Facial weakness in a patient with a positive test for SARS-CoV-2.
A 44-year-old Hispanic male presented to the emergency department with complaints of bilateral facial weakness and loss of taste. The patient reported left teary eye for three days before facial weakness began. The day he developed left-sided facial weakness, his symptoms worsened and he also developed right-sided facial weakness. By then he was also unable to raise eyebrows, smile, or shut his eyes. He had lost taste sensations too.
The patient had a history of hypertension and asthma. His usual medications included amlodipine and albuterol inhaler.
He had no complaints of cough, shortness of breath, headache, dizziness, gastrointestinal symptoms, fatigue, confusion, numbness, dysphagia, visual disturbances, and weakness of the extremities.
There was no history of travel, alcohol or substance abuse, trauma, or smoking.
Physical examination:
On physical examination, patient was well, alert, and of normal built and height. He was afebrile, with a heart rate of 94 beats per min, blood pressure of 136/94 mmHg, and respiratory rate of 18 breaths per min. His oxygen saturation on room air was 98%. Auscultation of the lung revealed bronchial breathing sounds bilaterally.
The rest of the cardiovascular and gastrointestinal examinations were normal. However, neurological examination revealed normal GCS score, normal motor and sensory examination. The cranial nerve examination was also normal. However, complete lower motor neuron facial weakness was observed. Therefore, the patient was unable to raise his eyebrows, frown, close his eyes, smile, or pucker his lips. Nasolabial folds were flat bilaterally and bilateral orbicularis oris, orbicularis oculi, buccinators, and frontalis were also involved. The findings suggested lower motor neuron facial weakness. The doctors graded the weakness as grade V severe dysfunction, with bare minimum perceptible motion, mouth deviation, asymmetry with no motion of the forehead, and incomplete eye closure. However, corneal reflex was intact and the patient had no complaints of hyperacusis.
Brudzinski’s and Kernig’s signs were negative.
Examination of the external ear was normal. Parotid gland was not enlarged. However, bilateral pedal edema was present on the extremities.
Investigations for evaluating the cause of facial weakness:
Serological investigations showed a normal metabolic panel, complete blood count, D-dimer, serum ferritin, lactate dehydrogenase, and C-reactive protein levels. Plain radiograph of the chest was also normal and so was the computed tomography scan of the head.
Since, the patient complained of loss of taste sensation and the COVID-19 pandemic wasn’t over yet, the doctors decided to perform a nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR) test for SARS-CoV-2. The patient tested positive for COVID-19.
The doctors performed a bedside lumbar puncture. The cerebrospinal fluid (CSF) showed high protein levels (92 mg/dL), normal glucose levels, no leukocytes, and a negative Gram stain. However, the CSF RT-PCR test for SARS-CoV-2 was negative. Moreover, CSF tested negative for other viruses too. Conversely, CSF analysis showed albuminocytologic dissociation. The latter finding suggested a diagnosis of Guillain-Barré syndrome (GBS).
Magnetic resonance imaging (MRI) of the brain and the cervical spine was also normal.
Management:
Since the clinical manifestations and the CSF analysis were consistent with the diagnosis of GBS, the doctors started him on intravenous immunoglobulin (IVIG).
The patient showed considerable improvement by the 4th dose, he was able to frown, smile, clench, close his right eye partially, however, the left eye didn’t improve.
By the 10th day of hospitalisation, he could close both his eyes. Since he had improved substantially, the doctors discharged him on the 12th day of hospital stay. However, the doctors advised him to follow-up in the neurology clinic.
References:
Khaja M, Gomez GPR, Santana Y, et al. A 44-Year-Old Hispanic Man with Loss of Taste and Bilateral Facial Weakness Diagnosed with Guillain-Barré Syndrome and Bell’s Palsy Associated with SARS-CoV-2 Infection Treated with Intravenous Immunoglobulin. Am J Case Rep. 2020;21:e927956. Published 2020 Oct 31. doi:10.12659/AJCR.927956
