key: cord-0972226-bdnmyxz4
authors: Novak, Peter
title: Post COVID-19 syndrome associated with orthostatic cerebral hypoperfusion syndrome, small fiber neuropathy and benefit of immunotherapy: a case report
date: 2020-09-20
journal: eNeurologicalSci
DOI: 10.1016/j.ensci.2020.100276
sha: ca889e02666c57d83a0e591144b8a903753b5c5c
doc_id: 972226
cord_uid: bdnmyxz4

Coronavirus disease (COVID-19) is a novel highly contagious infectious disease caused by the coronavirus SARS-CoV2. The virus affects the human respiratory and other systems, and presents mostly as acute respiratory syndrome with fever, fatigue, dry cough, myalgia and dyspnea. The clinical manifestations vary from no symptoms to multiple organ failure. Majority of patients fully recover. Several postinfectious presumably autoimmune complications of COVID-19 affecting the brain or peripheral large nerve fibers have been reported. This report describes a post COVID-19 patient who developed chronic fatigue, orthostatic dizziness and brain fog consistent with orthostatic hypoperfusion syndrome (OCHOS), a form of orthostatic intolerance, and painful small fiber neuropathy (SFN). Initially, the patient was diagnosed with. OCHOS (detected by the tilt test with transcranial Doppler monitoring) and SFN (confirmed by skin biopsy), and both OCHOS/SFN were attributed to Post Treatment Lyme Disease Syndrome of presumed autoimmune etiology. Patient recovered on symptomatic therapy. COVID-19 triggered exacerbation of OCHOS/SFN responded to immunotherapy with intravenous immunoglobulins. This case suggests that post COVID-19 syndrome may present as an autoimmune OCHOS/SFN and that early immunotherapy may be effective. Further studies are necessary to confirm the link between OCHOS/SFN and COVID-19 disease as well as to confirm the benefit of immunotherapy.

Coronavirus disease (COVID-19) is a novel highly contagious infectious disease caused by the coronavirus SARS-CoV2 1 . The virus affects the human respiratory and other systems and presents mostly as acute respiratory syndrome with fever, fatigue, dry cough, myalgia and dyspnea. The clinical manifestations vary from no symptoms to multiple organ failure. Majority of patients fully recover. The virus can invade central and peripheral nervous system 2 and cause acute neurological complications. Several postinfectious presumably autoimmune complications of COVID-19 affecting the brain or peripheral large nerve fibers have been reported 3 . This report describes a post COVID-19 patient who developed symptoms (chronic fatigue, orthostatic dizziness and brain fog) consistent with orthostatic hypoperfusion syndrome (OCHOS) 4 , a form of orthostatic intolerance; and painful small fiber neuropathy (SFN) with good response to immunotherapy.

A 64-year-old woman presented with a cough and dyspnea. She has a past medical history of headaches hypothyroidism (euthyroid on liothyronine), Lyme disease, SFN and OCHOS. Four years ago she experienced a tick bite with Bull's eye rash, arthralgia and swollen lymph nodes.

She was treated with oral doxycylin for 3 weeks. Three months later she experienced headaches, several pain syndromes, disabling fatigue, brain fog and mood lability. Her neurological evaluation including magnetic resonance imaging of the brain was unrevealing. She was treated In summary, this case describes a probable OCHOS and SFN in post-COVID disease. This reports provides an additional evidence that COVID-19 disease can trigger autoimmunity which is consistent with previous reports of several autoimmune neurological diseases including GBS in post-COVID disease, although exact mechanism how the coronavirus is triggering

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