Selective cranial multineuritis in severe COVID-19 pneumonia: two cases and literature review

Abstract

Objective To report two cases of cranial multineuritis after severe acute respiratory syndrome caused by coronavirus-2. Methods Patients' data were obtained from medical records of the clinical chart of dell'Angelo Hospital, Venice, Italy. Results The first patient is a 42-year-old male patient who developed, 10 days after the resolution of coronavirus-2 pneumonia and intensive care unit hospitalization with hyperactive delirium, a cranial multineuritis with asymmetric distribution (bilateral hypoglossus involvement and right Claude Bernard Horner syndrome). No albumin-cytologic dissociation was found in cerebrospinal fluid; severe bilateral denervation was detected in hypoglossus nerve, with normal EMG of other cranial muscles, blink reflex, and cerebral magnetic resonance with gadolinium. He presented a striking improvement after intravenous human immunoglobulin therapy.The second case is a 67-year-old male patient who developed a cranial neuritis (left hypoglossus paresis), with dyslalia and deglutition difficulties. He had cerebrospinal fluid abnormalities (albumin-cytologic dissociation), no involvement of ninth and 10 th cranial nerves, diffuse hyporeflexia, and brachial diparesis. Discussion Cranial neuritis is a possible neurological manifestation of coronavirus-2 pneumonia. Etiology is not clear: it is possible a direct injury of the nervous structures by the virus through olfactory nasopharyngeal terminations. However, the presence of albumin-cytological dissociation in one patient, the sparing of the sense of smell, and the response to human immunoglobulin therapy suggests an immune-mediated genesis of the disorder.

Persistent chemosensory dysfunction in a young patient with mild COVID-19 with partial recovery 15 months after the onset

“…Indeed, a recent post-mortem study clearly showed SARS-CoV-2 into the human olfactory neurons [ 9 ]. This result is in line with previous experimental works showing that the SARS-CoV-1 might reach the brain via olfactory nerves [ 23 ] and cranial neuritis possibly linked to a direct viral injury of the nervous structures through olfactory fibers was recently reported [ 24 ]. Notably, ACE2 was also observed into the human olfactory bulb [ 25 , 26 ].…”

COVID‐19 and the peripheral nervous system. A 2‐year review from the pandemic to the vaccine era

“…Isolated or multiple cranial neuropathies not associated with polyneuropathy or other neurological disorders have been reported (Table 2). 93,96,111‐134 These included suspected bilateral olfactory neuropathy, 111,112 optic neuropathy, 113,114 oculomotor neuropathy either isolated 96,115,116,135 or associated with multiple cranial neuropathies, 93,128 unilateral 117‐124 or bilateral facial nerve palsy, 125‐127 sensorineural hearing loss, 129‐131 and lower cranial nerve impairment 132‐134 . Facial nerve palsy was the most commonly reported with 20 cases, followed by isolated oculomotor nerve neuropathy.…”

“…146 Three case of hypoglossal nerve neuropathy have been reported. [132][133][134] All occurred unilaterally and were temporally related with either endotracheal intubation or prone positioning, suggesting a iatrogenic etiology.…”

“…93,96, These included suspected bilateral olfactory neuropathy, 111,112 optic neuropathy, 113,114 oculomotor neuropathy either isolated 96,115,116,135 or associated with multiple cranial neuropathies, 93,128 unilateral [117][118][119][120][121][122][123][124] or bilateral facial nerve palsy, [125][126][127] sensorineural hearing loss, [129][130][131] and lower cranial nerve impairment. [132][133][134] Facial nerve palsy was the most commonly reported with 20 cases, followed by isolated oculomotor nerve neuropathy. With few exceptions, 114,135 all cases were painless.…”

The neuroimaging findings in CO-VID-19 patients A literature review

“…There is increasing documentation that the autoimmune mechanism plays a crucial role in cranial neuropathy in COVID disease [20,21] The loss of smell is an early symptom that suggests COVID-19 disease explained by acute olfactory impairment which is characterized by the absence of nasal obstruction. [22] The imaging findings of cranial neuritis are suspicious when abnormal signal intensity with an increase in the size of the affected cranial nerves with postcontrast enhancement.…”