key: cord-1053493-q8b3rg6w authors: Chattopadhyay, Sidhartha; Sengupta, Judhajit; Basu, Sagar title: Post‐infectious cerebellar ataxia following COVID‐19 in a patient with epilepsy date: 2022-05-02 journal: Clin Exp Neuroimmunol DOI: 10.1111/cen3.12700 sha: b6354935e4e695dee4b39e0bf4cbd98130c525d6 doc_id: 1053493 cord_uid: q8b3rg6w BACKGROUND: Various neurological manifestations have been described in relation to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and coronavirus disease 2019 (COVID‐19). However, the development of cerebellar ataxia after recovery from COVID‐19 is rare. We present a case of cerebellar ataxia 3 weeks after recovery from COVID‐19. CASE PRESENTATION: A 70‐year‐old male patient from an urban area of India presented with ataxia. He was hypertensive and had been receiving treatment for post‐traumatic epilepsy for the previous 3 years. He had previously had laboratory‐confirmed COVID‐19 infection with mild symptoms that resolved within 2 weeks. However, 3 weeks after symptom improvement, he developed severe pan‐cerebellar ataxia. Investigations were suggestive of post‐infectious cerebellar ataxia. Other causes of ataxia were excluded. He responded well to pulse methylprednisolone therapy and was discharged with mild tremor and ataxia. CONCLUSION: Post‐infectious cerebellar ataxia is an unusual presentation after COVID‐19. The clinician should be aware of such complications following COVID‐19 infection as early diagnosis and proper management leads to better outcomes in many patients. Guillain-Barré syndrome, and others during COVID-19 infection have been recorded. 2 But ataxia as a post-COVID-19 manifestation has rarely been described (<1% of patients). 3 These include acute cerebellar ataxia, ataxia due to Miller Fisher syndrome, opsoclonus myoclonus ataxia syndrome, and ataxia associated with encephalopathy as described in the literature. 4 We describe a very unusual case of a 70-year-old man with known epilepsy who developed cerebellar ataxia 5 weeks after documented SARS-CoV-2 infection. A 70-year-old male patient with epilepsy and hypertension presented to our neurology clinic with sudden onset of severe imbalance leading to difficulty walking and maintaining a sitting posture with tremulousness of both hands for the previous 2 days. He had no history of alcoholism, gluten hypersensitivity, significant weight loss, substance abuse, nausea, vomiting, dizziness, tinnitus, visual disturbance, headache, altered sensorium, convulsion, paresis, or sphincteric involve- He was also given antiplatelets (clopidogrel 75 mg) and statins (atorvastatin 10 mg) in addition to his regular anticonvulsant and antihypertensive medications as the brain MRI with contrast revealed evidence of cerebral small vessel disease. His walking and speech improved significantly on the 7th day. At discharge on the 10th day, he was experiencing mild tremors and ataxia. The neurological manifestation of COVID-19 is probably due to the invasion of SARS-CoV-2 virus particles in the central nervous system (CNS) via a neuronal or hematogenous route. 1 It has also been hypothesized that SARS-CoV-2 virus can attach to the angiotensin-converting enzyme-2 receptor on neuron and glia and circulates in various parts of the CNS such as the hypothalamus, basal ganglia, midbrain, pons, medulla, and cerebellum. 5 The cerebellum is also believed to modulate seizure activity, but the concept of cerebellar epilepsy is controversial. Ataxia is a presenting manifestation of various epilepsies such as SCN1A, SCN2A, KCTD7, KCNJ10, and CACNA1A gene mutations and of various deficiency disorders and metabolically conditioned diseases (such as folic acid transport disorders, vitamin E deficiency, and glucose transporter 1 deficiency). 6 Ataxia may also be seen as a consequence of epilepsy, possibly due to cerebellar atrophy (but the pathogenesis not yet clear) or as an adverse effect of antiepileptic drugs such as phenytoin, carbamazepine, clobazam, clonazepam, and zonisamide, among others. Levetiracetam also caused ataxia in about 1.5% of patients in a randomized placebo-controlled study. 7 Our patient had epilepsy for 3 years, and it was well controlled with levetiracetam, so levetiracetaminduced ataxia was unlikely after so many years. Cerebellar ataxia is very uncommon and is not frequently seen after SARS-CoV-2 infection. This is a rare presentation of post-infective cerebellar ataxia due to COVID-19 infection, probably due to an immune-mediated mechanism. However, further research is needed for a better understanding of the pathophysiology. Clinicians should be aware of such complications of COVID-19 infection, which often respond to treatment. Not applicable. The authors have no conflicts of interest. Approval of the research protocol: Not Applicable; Informed consent: informed consent was obtained from the subject; Registry and the Registration No. of the study/trial: Not Applicable; Animal Studies: not Applicable. 2 CHATTOPADHYAY ET AL. The data that support the findings of this study are available from the corresponding author upon reasonable request. https://orcid.org/0000-0001-9697-7761 Neurologic manifestations of hospitalized patients with coronavirus disease Guillain-Barre syndrome during COVID-19 pandemic: an overview of the reports Subacute cerebellar ataxia following respiratory symptoms of COVID-19: a case report Myoclonus and cerebellar ataxia associated with COVID-19: a case report and systematic review Neuromechanisms of SARS-CoV-2: a review Cerebellar dysfunction and ataxia in patients with epilepsy: coincidence, consequence, or cause? Tremor Other Hyperkinet Mov (N Y) Drug-induced cerebellar ataxia: a systematic review Tremor and ataxia in COVID-19 Miller-fisher-like syndrome related to SARS-CoV-2 infection (COVID 19) Miller fisher syndrome diagnosis and treatment in a patient with SARS-CoV-2 Opsoclonus-myoclonus-ataxia syndrome related to the novel coronavirus (COVID-19) Myoclonus-ataxia syndrome associated with COVID-19 Post-infectious cerebellar ataxia following COVID-19 in a patient with epilepsy