key: cord-0694097-6c8dzcjf
authors: Dijkstra, Femke; Van den Bossche, Tobi; Willekens, Barbara; Cras, Patrick; Crosiers, David
title: Myoclonus and cerebellar ataxia following Coronavirus Disease 2019 (COVID‐19)
date: 2020-08-07
journal: Mov Disord Clin Pract
DOI: 10.1002/mdc3.13049
sha: a0c70f525d1c41b26fb0eddb0d9c9fac838640e3
doc_id: 694097
cord_uid: 6c8dzcjf

The Coronavirus disease 2019 (COVID‐19) outbreak has led to a pandemic with an overwhelming impact on daily living and the health care system. Major life‐threatening complications may occur [1]. Although most patients suffer from respiratory symptoms, different neurological symptoms have been described, either directly or indirectly caused by COVID‐19 [2]. Within the movement disorder spectrum, myoclonus has been observed as a COVID‐19‐related feature in several patients [3‐5].

The Coronavirus disease 2019 (COVID-19) outbreak has led to a pandemic with an overwhelming impact on daily living and the health care system. Major life-threatening complications may occur [1] . Although most patients suffer from respiratory symptoms, different neurological symptoms have been described, either directly or indirectly caused by COVID-19 [2] . Within the movement disorder spectrum, myoclonus has been observed as a COVID-19-related feature in several patients [3] [4] [5] .

We report a patient with severe myoclonic jerks, cerebellar ataxia, and mild neurocognitive symptoms, following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

infection. This 44-year old Caucasian male without relevant medical history or medication use presented with a new-onset tremulous body sensation, slurred speech and unsteady gait. The clinical nadir of the neurological syndrome was reached three days after onset, followed by a plateau phase lasting four days. At day seven, corticosteroid therapy (methylprednisolone 1 gram IV daily during 5 days) was instituted. Slow but clear recuperation was noted. Due to remaining debilitating signs (gait ataxia and neurocognitive symptoms), additional intravenous immunoglobulin infusion (0.4 gram/kilogram) was administered during three days, starting at day fifteen. Further improvement was observed, though with remaining non-disabling signs (mild ataxia and concentration problems) for which outpatient rehabilitation was started, with full recovery within 2 months.

This case provides further evidence of a COVID-19-associated myoclonic syndrome, characterized by a generalized stimulus-sensitive and action myoclonus. The subacute onset after SARS-CoV-2 infection, in addition with the characteristic symptomatology and clear positive response to immunotherapy are, similar to the previously reported cases [3] [4] [5] , pointing towards a post-infectious auto-immune encephalitis. Besides the myoclonus, our patient presented prominent limb ataxia, stuttering speech and neuropsychiatric symptoms, which is most frequently described in the context of the opsoclonus-myoclonus-ataxia syndrome (OMA) [6] . Although the patient showed mild oculomotor abnormalities, he never developed an opsoclonus and neither did the previously reported COVID-19 cases [2] [3] [4] [5] .

However, since the overall majority of his symptoms and disease course are very typical for OMA, our case might have developed an OMA-like syndrome, that occurs as a myoclonus/ataxia dominant variant without opsoclonus.

The etiology of OMA is in the majority of cases either para-infectious or paraneoplastic, highlighting the relevance of a neoplastic workup, especially in children [6] . The parainfectious variant of OMA is usually responsive to immunotherapy although symptoms may last for several months. We started, in line with the current literature, treatment with corticosteroids with a modest effect, followed by immunoglobulin infusion, with a good

WHO Declares COVID-19 a Pandemic

Neurological associations of COVID-19

Postinfectious brainstem encephalitis associated with SARS-CoV-2

Delirium in COVID-19: A case series and exploration of potential mechanisms for central nervous system involvement

Generalized myoclonus in COVID-19. Neurology 2020, online ahead of print

Update on opsoclonus-myoclonus syndrome in adults