Pearls & Oy-sters: Facial nerve palsy in COVID-19 infection

Abstract

Coronavirus disease 2019 (COVID-19) has been associated with various neurologic manifestations, including anosmia, acute ischemic stroke, Guillain-Barré syndrome, and encephalopathy.c During the COVID-19 pandemic, physicians seeing patients with these neurologic manifestations should consider COVID-19 as a differential diagnosis to prevent diagnostic delays and further transmission of disease.c Cranial nerve involvement could potentially be associated with COVID-19. Oy-sters cWhen a patient presents with isolated facial nerve palsy, a careful neurologic examination is required to rule out concomitant cranial nerve involvement (such as trigeminal nerve or vestibulocochlear nerve palsies) that would suggest alternative localization sites.c Facial nerve palsy is commonly due to, or associated with, a viral infection and should not be assumed to be idiopathic.c Investigations such as CSF analysis and MRI can be helpful in evaluating for CNS infection, inflammation, and other secondary causes.In early March 2020, a previously healthy 27-year-old man was admitted directly to the isolation ward of a tertiary health care center in Singapore with symptoms of myalgia, cough, and fever for 4 days.His symptoms started the day after he returned from Spain.He also complained of a new left-sided throbbing headache with no associated photophobia or neck stiffness.On examination, he had mild bilateral conjunctival injection and respiratory examination was unremarkable.He did not have any focal neurologic deficits.Chest radiography did not show any infiltrates and a nasopharyngeal swab returned positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on real-time reverse transcription PCR (RT-PCR) assay.On the third day of hospitalization (day 6 of illness), the patient developed left facial weakness, which was preceded by left retro-auricular pain and dysgeusia.Neurologic examination revealed involvement of the left frontalis, orbicularis oculi, buccinator, and orbicularis oris, consistent with a left lower motor neuron type facial nerve palsy.Corneal reflex was present, and there was no hyperacusis.The rest of the neurologic examination was unremarkable and his reflexes were normal.Kernig and Brudzinski signs were negative.There were no associated vesicles in the outer ear nor was there any parotid swelling.HIV screen was negative.CSF analysis did not show any pleocytosis, and glucose and protein levels were normal.CSF PCR for herpes simplex virus (HSV), varicella-zoster virus (VZV), Epstein-Barr virus, and cytomegalovirus and RT-PCR for SARS-CoV-2 were negative.MRI of the brain showed enhancement of the left facial nerve (figure, A).He was started on prednisone and valacyclovir for treatment of Bell palsy.