Movement Disorders in COVID-19: Whither Art Thou?

New-Onset Movement Disorders in COVID-19: Much Ado about Nothing?

This is an editorial commenting on the paper by Brandão and colleagues [Brandão PRP, Grippe TC, Pereira DA, Munhoz RP, Cardoso F. New-Onset Movement Disorders Associated with COVID-19. Tremor and Other Hyperkinetic Movements. 2021; 11(1): 26. DOI: http://doi.org/10.5334/tohm.595]

New-Onset Movement Disorders Associated with COVID-19

Introduction

Movement disorders are increasingly described in hospitalized and milder cases of SARS-CoV-2 infection, despite a very low prevalence compared to the total patients.

Methods

We reviewed the scientific literature published in English, spanning from the initial descriptions of COVID-19 until January 25, 2021, in the PubMed/MEDLINE database.

Results

We identified 93 new-onset movement disorders cases (44 articles) from 200 papers screened in the database or reference lists. Myoclonus was present in 63.4% (n = 59), ataxia in 38.7% (n = 36), action/postural tremor in 10.8% (n = 10), rigid-akinetic syndrome in 5.38% (n = 5), oculomotor abnormalities in 20.4% (n = 19), catatonia in 2.1% (n = 2), dystonia in 1.1% (n = 1), chorea in 1.1% (n = 1), functional (psychogenic) movement disorders in 3.2% (n = 3) of the reported COVID-19 cases with any movement disorder. Encephalopathy was a common association (n = 37, 39.78%).

Discussion

Comprehensive neurophysiological, clinical, and neuroimaging descriptions of movement disorders in the setting of SARS-CoV-2 infection are still lacking, and their pathophysiology may be related to inflammatory, postinfectious, or even indirect mechanisms not specific to SARS-CoV-2, such as ischemic-hypoxic brain insults, drug effects, sepsis, kidney failure. Cortical/subcortical myoclonus, which the cited secondary mechanisms can largely cause, seems to be the most common hyperkinetic abnormal movement, and it might occur in association with encephalopathy and ataxia.

Conclusion

This brief review contributes to the clinical description of SARS-CoV-2 potential neurological manifestations, assisting clinical neurologists in identifying features of these uncommon syndromes as a part of COVID-19 symptomatology.

Highlights

- Movement disorders are probably uncommon neurological manifestations in SARS-CoV-2 infection;- Myoclonus is the most reported movement disorder associated with COVID-19, its clinical complications or pharmacological management;- The pathophysiology is yet not well-understood but can include systemic inflammation, autoimmune mechanisms, or hypoxia.

De Novo Movement Disorders and COVID-19: Exploring the Interface

Background

Neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are being widely documented. However, movement disorders in the setting of 2019 coronavirus infectious disease (COVID-19) have been a strikingly less discussed topic.

Objectives

To summarize available pieces of evidence documenting de novo movement disorders in COVID-19.

Methods

We used the existing PRISMA consensus statement. Data were collected from PubMed, EMBASE, Web of Science, and Scopus databases up to the 29th January, 2021, using pre-specified searching strategies.

Results

Twenty-two articles were selected for the qualitative synthesis. Among these, a total of 52 patients with de novo movement disorders were reported. Most of these had myoclonus, ataxia, tremor or a combination of these, while three had parkinsonism and one a functional disorder. In general, they were managed successfully by intravenous immunoglobulin or steroids. Some cases, primarily with myoclonus, could be ascribed to medication exposures, metabolic disturbances or severe hypoxia, meanwhile others to a post-or para-infectious immune-mediated mechanism. SARS-CoV-2 could also invade the central nervous system, through vascular or retrograde axonal pathways, and cause movement disorders by two primary mechanisms. Firstly, through the downregulation of angiotensin-converting enzyme 2 receptors, resulting in the imbalance of dopamine and norepinephrine; and secondly, the virus could cause cellular vacuolation, demyelination and gliosis, leading to encephalitis and associated movement disorders.

Conclusion

De novo movement disorders are scantly reported in COVID-19. The links between SARS-CoV-2 and movement disorders are not yet established. However, we should closely monitor COVID-19 survivors for the possibility of post-COVID movement disorders.

Myoclonus and Cerebellar Ataxia Associated with SARS-CoV-2 Infection: Case Report and Review of the Literature

The current SARS-CoV-2/COVID-19 pandemic has led to a global health crisis. The clinical spectrum of SARS-CoV-2 infection ranges from asymptomatic infection to critical illness affecting almost every organ including the central and peripheral nervous systems. Myoclonus, a less expected and relatively unusual neurological complication, together with ataxia, has lately been associated with SARS-CoV-2 infection. We describe the case of a 67-year-old male patient, admitted to our hospital for interstitial bilateral pneumonia due to SARS-CoV-2 infection, who progressively developed general myoclonus and later cerebellar ataxia and gait disturbance. Given the timeline from COVID-19 systemic symptoms to neurological manifestations and the normal results of extensive and non-conclusive diagnostic work-up (blood test, lumbar puncture, EEG, cerebral MRI), a para-infectious encephalopathy related to SARS-CoV-2 was contemplated and a high dose of methylprednisolone was started with prompt symptom improvement. Further investigation and neuroepidemiological studies are needed to help define the mechanism of neuroinvasion and the entire spectrum of neurological manifestations of SARS-CoV-2 infection, even in mildly affected patients, in terms of prevention, treatment and possible neurological sequelae.

LEARNING POINTS

SARS-CoV-2 infection can be related to neurological symptoms and sequelae.Myoclonus, specifically when associated with ataxia, might represent the expression of COVID-19-related encephalopathy.Myoclonus associated with SARS-CoV-2 infection mostly responds to treatment with steroids.