key: cord-1005369-s3foqtmz
authors: Taouihar, S.; Bouabdallaoui, A.; Aabdi, M.; Kaouini, A.El; El aidouni, G.; Merbouh, M.; Zaid, I.; Bkiyar, H.; Housni, B.
title: Peripheral facial paralysis as the only symptom revealing sars cov 2 infection: Case report
date: 2021-07-08
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2021.102550
sha: 7dc59bac229fcbc95a5adc3015451400dcd51c1b
doc_id: 1005369
cord_uid: s3foqtmz

The SARS cov 2 infection was initially marked by its respiratory symptomatology. Nevertheless, other non-respiratory manifestations have been raised as atypical revealing symptoms, namely cardiac and neurological attacks. Several neurological manifestations have been described during this pandemic. We describe in this case report the clinical, biological and radiological characteristics of two patients presenting to the emergency department with facial paralysis revealing a Sars cov 2 viral infections after investigation.

The SARS cov 2 infection was initially marked by its respiratory symptomatology. Nevertheless, other non-respiratory manifestations have been raised as atypical revealing symptoms, namely cardiac and neurological attacks.

Several neurological manifestations have been described during this pandemic.

We describe in this case report the clinical, biological and radiological characteristics of two patients presenting to the emergency department with facial paralysis revealing a Sars cov 2 viral infections after investigation. The most frequent revealing symptoms are fever, cough, asthenia, headache, and myalgia, with a revealing respiratory picture in the majority of the cases, however other atypical symptoms can occur and be the only picture revealing the infection to sars cov 2 as the cardiac and neurological attack(1,2).

We report in this paper the case of a young patient presenting to the emergency room for facial paralysis whose diagnostic investigation revealed a sars cov 2 infection.

First case report:

A 39-year-old male patient with a medical history of diabetes and chronic myeloid leukemia treated with chemotherapy presented to the emergency room with facial asymmetry, slurred speech, and difficulty chewing without any other signs.

The initial clinical examination was as follow: the temperature was 36.9 °C, blood pressure at 130/70mmhg, heart rate at 130 beats /min, breath rate at 25 breaths/min with pulsed oximetry at 85% on room air, The neurological examination: Glasgow coma scale at 15/15, and a right peripheral facial paralysis, the Ear Nose Throat examination (ENT) showed no abnormalities.

Given the epidemiological context A polymerase chain reaction (PCR) for sars cov2 was carried out coming back positive and a thoracic scanner was carried out coming back in favor of a pneumopathy with sars cov 2 with lung damage between 50-75%. The diagnosis of peripheral facial paralysis secondary to an infectious origin probably related to sars cov 2 was retained.

SARS cov2 protocol was initiated and the patient was put under azithromycin 500mg the first day then 250mg per day for 5 days, zinc 90mg per day, vitamin C 2g/12h, dexamethasone 6mg/day, preventive anticoagulation 6000ui/day.

The evolution was favorable on both clinical and biological level improvement, with a significant disappearance of the facial paralysis after 3 weeks and he was discharged J o u r n a l P r e -p r o o f 30 days after admission with a pulsed O2 saturation at 92% on ambient air. 

A 57-year-old male patient with a medical history of diabetes treated by insulin and hypertension treated with a calcium channel blocker presented to the emergency room with facial paralysis and swallowing disorder.

The initial clinical examination was as follow: the temperature was 37.2 °C, blood pressure at 140/80mmhg, heart rate at 90 beats /min, breath rate at 20 breaths/min with pulsed oximetry at 89% on room air, The neurological examination: Glasgow coma scale at 13/15, and a right peripheral facial paralysis, fall off the labial commissure with deviation to the left, dysarthria with no sensory-motor deficit.

the Ear Nose Throat examination (ENT) showed a fall of the labial commissure with a negative Charles bell sign without any other sign at the clinical examination(figure3) . A biological check-up showed at the complete blood count white blood cells at 11.070/µl, C-reactive protein at 70 mg/l, ferritin at 7960 µg/l, Procalcitonin at 0.40 ng/ml (normal <0.5),

The patient was admitted to the intensive care unit for therapeutic management, put on a nasal cannula with an improvement of 93 % saturation under 3l of oxygen.

Looking for another cause of facial paralysis, Serologies of the Herpes simplex virus (HSV) and Herpes zoster virus (HZV), HIV, TPHA (Treponema pallidum haemagglutination assay) were performed and came back negative.

An encephalic magnetic resonance imaging (MRI ) was performed coming back without any abnormalities. (Figure 5 )

The diagnosis of peripheral facial paralysis secondary to an infectious origin probably related to sars cov 2 was retained. Figure 5 : An encephalic magnetic resonance imaging without any abnormalities.

SARS cov2 protocol was initiated and the patient was put under azithromycin 500mg the first day then 250mg per day for 5 days, zinc 90mg per day, vitamin C 2g/12h, dexamethasone 6mg/day, and preventive anticoagulation .

The evolution was favorable and the patient was discharged after 10 days.

J o u r n a l P r e -p r o o f SARS-CoV 2 infection primarily affects the respiratory system resulting in respiratory failure, but extrapulmonary involvement exists and has been described in the literature including cardiac and neurological involvement (1,2).

Entry of SARS-CoV into human host cells is primarily mediated by a cellular receptor, angiotensin-converting enzyme 2 (ACE2), which is expressed in human airway epithelia, lung parenchyma, vascular endothelia, kidney cells, and small intestine cells.

( Experimental studies using transgenic mice have further revealed that SARS-CoV 34 or MERS-COV 13, when administered intranasally, can enter the brain, possibly via the olfactory nerves, and then rapidly spread to specific areas of the brain, including the thalamus and brainstem. (4) A study by Mao et al. found that 88% of patients with sars cov 2 showed neurological signs. (5) In a review of the literature, a few cases of facial paralysis secondary to SARS-CoV infection were reported. (6) (7) (8) In a prospective study conducted by Y.islamglu, 24.3% of patients with facial paralysis had a SARS cov2 positive serology (igg and IgM positive) (8) In addition, several causes can lead to facial paralysis, namely infectious causes that represent 6.5% (9) of causes such as herpes zoster virus and Lyme disease, which were ruled out in the absence of skin and ear lesions, and in the absence of antecedent tick bites in our case. (9) HIV has been ruled out in the face of negative serology. Tumor causes that represent 3.1% (9) was ruled out by the normal clinical and radiological examination (MRI. (9) 

Middle East respiratory syndrome coronavirus causes multiple organ damage and lethal disease in mice transgenic for human dipeptidyl peptidase 4

Neurological Manifestations of Hospitalized Patients with COVID-19 in Wuhan, China: a retrospective case series study

Peripheral facial paralysis as presenting symptom of COVID-19 in a pregnant woman FigueiredoR

2& Marcus Tulius T. Silva1,3 &Cristiane N. Soares4 & Renan Coutinho2 & Henrique S.Oliveira5 & Livia Afonso2 &Otávio Espíndola1 & Ana Claudia Leite1 &Abelardo Araujo. Peripheral facial nerve palsy associated with COVID-19

Facial paralysis as the only symptom of COVID-19: A prospective study YuceIslamoglua

Paralysie faciale : diagnostic et prise en charge

CARE guidelines for case reports: explanation and elaboration documentJ

Written informed consent was obtained from the patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Taouihar Salma; Bouabdallaoui Amine.

The authors state that they have no conflicts of interest for this report.

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