Third Cranial Nerve Palsy Presenting with Unilateral Diplopia and Strabismus in a 24-Year-Old Woman with COVID-19

Abstract

Patient: Female, 24-year-old Final Diagnosis: Third cranial nerve palsy in a women presenting COVID-19 Symptoms: Ophthalmoplegia Medication:— Clinical Procedure: — Specialty: Ophthalmology Objective: Rare disease Background: Coronavirus disease (COVID 19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is the causative agent of a serious disease that is of great global public health concern. Palsy of the third cranial nerve is very rare in patients with confirmed 2019 novel coronavirus disease (COVID-19). We describe the case of a patient with an incomplete palsy of the left third cranial nerve sparing the pupils in the context of SARS-CoV-2 virus infection. Case Report: We report the case of a 24-year-old woman with confirmed COVID-19, which presented with acute onset of diplopia and strabismus of the left eye that occurred 3 days after the start of general symptoms. The patient had no significant medical history. Based on detailed ophthalmic and neurological examination, acute painless incomplete palsy of the third cranial nerve was suspected. Oculo-cerebral magnetic resonance angiography was unremarkable. Blood tests revealed mild normocytic regenerative anemia. According to the Moroccan recommendations, chloroquine and azithromycin were started. After what, a quick improvement of exotropia and diplopia was observed, and complete recovery was obtained by the sixth day of treatment. No adverse effects of the treatment were noted. Conclusions: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause neurological complications such as cranial nerve palsy. The pathological mechanism remains unclear. Full recovery of the ocular motricity is possible, and prognosis depends on the severity of the respiratory illness.

Abducens Palsy and Anosmia Associated with COVID-19: A Case Report

“…He was treated with acetaminophen and the nerve palsy resolved within two weeks. Similarly, Belghmaidi et al (2020) reported a 24-year-old female with left oculomotor cranial nerve palsy. She was treated with chloroquine and azithromycin, the nerve palsy completely resolved within six days.…”

“…Recent reports have described neurological involvement in COVID-19, affecting the central nervous system (CNS), peripheral nervous system (PNS) and muscle, as well as causing olfactory dysfunction (Asadi-Pooya & Simani 2020;Mao et al 2020). Incidences of: Guillain-Barre syndrome, Miller-Fisher syndrome, large vessel stroke and isolated cranial neuropathies have recently been reported in the setting of confirmed SARS-CoV-2 infection (Belghmaidi et al 2020;Ben-David et al 2020;Dinkin et al 2020;Falcone et al 2020;Faucher et al 2020;Gutiérrez-Ortiz et al 2020;Oxley et al 2020;Toscano et al 2020). To date, there are few case reports describing isolated cranial nerve palsies.…”

COVID-19 and Eye

“… Miller Fisher Syndrome (MFS) and cranial nerve palsy MFS with acute onset ataxia, loss of tendon reflexes, and ophthalmoplegia and cases of cranial nerve palsies have been reported in several patients recently diagnosed with COVID-19. [ 59 60 61 62 63 64 ] Patients give history of acute onset of diplopia as the ocular complaint. 6 th nerve was most commonly involved followed by oculomotor nerve [ Fig.…”

Peripheral Nervous System Manifestations Associated with COVID-19

“… Retrospective Brazil Camelo-Fiho et al, 2020 [ 100 ] Neuro-ophtalmalogical disorder Using OCT, hyperreflective lesions at the level of ganglion cells and inner plexiform layers were found, especially at the papillomacular bundle of both eyes in 11 adult patients. Case series Brazil Marinho et al, 2020 [ 105 ] Optic neuritis in one of 841 patients Retrospective Spain Romero-Sanchez et al, 2020 [ 71 ••] Ophtalmoparesis from cranial nerve palsy Case report USA Dinkin et al, 2020 [ 106 ] Third cranial nerve palsy Case report Morocco Belghmaidi et al, 2020 [ 107 ] Hearing loss SNHL Case report Thailand Sriwijitalai et al, 2020 [ 109 ] SNHL Case report Egypt Abdel Rhman et al, 2020 [ 110 ] COVID-19 was confirmed 1 out of 5 patients with SNHL. Case series Turkey Kilic et al, 2020 [ 111 ] Complete deafness on the right side and profound SNHL on the left side Case report Germany Degen et al, 2020 [ 112 ] FLAIR , fluid-attenuated inversion recovery; GBS , Guillain-Barré Syndrome; ICA , internal carotid artery; MG , myasthenia gravis; MRC , Medical Research Council; OCT , optical coherence tomography; NMS , neuroleptic malignant syndrome; SNHL , sensorineural hearing loss …”

“…His symptoms deteriorated with worsening left eyelid ptosis, complete loss of depression, horizontal eye movements on the left, and loss of abduction on the right. Moreover, a 24-year woman in Morocco developed diplopia and strabismus of the left eye 3 days after the onset of COVID-19 symptoms [ 107 ]. She was diagnosed as having an acute painless third partial cranial nerve palsy.…”