key: cord-0832044-jll0zury
authors: Cunha, Paulina; Herlin, Bastien; Vassilev, Kosta; Kas, Aurelie; Lehericy, Stephane; Worbe, Yulia; Apartis, Emmanuelle; Vidailhet, Marie; Dupont, Sophie
title: Movement disorders as a new neurological clinical picture in severe SARS‐CoV‐2 infection
date: 2020-08-12
journal: Eur J Neurol
DOI: 10.1111/ene.14474
sha: e39150ceefb444051870c1401ae7c0d15c52be86
doc_id: 832044
cord_uid: jll0zury

New forms of neurological complications of severe SARS‐CoV‐2 infection have been described, mainly including encephalopathy, agitation and confusion.(1) Only one publication reveals the emergence of de novo myoclonus in three patients,(2) with most publications reporting the aggravation of pre‐existing abnormal movements disorders. Here, we identified and characterized in depth clinically a new type of delayed onset movement disorders in five patients who were admitted to the AP‐HP intensive care unit (ICU) units for severe SARS‐CoV‐2 infection. All patients underwent intubation and mechanical ventilation.

This article is protected by copyright. All rights reserved New forms of neurological complications of severe SARS-CoV-2 infection have been described, mainly including encephalopathy, agitation and confusion. 1 Only one publication reveals the emergence of de novo myoclonus in three patients, 2 with most publications reporting the aggravation of pre-existing abnormal movements disorders. Here, we identified and characterized in depth clinically a new type of delayed onset movement disorders in five patients who were admitted to the AP-HP intensive care unit (ICU) units for severe SARS-CoV-2 infection. All patients underwent intubation and mechanical ventilation.

Abnormal movements developed 23 ± 7 days (mean + SD) after ICU discharge. Upper limbs postural and action-tremor was observed in 4 patients, one of them (patient 2) had also irregular orthostatic tremor and one patient (patient 4) had bilateral upper limbs jerky/myoclonic abnormal movements at rest and during posture and action (Table 1) . Associated signs included a moderate proximal motor deficit attributed to a critical illness myopathy in 4 patients and a mild hemiparesis attributed to a critical illness neuropathy confirmed by electroneuromyography in one patient.

Electrophysiological exploration of the movement disorders was performed in patients 2 and 4 and recorded myoclonic jerks of short duration (40 -60 ms) that were synchronous among the EMG, associated with post-myoclonic inhibition period in one patient and with jerks of longer duration (50 -100 ms) and increased long loop C-reflex with latency of 50 ms recorded from tenar muscles in the second. Overall, the recordings supported a mixed cortical-subcortical pattern of myoclonic jerks (see figure1). For the first hypothesis, SARS-CoV-2 is known to enter the brain 5 where it can bind to the enzyme, angiotensin-converting enzyme 2 and cause neuronal death. In line with that, we

This article is protected by copyright. All rights reserved observed MRI abnormalities such as alterations of nigrosomes (substantia nigra) and frontotemporal hypo-perfusion on MRI perfusion sequence that could be directly or indirectly related to SARS-CoV-2. 4 The delayed-onset (3 weeks after ICU discharge) of these movement disorders can also be in favor of SARS-COV-2 related immune implication. Alternatively, cortical and subcortical myoclonus may be related to post-infectious myoclonus, although this hypothesis is less likely in the absence of opsoclonus or ataxia. Finally, electrophysiological exploration documented cortical (abnormal long loop C-reflex) and sub-cortical (long duration bursts) myoclonus. We cannot thus exclude a combination with chronic post-hypoxic myoclonus with action and intention myoclonus of sub-cortical and cortical origin with possible additional metabolic origin in patient 4 with renal failure syndrome.

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Neurologic Features in Severe SARS-CoV-2 Infection

Generalized myoclonus in COVID 19

Critical Illness-Associated Cerebral Microbleeds

Myoclonus in the critically ill: Diagnosis, management, and clinical impact

Post-hypoxic Myoclonus: Current Concepts

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