia may contribute as well 163,164 . Finally, long-term cognitive impairment is well recognized in the post-critical illness setting, occurring in 20-40% of patients discharged from an ICU 165 .…”

Hydroxychloroquine, nitazoxanide and ivermectin have similar effects in early COVID-19: a head-to-head comparison of the Pre-AndroCoV Trial.

“…The apparently high rate of post-COVID syndrome, presented as a wide variety of physical and mental symptoms, that impair normal functionality (31)(32)(33)(34)(35)(36), likely leading to a post-COVID public health issue, should become a key clinical outcome when evaluating and proposing interventions for patients with COVID-19. The persistence of symptoms or occurrence of new symptoms after COVID-19 cure in the population of the present study was as low as 1.5%, consistent throughout the different populations and drugs used, in contrast to the almost 90% of patients with manifestations after recovery, including 72.8% complaining of fatigue, when not pharmacologically approached during early COVID-19 (33).…”

An open-label prospective observational study of antiandrogen and non-antiandrogen early pharmacological approaches in females with mild-to-moderate COVID-19. The Pre-AndroCoV Female Trial

“…shown to be present in at least 20 to 30% of patients, and includes autoimmune, mental, psychiatric, muscular, respiratory and gastrointestinal disorders, and persisted fatigue, resembling chronic fatigue syndrome (CFS), unrelated to any specific biochemical marker to date (27,28). Hence, whenever a pharmacological intervention study is complication.…”

“…The importance of unveiling potential effective treatments for COVID-19 not only lays on preventing hospitalization, mechanical ventilation, and death, but also preventing long-term, post-cure persisting symptoms, termed as "post-COVID syndrome", that has shown to be present in at least 20 to 30% of patients, and includes autoimmune, mental, psychiatric, muscular, respiratory and gastrointestinal disorders, and persisted fatigue, resembling chronic fatigue syndrome (CFS), unrelated to any specific biochemical marker to date (27,28). Hence, whenever a pharmacological intervention study is conducted, researchers should not only consider acute, but also chronic complications as targets to evaluate efficacy.…”