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DOI: 10.1590/0004-282X20200052
Bilateral trochlear nerve palsy due to cerebral vasculitis related to COVID-19 infection
Paralisia bilateral do nervo troclear por vasculite cerebral relacionada à infecção por COVID-19A 69-year-old Caucasian man presented fever (38°C) with abdominal pain, left posterior chest pain without cough or dyspnea, and mild occipital headache that persisted in the next few days. Eleven days later, he woke up with binocular diplopia and severe stabbing occipital headache. There were no peripheral signs of systemic vasculitis. The neurological evaluation identified bilateral paresis of the fourth cranial nerve. He had well-controlled arterial hypertension and denied trauma or use of other medications. COVID-19 infection was confirmed by the reverse transcription technique followed by polymerase chain reaction (RT-PCR) in a nasopharyngeal swab. A brain magnetic resonance imaging (MRI) with MRI angiography and vessel wall imaging showed signs of vasculitis of the vertebrobasilar system[1], as well as inflammatory radiologic signs in the periaqueductal region, along the topography of the trochlear nuclei ([Figure 1]). Chest computed tomography (CT) showed peripheral parenchymal ground-glass opacities, suggesting viral pneumonia. Cerebrospinal fluid (CSF) revealed 2 cells/mm3 (69% lymphocytes, 29% monocytes, 2% macrophages) and proteins slightly increased to 46 mg/dL (with 17.01% gamma globulin). CSF antibody testing was negative for syphilis and other viruses. Rheumatological causes, hypovitaminosis, and thyroid dysfunction were ruled out. Erythrocyte sedimentation rate (ESR) was 33 mm/h. He received IV methylprednisolone for five days with complete improvement of pain and diplopia.
This is the first case report of cerebral vasculitis related to COVID-19 infection in an adult patient. We emphasize that headache[2] could be a warning sign of cerebral vasculitis in these individuals.
Publication History
Received: 06 May 2020
Accepted: 11 May 2020
Article published online:
13 June 2023
© 2020. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Mandell DM, Mossa-Basha M, Qiao Y, Hess CP, Hui F, Matouk C, et al. Intracranial vessel wall MRI: principles and expert consensus recommendations of the American Society of Neuroradiology. AJNR Am J Neuroradiol. 2017 Feb;38(2):218-29. https://doi.org/10.3174/ajnr.A4893
- 2 Mao L, Jon H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with Coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020 Apr. [Epub ahead of print]. https://doi.org/10.1001/jamaneurol.2020.1127