key: cord-0689499-qj2t6m2l authors: Derollez, Céline; Alberto, Tifanie; Leroi, Iracema; Mackowiak, Marie‐Anne; Chen, Yaohua title: Facial nerve palsy: an atypical clinical manifestation of COVID‐19 infection in a family cluster date: 2020-08-27 journal: Eur J Neurol DOI: 10.1111/ene.14493 sha: 267e298f2ea90a9199218bf2585f8a7c6c2b2970 doc_id: 689499 cord_uid: qj2t6m2l Typical clinical manifestations related to COVID‐19 include fever, fatigue and respiratory syndrome. However, an increasing number of reports of neurological manifestations emerged(1). We report the case of a 57‐year‐old woman referred early April 2020 to the neurology inpatient ward because of acute left‐side facial nerve palsy noticed upon awakening. Typical clinical manifestations related to COVID-19 include fever, fatigue and respiratory syndrome. However, an increasing number of reports of neurological manifestations emerged 1 . We report the case of a 57-year-old woman referred early April 2020 to the neurology inpatient ward because of acute left-side facial nerve palsy noticed upon awakening. Our patient's medical history was unremarkable besides being overweight (body mass index: 27.7 kg/m 2 ). Neurological exam revealed left weakness of the upper and the lower face and Bell's phenomenon. She had no hyperacusis, no vesicles in the outer ear and no parotid swelling. Corneal reflex was present. The rest of the neurological examination was normal (motor, sensory, other cranial nerves, osteo-tendinous reflexes). The remainder of her physical examination was unremarkable. A detailed medical history revealed she had presented 7 days before with fatigue, muscular pain and moderate cough of three days' duration. She did not report fever but had chills. In the context of the pandemic, COVID-19 was immediately suspected as a possible diagnosis; this was confirmed by naso-pharyngeal and tracheal real-time reverse-transcription-polymerase-chainreaction (RT-PCR) assays. Chest radiography showed infiltrates. Using appropriate protective measures, further investigations were undertaken. Results are outlined in Table 1 . The PCR of SARS-Cov2 was negative in cerebrospinal fluid (CSF). She received the usual symptomatic treatment of facial nerve palsy (e.g. ocular protection), although oral corticosteroids were omitted due to the COVID-19 infection. She was subsequently transferred to a dedicated COVID-19 unit for further observation. On the third day of hospitalization, she developed hypoxemia and required 24-hour oxygen support. One month later, she completely recovered from both neurologic and respiratory conditions. It was notable that our patient had been visiting her mother regularly two weeks prior to the onset of her symptoms. Her 84-year-old mother had been admitted to the geriatric COVID-19 unit one week earlier due to intractable diarrhea and deconditioning (See time-line in Figure 1 ). She was frail and had a long list of comorbidities, such as mild cognitive impairment, chronic skin sores, obesity, falls, arthritis and depression. Prior to the hospitalization, her mother had remained in a rehabilitation center for two months, until discharge following a negative swab for SARS-Cov2 that she had due to a systematic screening. The diagnosis of COVID-19 was finally confirmed in Accepted Article the geriatric unit with her mother by naso-pharyngeal and feces RT-PCR assays. Our case-report supports isolated cranial nerve deficit, especially facial nerve palsy, as a possible neurological manifestation due to COVID-19 infection. Facial nerve palsy is known to be associated with various viral infectious agents, including herpes simplex, varicella zoster, and human immunodeficiency viruses. Additionally, coronavirus-related neurotropism has been reported 2 . In the case of COVID-19, putative mechanisms of the broad range of neurological manifestations are still unclear 3 . As with our patient, in these cases, CSF analyses were negative or under the threshold of detection using the RT-PCR assay, thus arguing against direct viral toxicity. It is worth noting that even in cases of meningitis or encephalitis, PCR for SARS-Cov2 in CSF were nearly always negative 4 . As immune-mediated mechanisms are involved in several systemic injuries due to COVID-19, it is possible that such mechanism account for cranial nerves deficits as well. The delay about 7-10 days before the onset of neurological symptoms, which seems to be typical, supports this hypothesis 2 . Cranial nerve involvement has been described in the context of Guillain Barré syndrome 5 and its variants [6] [7] [8] . Descriptions of isolated cranial nerve involvement in the context of COVID-19 are scarce 9 . Moreover, typical respiratory manifestations of COVID-19 were also absent in our patient's mother, as is often observed in frail older people 10 . This suggests that due to the high contagiousness and ongoing global pandemic caused by COVID-19, careful physical examinations and medical histories should be performed in order to avoid diagnostic delays and further transmission of the virus. Still, physicians will need to have a high index of suspicion for COVID. In particular, clinicians should be aware of atypical presentations among frail and older people. Preventive measures during medical investigations and social isolation of relatives and contactcases are key strategies to arrest the spread of the pandemic. Furthermore, since many unanswered questions about the exact mechanisms underlying neurological manifestations due to COVID-19 remain; more reports of cases, and case definitions are needed to further our understanding 11,12 . Accepted Article Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease COVID-19, SARS and MERS: A neurological perspective A systematic review of neurological manifestations of SARS-CoV-2 infection: the devil is hidden in the details Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. The lancet Psychiatry SARS-CoV-2 and Guillain-Barré syndrome: AIDP variant with favorable outcome Miller Fisher Syndrome and polyneuritis cranialis in COVID-19 Facial diplegia, a possible atypical variant of Guillain-Barré Syndrome as a rare neurological complication of SARS-CoV-2 COVID-19 and herpes zoster co-infection presenting with trigeminal neuropathy Pearls and Oy-sters: Facial nerve palsy as a neurological manifestation of Covid-19 infection Clinical Presentation of COVID19 in Dementia Patients The neurology of COVID-19 revisited: A proposal from the Environmental Neurology Specialty Group of the World Federation of Neurology to implement international neurological registries COVID-19 -neurologists stay aware! This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved