Neuromuscular presentations in patients with COVID-19

Abstract

COVID-19 is caused by the coronavirus SARS-CoV-2 that has an affinity for neural tissue. There are reports of encephalitis, encephalopathy, cranial neuropathy, Guillain-Barrè syndrome, and myositis/rhabdomyolysis in patients with COVID-19. In this review, we focused on the neuromuscular manifestations of SARS-CoV-2 infection. We analyzed all published reports on SARS-CoV-2-related peripheral nerve, neuromuscular junction, muscle, and cranial nerve disorders. Olfactory and gustatory dysfunction is now accepted as an early manifestation of COVID-19 infection. Inflammation, edema, and axonal damage of olfactory bulb have been shown in autopsy of patients who died of COVID-19. Olfactory pathway is suggested as a portal of entry of SARS-CoV-2 in the brain. Similar to involvement of olfactory bulb, isolated oculomotor, trochlear and facial nerve has been described. Increasing reports Guillain-Barrè syndrome secondary to COVID-19 are being published. Unlike typical GBS, most of COVID-19-related GBS were elderly, had concomitant pneumonia or ARDS, more prevalent demyelinating neuropathy, and relatively poor outcome. Myalgia is described among the common symptoms of COVID-19 after fever, cough, and sore throat. Duration of myalgia may be related to the severity of COVID-19 disease. Few patients had muscle weakness and elevated creatine kinase along with elevated levels of acute-phase reactants. All these patients with myositis/rhabdomyolysis had severe respiratory complications related to COVID-19. A handful of patients with myasthenia gravis showed exacerbation of their disease after acquiring COVID-19 disease. Most of these patients recovered with either intravenous immunoglobulins or steroids.

Central and peripheral nervous system complications of COVID-19: a prospective tertiary center cohort with 3-month follow-up

“…All 8 patients had prolonged admissions to the ICU, sepsis and multi-organ failure, resembling typical ICU-acquired weakness [ 34 ]. Previous studies on PNS complications in COVID-19 have mainly focused on Guillain–Barré syndrome [ 35 ] which we did not observe, even though our center is the referral center for GBS cases in the Greater Copenhagen area with 1.9 million inhabitants. We did, however, observe one case of rhabdomyolysis as a presenting complication of COVID-19, and myalgia with elevated CK in COVID-19 has indeed been previously reported [ 35 ].…”

“…Previous studies on PNS complications in COVID-19 have mainly focused on Guillain–Barré syndrome [ 35 ] which we did not observe, even though our center is the referral center for GBS cases in the Greater Copenhagen area with 1.9 million inhabitants. We did, however, observe one case of rhabdomyolysis as a presenting complication of COVID-19, and myalgia with elevated CK in COVID-19 has indeed been previously reported [ 35 ]. Our patient with rhabdomyolysis and acute myopathy had no obvious cause for muscle injury other than COVID-19, but we were unable to obtain a muscle biopsy to determine if there were signs of direct viral invasion or inflammatory cell infiltrates.…”

Neuromuscular Diseases Care in the Era of COVID-19

“…In general terms, SARS-CoV2 is believed to have neurotropism and can access the central nervous system through the olfactory nerves as well as other cranial nerves. This could explain why some patients have persistent anosmia or other cranial neuropathies (3,4). At the level of the peripheral nerve, the mechanisms that cause its involvement are not fully understood.…”

“…SARS-CoV2, apart from binding to the angiotensin-converting enzyme 2 (ACE2), binds to glycoproteins and gangliosides on cell surfaces. This last interaction makes it plausible that a cross-reaction occurs between SARS-CoV2 spike-bearing gangliosides and sugar residues of surface peripheral nerve glycolipids (3,4). The hypothesis of molecular mimicry is supported by the median time interval between COVID-19 symptoms and GBS onset (11.5 days), the acellular cerebrospinal fluid (CSF), and that many of them have responded favorably to IVIG (5,6).…”

Potential for increased prevalence of neuropathic pain after the COVID-19 pandemic

“…Thus far, the most common pain-related symptom after COVID-19–induced GBS has been myalgia. 50 However, GBS often causes acute neuropathic pain, mainly through impairment of small nociceptive fibers, 45 and chronic neuropathic pain has also been reported in severe cases.…”