Pearls & Oy-sters: Facial nerve palsy in COVID-19 infection

An integrated network pharmacology approach to discover therapeutic mechanisms of Commiphora wightii for the treatment of Bell's palsy

Bell's palsy (BP) can result in facial paralysis. Inflammation or injury to the cranial nerves that regulate the facial muscles is primarily responsible for that disease. Commiphora wightii remains recognized as a cure for a few human ailments. This study focused on therapeutic phenomena of C. wightii for the treatment of Bell's palsy, utilizing the network drug discovery and molecular docking techniques. Active biological constituents of C. wightii were retrieved from literature and independent databases. Potential therapeutic targets (431) of 13 bioactive phytochemicals were fetched via SwissTargetPrediction tool. Putative intersecting targets (855) of Bell's palsy were computed through the DisGeNET and GeneCards datasets. Subsequently, by the analysis of potential shared targets (87) of C. wightii and Bell's palsy, a Venn diagram was drawn. DAVID database was used to evaluate gene functional annotations and enriched pathways that are involved in Bell's palsy. STRING database was used for generating the protein-protein relationship complex. Visual presentations of the interactions of potential targets to active chemical constituents were done by the Cytoscape. Whereas, the conformational research sorted out 10 key targets through the protein-protein interactions network. Moreover, the capacity of therapeutic ingredients to interact with a target inhibiting Bell's palsy was confirmed by molecular docking, which might ratify the findings of network pharmacology. In the molecular complex of AKT1-cholesterol, a 100-ns simulation unveiled a graceful stability, with a minimal 0.167 Å ligand shift and resilient hydrogen bonds (ASN54 and SER205). The final 20 ns showcased a P1 motif pirouette, gracefully forming aromatic bonds with H165 and W186, underscoring the complex's dynamic finesse. This study evaluated compound-target interactions and their impact on disease-related genes. It revealed that five genes (AKT1, TNF, MAPK3, EGFR and SRC) of C. wightii might be useful therapeutic targets for the treatment of Bell's palsy, as well as helping in lowering down the blood pressure.Communicated by Ramaswamy H. Sarma.

Risk of Bell's palsy following SARS-CoV-2 infection: a nationwide cohort study

OBJECTIVES

Despite some evidence of an increased risk of neurologic symptoms following viral vector COVID-19 vaccine administration, it is unclear whether SARS-CoV-2 infection is associated with Bell's palsy (BP), especially over a long enough follow-up period.

METHODS

The study population of this nationwide population-based study was derived from the South Korean population, including 11 593 365 and 36 565 099 participants with and without COVID-19, respectively. The Fine and Gray's regression model was utilized to calculate the adjusted subdistribution hazard ratio (aSHR), considering death as a competing risk, to assess the association between SARS-CoV-2 infection and the risk of BP. All participants were followed up from 1 December 2021, until the incident BP, SARS-CoV-2 infection, death, or 31 March 2022. Subgroup analyses were conducted based on participants' vaccination status (completion of the primary series vs. unvaccinated).

RESULTS

COVID-19 was associated with an increased risk of BP in all participants (aSHR, 1.24; CI, 1.19-1.29). However, the size of the COVID-19-related BP risk was significantly lower among those who completed the primary series of the COVID-19 vaccine (aSHR, 1.20; 95% CI, 1.15-1.25) compared to those who were unvaccinated (aSHR, 1.84; 95% CI, 1.59-2.12; p for interaction: <0.001). The severity of COVID-19 exhibited a gradual escalation in BP risk for both vaccinated and unvaccinated individuals.

DISCUSSION

While both unvaccinated individuals and those who completed the primary series of the COVID-19 vaccine may be at an increased risk of developing BP due to COVID-19, the risk appears to be lower among those who completed the vaccination.

Simultaneous Sudden Hearing Loss and Peripheral Facial Paralysis in a Patient With Covid-19

Although peripheral facial paralysis and sudden sensorineural hearing loss are not as common as anosmia, they are reported neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We present a 62-year-old, serologically COVID-19 positive woman with seventh and eighth nerve involvement showed electrophysiologically with Auditory Brainstem Response and electroneurography and radiologically with internal acoustic canal magnetic resonance imaging. This single case report suggests a possible association between the SARS-CoV-2 infection with simultaneous sudden sensorineural hearing loss and isolated facial paralysis. However, further studies are needed to determine whether this relationship is coincidental or occasional.

Pathophysiology, diagnosis, and management of neuroinflammation in covid-19

Although neurological complications of SARS-CoV-2 infection are relatively rare, their potential long term morbidity and mortality have a significant impact, given the large numbers of infected patients. Covid-19 is now in the differential diagnosis of a number of common neurological syndromes including encephalopathy, encephalitis, acute demyelinating encephalomyelitis, stroke, and Guillain-Barré syndrome. Physicians should be aware of the pathophysiology underlying these presentations to diagnose and treat patients rapidly and appropriately. Although good evidence has been found for neurovirulence, the neuroinvasive and neurotropic potential of SARS-CoV-2 is limited. The pathophysiology of most complications is immune mediated and vascular, or both. A significant proportion of patients have developed long covid, which can include neuropsychiatric presentations. The mechanisms of long covid remain unclear. The longer term consequences of infection with covid-19 on the brain, particularly in terms of neurodegeneration, will only become apparent with time and long term follow-up.

Neurologic Complications of COVID-19

OBJECTIVE

This article describes the spectrum of neurologic complications occurring in acute or postacute infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as the neurologic risks and benefits of vaccination against SARS-CoV-2.

LATEST DEVELOPMENTS

Early in the COVID-19 pandemic, reports of neurologic complications of COVID-19 began to surface. A variety of neurologic conditions have since been reported in association with COVID-19. Understanding of the underlying mechanism of COVID-19 neurologic involvement continues to evolve; however, the evidence seems to suggest that aberrant inflammatory responses may play a role. In addition to neurologic symptoms in acute COVID-19, neurologic post-COVID-19 conditions are increasingly recognized. The development of COVID-19 vaccines has been essential in preventing the spread of COVID-19. With increasing numbers of vaccine doses administered, various neurologic adverse events have been reported.

ESSENTIAL POINTS

Neurologists must be aware of the potential acute, postacute, and vaccine-associated neurologic complications associated with COVID-19 and be poised to serve as integral members of multidisciplinary care teams for patients with COVID-19-related conditions.

Association of SARS-CoV-2 Vaccination or Infection With Bell Palsy: A Systematic Review and Meta-analysis

Importance

Bell palsy (BP) has been reported as an adverse event following the SARS-CoV-2 vaccination, but neither a causative relationship nor a higher prevalence than in the general population has been established.

Objective

To compare the incidence of BP in SARS-CoV-2 vaccine recipients vs unvaccinated individuals or placebo recipients.

Data Sources

A systematic search of MEDLINE (via PubMed), Web of Science, Scopus, Cochrane Library, and Google Scholar from the inception of the COVID-19 report (December 2019) to August 15, 2022.

Study Selection

Articles reporting BP incidence with SARS-CoV-2 vaccination were included.

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and was conducted with the random- and fixed-effect models using the Mantel-Haenszel method. The quality of the studies was evaluated by the Newcastle-Ottawa Scale.

Main Outcomes and Measures

The outcomes of interest were to compare BP incidence among (1) SARS-CoV-2 vaccine recipients, (2) nonrecipients in the placebo or unvaccinated cohorts, (3) different types of SARS-CoV-2 vaccines, and (4) SARS-CoV-2-infected vs SARS-CoV-2-vaccinated individuals.

Results

Fifty studies were included, of which 17 entered the quantitative synthesis. Pooling 4 phase 3 randomized clinical trials showed significantly higher BP in recipients of SARS-CoV-2 vaccines (77 525 vaccine recipients vs 66 682 placebo recipients; odds ratio [OR], 3.00; 95% CI, 1.10-8.18; I2 = 0%). There was, however, no significant increase in BP after administration of the messenger RNA SARS-CoV-2 vaccine in pooling 8 observational studies (13 518 026 doses vs 13 510 701 unvaccinated; OR, 0.70; 95% CI, 0.42-1.16; I2 = 94%). No significant difference was found in BP among 22 978 880 first-dose recipients of the Pfizer/BioNTech vaccine compared with 22 978 880 first-dose recipients of the Oxford/AstraZeneca vaccine (OR, 0.97; 95% CI, 0.82-1.15; I2 = 0%). Bell palsy was significantly more common after SARS-CoV-2 infection (n = 2 822 072) than after SARS-CoV-2 vaccinations (n = 37 912 410) (relative risk, 3.23; 95% CI, 1.57-6.62; I2 = 95%).

Conclusions and Relevance

This systematic review and meta-analysis suggests a higher incidence of BP among SARS-CoV-2-vaccinated vs placebo groups. The occurrence of BP did not differ significantly between recipients of the Pfizer/BioNTech vs Oxford/AstraZeneca vaccines. SARS-CoV-2 infection posed a significantly greater risk for BP than SARS-CoV-2 vaccination.

Acute Neurological Complications of Coronavirus Disease

The coronavirus disease (COVID-19) pandemic has impacted many lives globally. Neurologic manifestations have been observed among individuals at various stages and severity of the disease, the most common being stroke. Prompt identification of these neurologic diagnoses can affect patient management and prognosis. This article discusses the acute neuroradiological features typical of COVID-19, including cerebrovascular disease, intracerebral hemorrhage, leukoencephalopathy, and sensory neuropathies.

Cranial Nerve Impairment Associated With COVID-19 Infections: A Systematic Review

The COVID-19 pandemic has created huge economic and healthcare burdens. In most cases, the virus affects the lungs and causes respiratory symptoms. Additionally, its impact on the cranial nerves remains unclear. We thus aimed to investigate cranial nerve dysfunction in patients with COVID-19 infection.  We conducted a systematic literature search of relevant and eligible literature in five databases: PubMed, Web of Science, Medline, EBSCO, and Google Scholar.  Our sample included 21 case reports, one case series with 29 patients, and one analytical study with 135 cases. Participant ages ranged from 23 months to 72 years (mean age of 47.5 ± 19.02). The mean time from respiratory symptoms to the onset of neurological signs was (9.6 ± 7.4) days, and the mean recovery time was (16.3 ± 15.3) days.  Cranial nerve impairment associated with COVID-19 infection has affected a large population, from infants to the elderly. Facial and abducent nerves were the most commonly affected cranial nerves with reported good prognosis or complete recovery within a few days to weeks. Olfactory dysfunctions were widely detected among COVID-19 patients.

Facial palsy as a manifestation of COVID-19: A systematic review of cases

Background and Aims

Facial palsy is a rare complication of the COVID-19 infection. Herein, we conducted a systematic review of all published cases of facial palsy post-COVID-19 infection in an attempt to educate the general population and medical practitioners regarding the likely occurrence of facial palsy in COVID-19 patients, its detection, effective treatment plan, and prognosis of the condition.

Methods

We searched PubMed, Google Scholar, and Directory of Open Access Journals (DOAJ) from December 1, 2019 to September 21, 2021.

Results

We included 49 studies bearing accounts of 75 cases who had facial palsy. The mean age of patients was 42.9 ± 19.59 years, with a male-to-female ratio of 8:7. The majority of the cases were reported from Brazil (n = 14), USA (n = 9), Turkey (n = 9), and Spain (n = 9). Noticeably, 30.14% of COVID-19 patients were diagnosed with Guillain-Barré syndrome. In total, 22.97% of patients complained of bilateral facial paralysis (n = 17), whereas ipsilateral paralysis was observed in 77.03% (n = 57). These were common complaints of Lagophthalmos, otalgia, facial drooping, dysarthria, and compromised forehead wrinkling. The treatment regimen mainly included the use of corticosteroids (n = 51) (69.86%), antivirals (n = 23) (31.51%), IVIG (n = 18) (24.66%), antibiotics (n = 13) (17.81%), antiretroviral (n = 9) (12.33%), and antimalarial (n = 8) (10.96%) medications. In all, 35.62% of patients (n = 26) adhered to a combination of antiviral and corticosteroid-based therapy. Positive treatment outcomes were observed in 83.58% (n = 56) of cases. In contrast, 10 patients (14.93%) showed nonsignificant recovery, out of which 3 (4.48%) died from the disease.

Conclusion

The association of facial palsy with COVID-19 is controversial and therefore requires further investigation and published work to confirm a causal relationship. However, physicians should not overlook the likelihood of facial palsy post-COVID-19 infection and treat it accordingly.

Psychosis and Bilateral Peripheral Facial Palsy Associated With COVID-19

Neuropsychiatric disorders associated with coronavirus infections emerged with the coronavirus disease 2019 (COVID-19) pandemic. We describe the clinical, laboratory and radiological features of a patient who presented, after recent COVID-19, two rare neuropsychiatric manifestations: a brief psychotic break followed by severe bilateral peripheral facial palsy.

Late peripheral facial paralysis after COVID-19: a rapid systematic review and two case reports

Peripheral facial paralysis (PFP) has been shown to be a neurological manifestation of COVID-19. The current study presents two cases of PFP after COVID-19, along with a rapid review of known cases in the literature. Both case reports were conducted following CARE guidelines. We also performed a systematic review of PFP cases temporally related to COVID-19 using PubMed, Embase, and Cochrane Library databases on August 30, 2021, using a rapid review methodology. The two patients experienced PFP 102 and 110 days after COVID-19 symptom onset. SARS-CoV-2 RNA was detected in nasal samples through reverse-transcription real-time polymerase chain reaction (RT-qPCR) testing. Anosmia was the only other neurological manifestation. PFP was treated with steroids in both cases, with complete subsequent recovery. In the rapid review, we identified 764 articles and included 43 studies. From those, 128 patients with PFP were analyzed, of whom 42.1% (54/128) were male, 39.06% (50/128) female, and in 23 cases the gender was not reported. The age range was 18 to 59 (54.68%). The median time between COVID-19 and PFP was three days (ranging from the first symptom of COVID-19 to 40 days after the acute phase of infection). Late PFP associated with COVID-19 presents mild symptoms and improves with time, with no identified predictors. Late PFP should be added to the spectrum of neurological manifestations associated with the long-term effects of SARS-CoV-2 infection as a post COVID-19 condition.

Facial Nerve Palsy as a Common Presentation during the Epidemic of Coronavirus Disease Associated Rhinocerebral Mucormycosis

Purpose

The main purpose of this study is to highlight the involvement of the facial nerve as one of the presenting symptoms in patients suspected of coronavirus disease associated mucormycosis (CAM).

Methods

This is a retrospective observational study conducted at a tertiary care referral centre which included 300 patients with past history of being treated for coronavirus disease and who presented to our department with symptoms of invasive fungal sinusitis. All the patients were evaluated clinically and radiologically for presence of facial nerve palsy (FNP) in suspected cases of CAM. All the patients were managed with combined modality treatment with antifungal therapy and radical endoscopic debridement of the necrotic tissue and fungal debris.

Results

The data were analysed to assess the possible epidemiological factors linked to CAM. Diabetes mellitus was the most common associated factor identified for aggravating of CAM. FNP is also one of the common presentation seen among 53 patients with CAM.

Conclusion

FNP is an unusual but significant sign in presentation of mucormycosis. It could be easily misdiagnosed as cerebrovascular accident leading to delay in the treatment. During this era of Covid-19 pandemic where wearing of masks has become mandatory, there is a high probability of this finding to be missed. Thus, our study emphasises for thorough cranial nerve examination in all cases of CAM, for an early and an immediate intervention to prevent the spread of the disease and also to improve the overall general condition of the patient.

Parálisis facial aislada posterior a infección por virus de chikunguña: un nuevo diagnóstico diferencial

En las últimas décadas, se ha incrementado el reporte de manifestaciones neurológicas asociadas con la infección por el virus de chikunguña. Se informa el caso de un adulto joven previamente sano que presentó parálisis facial izquierda aislada después de una infección reciente por el virus de chikunguña en el trópico colombiano. Se describen aspectos importantes de la fisiopatología del virus y su tropismo por el sistema nervioso central y periférico, y se sugiere considerar este virus en el diagnóstico diferencial de la parálisis facial en pacientes con infección confirmada por el virus de chikunguña en regiones tropicales endémicas o en aquellos con antecedente de viajes recientes a dichas regiones.

Therapeutic Approaches to the Neurologic Manifestations of COVID-19

As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.

Facial Nerve Paralysis and COVID-19: A Systematic Review

Objective

Several cases of facial nerve paralysis (FNP) post‐COVID‐19 infection have been reported with varying presentations and management. This study aims to identify FNP clinical characteristics and recovery outcomes among patients acutely infected with COVID‐19. We hypothesize that FNP is a potentially unique sequalae associated with COVID‐19 infections.

Methods

A systematic review of PubMed‐Medline, OVID Embase, and Web of Science databases from inception to November 2021 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.

Results

This search identified 630 studies with 53 meeting inclusion criteria. This resulted in 72 patients, of which 30 (42%) were diagnosed with Guillain‐Barré Syndrome (GBS). Non‐GBS patients were on average younger (36 vs. 53 years) and more likely to present with unilateral FNP (88%) compared to GBS patients who presented predominantly with bilateral FNP (74%). Among non‐GBS patients, majority (70%) of FNP presented a median of 8 [IQR 10] days after the onset of initial COVID‐19 symptom(s). Treatment for non‐GBS patients consisted of steroids (60%), antivirals (29%), antibiotics (21%), and no treatment (21%). Complete FNP recovery in non‐GBS patients was achieved in 67% patients within a median of 11 [IQR 24] days.

Conclusion

FNP is a possible presentation post COVID‐19 infections, associated with both GBS and non‐GBS patients. Although no causation can be assumed, the clinical course of isolated FNP associated with COVID‐19 raises the possibility of a unique presentation differing from Bell's palsy, seen with higher proportion of patients developing bilateral FNP and a shorter duration to complete recovery. Laryngoscope, 2022

Epidemiology, clinical features, and treatment modalities of facial nerve palsy in COVID-19 patients: a systematic review

Background

Coronavirus disease 2019 (COVID-19) is responsible for a wide variety of multi-system clinical features. Facial nerve palsy (FNP) is identified as one of the neurological complications of the virus. This work aims to systematically review the clinical picture, laboratory/imaging findings, treatment options, and prognostic factors of FNP in COVID-19 patients.

Methods

Using six online databases, a search was conducted to include all articles with patients infected with COVID-19 and presenting with unilateral or bilateral FNP. Screening for eligibility and data extraction were done by three and four independent reviewers, respectively. Descriptive analyses and data visualizations were done using Google Sheets. Survival analysis and Kaplan–Meier plotting were done by R software.

Results

The data from 22 studies included 32 patients who were infected with COVID-19 and presented with clinical features of FNP. Fourteen patients were male while 18 were female. FNP affected 29 patients unilaterally and 3 patients bilaterally. The imaging findings confirmed that complications of FNP were COVID-19 related. Additionally, antivirals combined with steroids had the lowest median time (21, IQR = 8) to clinical improvement compared to steroid-only (30, IQR = 15) and antiviral-only (33, IQR = 3.5) treatments.

Conclusion

This study has shown a potential correlation between the increased incidence of FNP and COVID-19. We have also found that combining antivirals with steroids may have better outcomes in patients with FNP and COVID-19 although the evidence to support this claim is not strong enough. Further studies are required to assess the extent of linkage between the two conditions and how to properly manage FNP when encountered in COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13760-022-02026-8.

Bilateral facial palsy after COVID-19 vaccination

Guillain-Barrè syndrome (GBS) is an acute immune-mediated neuropathy, possibly triggered by a recent infection or vaccination, and driven by an immune attack targeting the peripheral nervous system. GBS typically leads to ascending limb weakness, often with sensory and cranial nerve involvement 1-2 weeks after immune stimulation, but emergency and neurology physicians should be aware of its important clinical heterogeneity. In rare cases, bilateral facial nerve palsy can be the main clinical manifestation, as the case of the variant formerly known as bilateral facial weakness with paresthesias. An increasing number of case reports of GBS in patients receiving COVID-19 vaccination have been reported both during the pre-clinical phase and after large-scale authorities' approval. We report two cases of bifacial palsy with paresthesias, a rare variant of GBS, both occurring after the first dose of COVID-19 vaccine Vaxzevria™ (formerly COVID-19 vaccine AstraZeneca), showing a favorable outcome after high-dose immunoglobulin therapy, and discuss the literature of GBS post-COVID-19 vaccination.

Anosmia Testing as Early Detection of SARS-CoV-2 Positivity; A Prospective Study under Screening Conditions

Sudden onset of anosmia is a phenomenon often associated with developing COVID-19 disease and has even been described as an initial isolated symptom in individual cases. In this case-control study, we investigated the feasibility of this condition as a suitable screening test in a population at risk. We performed a prospective study with a total of 313 subjects with suspected SARS-CoV-2 infection. In parallel to routine PCR analysis, a modified commercial scent test was performed to objectify the presence of potential anosmia as a predictor of SARS-CoV-2 positivity. Furthermore, a structured interview assessment of the participants was conducted. A total of 12.1% of the study participants had molecular genetic detection of SARS-CoV-2 infection in the nasopharyngeal swab. It could be demonstrated that these subjects had a significantly weaker olfactory identification performance of the scents. Further analysis of the collected data from the scent test and medical history via random forest (Boruta) algorithm showed that no improvement of the prediction power was achieved by this design. The assay investigated in this study may be suitable for screening general olfactory function. For the screening of COVID-19, it seems to be affected by too many external and internal biases and requires too elaborate and selective pre-test screening.

Surge of Bell's Palsy in the era of COVID-19; Systematic review

BACKGROUND

With the progression of Coronavirus infectious disease-19 (COVID-19), various neurological manifestations have been noticed in these patients and Bell's palsy is one of the peripheral neuropathies among those. Bell's palsy has been associated with various other viral agents. Its evidence in patients with COVID-19 signifies the possibility of association between Bell's Palsy and Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2).

OBJECTIVE

To evaluate the number of published cases of Bell's palsy as the only major neurological manifestation in patients with COVID-19 from March 2020 to December 2021 and to investigate the association of SARS-CoV2 and Bell's palsy.

MATERIALS AND METHODS

A systematic review of the published English literature was performed using an electronic search in PubMed / Medline, Scopus, Research gate, Research square and Google Scholar databases, using keywords like 'COVID-19' OR/AND 'SARS-CoV-2', OR/AND 'Bell's palsy', OR/AND 'Facial nerve palsy', OR/AND 'Neurological', OR/AND 'Manifestation'.

RESULTS

Search strategy revealed 32 relevant publications with a total of 46 patients. Bell's palsy was the initial manifestation in 37% cases and in 63% cases it developed after COVID-19 symptoms. 71.7% cases showed complete recovery and 21.7% showed only partial relief from BP.

CONCLUSIONS

Although the number of documented cases in this research are not much, but evidence of Bell's palsy as the only major neurological manifestation in patients with COVID-19 signifies an important clinical finding and the possibility of another viral aetiology of BP. More evidence is needed to establish the exact co-relation between these two entities.

Neurological toll of COVID-19

The first case of coronavirus illness was discovered in Wuhan, China, in January 2020 and quickly spread worldwide within the next couple of months. The condition was initially only linked with respiratory disorders. After the evolution of various variants of the SARS-CoV-2, the critical impact of the virus spread to multiple organs and soon, neurological disorder manifestations started to appear in the infected patients. The review is focused on the manifestation of various neurological disorders linked with both the central nervous system and peripheral nervous system. Disorders such as cytokine release syndrome, encephalitis, acute stroke, and Bell's palsy are given specific attention and psychological manifestations are also investigated. For a clear conclusion, cognitive impairment, drug addiction disorders, mood and anxiety disorders, and post-traumatic stress disorder are all fully examined. The association of the SARS-CoV-2 with neurological disorders and pathway is yet to be clear. For better understanding, the explanation of the possible mechanism of viral infection influencing the nervous system is also attempted in the review. While several vaccines and drugs are already involved in treating the SARS-CoV-2 condition, the disease is still considered fatal and more likely to leave permanent neurological damage, which leads to an essential requirement for more research to explore the neurological toll of the COVID-19 disease.

COVID-19 and the Peripheral Nervous System. A 2-year review from the pandemic to the vaccine era

Increasing literature has linked COVID‐19 to peripheral nervous system (PNS) diseases. In addition, as we move from the pandemic to the vaccination era, literature interest is shifting towards the potential association between COVID‐19 vaccines and PNS manifestations. We reviewed published literature on COVID‐19, COVID‐19 vaccines and PNS manifestations between 1 January 2020 and 1 December 2021. For Guillain‐Barré syndrome (GBS), isolated cranial neuropathy (ICN) and myositis associated with COVID‐19, the demographic, clinical, laboratory, electrophysiological and imaging features were included in a narrative synthesis. We identified 169 studies on COVID‐19‐associated complications, including 63 papers (92 patients) on GBS, 29 papers (37 patients) on ICN and 11 papers (18 patients) on myositis. Additional clinical phenotypes included chronic inflammatory demyelinating polyneuropathy, vasculitic neuropathies, neuralgic amyotrophy, critical care‐related complications, and myasthenia gravis. PNS complications secondary to COVID‐19 vaccines have been reported during randomized clinical trials, in real‐world case reports, and during large‐scale surveillance programs. These mainly include cases of GBS, Bell's palsy, and cases of neuralgic amyotrophy. Based on our extensive review of the literature, any conclusion about a pathophysiological correlation between COVID‐19 and PNS disorders remains premature, and solely supported by their temporal association, while epidemiological and pathological data are insufficient. The occurrence of PNS complications after COVID‐19 vaccines seems limited to a possible higher risk of facial nerve palsy and GBS, to a degree that widespread access to the ongoing vaccination campaign should not be discouraged, while awaiting for more definitive data from large‐scale surveillance studies.

Wernicke's encephalopathy and cranial nerve VII palsy in a 24-year-old patient with COVID-19

Background

Many documented secondary neurologic manifestations are associated with COVID-19, including mild peripheral and central nervous system disorders (such as hypo/anosmia, hypo/ageusia, and cranial nerve VII palsy) and severe problems (such as ischemic stroke, Guillain-Barré syndrome, and encephalitis). The list is growing. A new addition is non-alcohol Wernicke’s encephalopathy.

Case presentation

We present the case of a 24-year-old male with no past medical history who developed stroke-like symptoms two days after testing positive for COVID-19. MRI of his brain showed T2 FLAIR hyperintensity in the splenium of the corpus collosum, mamillary bodies, periaqueductal gray matter, tectum, and ventral and dorsal medulla, an MRI signal concerning for non-alcohol Wernicke’s encephalopathy. Our patient had no risk factors for Wernicke’s encephalopathy. He was admitted and started on thiamine for Wernicke’s encephalopathy and steroids for his cranial VII nerve palsy. Both his symptoms and imaging improved. He was discharged on oral thiamine. Follow-up in the Neurology Clinic has confirmed his continued stable state.

Conclusions

This case is one of three documented cases of Wernicke’s encephalopathy believed to be caused by COVID-19 in patients without risk factors or chronic alcohol use. Ours is also the first case in which Wernicke’s encephalopathy presents with a concomitant cranial nerve VII palsy. While Emergency Medicine doctors must maintain a high index of suspicion for stroke in younger patients with COVID-19, our patient’s case augments the correlation between COVID-19 and Wernicke’s encephalopathy in patients without other risk factors for developing the syndrome.

Rehabilitation of peripheral facial palsy associated with COVID-19 in a child: A case report

COVID-19 has been associated with multiple neurological manifestations. Coronaviruses are known to have a neurotropic propensity, possibly leading to various neurological complications, including peripheral facial paralysis (PFP). However, the pathogenic mechanisms underlying neurological symptoms in COVID-19 are not completely understood. This report presents the first published case of facial palsy in an otherwise healthy child secondary to infection with the novel coronavirus SARS-Cov-2, with reflections on the natural course and the role of physical and rehabilitation medicine in this form of PFP. Thus, PFP may also be a manifestation of COVID-19 and in the current epidemiological context, physicians evaluating patients with facial palsy should exclude infection with SARS-Cov-2 to prevent diagnostic delays and further transmission of the disease. These patients may have a slower recovery and worse prognosis as compared with those with Bell's palsy. Thus, rehabilitation needs to be initiated promptly, and close follow-up must be assured to identify and address early complications.

SARS-CoV-2-Associated Cerebrovascular Disease Amid the COVID-19 Pandemic: A Systematic Review

Background

Cerebrovascular diseases associated with SARS-CoV-2 are being increasingly reported in the literature as the coronavirus disease 2019 (COVID-19) pandemic continues. However, a case-based retrospective analysis of the literature about SARS-CoV-2-cerebrovascular disease (SCVD) is not yet well established. Thus, we reviewed the literature on SCVD covering a comprehensive range of topics spanning the clinical features, mechanism, treatment, and outcomes of patients with SCVD.

Methods

We searched PubMed^® and included single-case reports and case series with full text in English that reported original data of patients with CVD and a confirmed recent SARS-CoV-2 infection. Clinical data were extracted.

Results

We included all 51 articles indexed in PubMed^® that were published between January 1, 2020, and June 20, 2020. The selected studies reported a total of 167 cerebrovascular events including ischemic stroke, cerebral hemorrhage, subarachnoid hemorrhage, and cerebral venous thrombosis in patients with confirmed COVID-19. The detailed demographic and clinical characteristics of patients with CVD are summarized.

Conclusion

This summary of patient characteristics may help clinicians better anticipate SCVD outcomes and complications in their COVID-19 patients.

A cluster of children with facial nerve palsy in a high prevalence area for COVID-19

BACKGROUND

COVID-19 is a disease of varying presentation and neurological sequelae of the disease are being studied. Following a cluster of paediatric facial nerve palsy (FNP) cases in an area of South Wales with a high prevalence of COVID-19, we conducted an opportunistic study to determine whether there has been an increase of incidence of FNP and if there is an association between the FNP and COVID-19 in children.

METHODS

We performed a retrospective review of the incidence of FNP between 2015 and 2020 across two hospitals within the health board. The incidence was compared with that in 2020 including a cluster of six children in 14 weeks, presenting to Royal Glamorgan Hospital between June and October.

RESULTS

There were 48 cases of children with FNP across both hospital within the study years. Seven (7) cases in 2020. The incidence was not statistically different in comparison to other years. Five out of six of these children in 2020 had antibody testing for COVID-19. All serology testing (100%) returned negative for SARS-CoV- 2 antibodies.

CONCLUSIONS

In high prevalence area for COVID-19, cases of children with FNP have not shown a commensurate increase. we have found no causal link between COVID-19 and FNP in children. While this is a small study, larger cohort studies are needed to support this finding. As new strains of COVID-19 are being reported in UK, South Africa and Brazil, physicians need to continue to be vigilant for consistent pattern of signs and symptoms, especially in children.

Facial Nerve Palsy as a Neurological Manifestation of COVID-19

Facial nerve palsy is the most frequent acute mononeuropathy and it is often of viral etiology, although many other causes have been identified. It has recently been described as a potential manifestation of COVID-19. We report the case of a patient with recent history of diarrhea and malaise that was admitted to the hospital presenting right facial paresis with orbicular muscle involvement. Nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the real-time reverse transcription polymerase chain reaction and magnetic resonance imaging showed no structural changes. During the hospital stay, the patient showed clinical improvement, and no other symptoms were observed. This case presentation suggests a possible association between neuropathies and SARS-CoV-2 infection.

Neuromuscular complications of coronavirus disease-19

PURPOSE OF REVIEW

Since its outbreak in Wuhan, China in late 2019, coronavirus disease-19 (COVID-19) has become a global pandemic. The number of affected cases and deaths continues to rise. Primarily a respiratory illness, COVID-19 is now known to affect various organ systems including peripheral nerve and skeletal muscle. The purpose of this review is to discuss the scope of neuromuscular manifestations and complications of COVID-19.

RECENT FINDINGS

Several neuromuscular conditions, including Guillain-Barré syndrome, rhabdomyolysis, and myositis, have been reported in patients infected with COVID-19, but even with a temporal association, a causal relationship remains unproven. Direct invasion of neurons or myocytes by the virus, and immune-mediated injury have been speculated but not consistently demonstrated. In addition to potentially causing the above conditions, COVID-19 can trigger exacerbations of preexisting neuromuscular conditions such as myasthenia gravis, and severe infections can lead to critical illness myopathy/polyneuropathy.

SUMMARY

COVID-19 appears to be potentially associated with a wide range of neuromuscular manifestations and complications. Further studies are needed to examine these possible associations, understand the pathogenesis, and develop preventive and treatment strategies.

Does the SARS-CoV-2 pandemic really increase the frequency of peripheral facial palsy?

PURPOSE

Publications about increased number of peripheral facial paralysis in the COVID-19 pandemic emerged in the literature. However, these studies comprised of an estimate rather than a broad analysis of exact numbers. In this study, we planned to investigate whether the pandemic really resulted in an increase in facial paralysis cases admitted to the hospital by evaluating the cases who applied to our hospital due to facial paralysis in the COVID-19 pandemic year and in the previous 4 years.

MATERIALS AND METHODS

Patients who applied to our hospital due to facial paralysis between March 2016-February 2017 (Group 1), between March 2017-February 2018 (Group 2), between March 2018-February 2019 (Group 3), between March 2019-February 2020 (Group 4), and between March 2020-February 2021 (Group 5) were investigated and detailed data were noted.

RESULTS

156, 164, 149, 172 and 157 patients were admitted to the hospital due to peripheral facial paralysis in Group 1, 2, 3, 4, and 5, respectively. Of these patients, 155, 164, 145, 169, and 153 were Bell's palsy, respectively. SARS-CoV-2 RT-PCR test was positive in only 2 of the 153 patients who were diagnosed in the year of the pandemic.

CONCLUSIONS

This study showed that the number of peripheral facial paralysis detected during the COVID-19 pandemic was similar to previous years. Very few number of positive SARS-CoV-2 RT-PCR test results may have been found incidentally in Bell's palsy patients. Theses stating that SARS-CoV-2 causes peripheral facial paralysis should be supported by laboratory studies and postmortem research.

Rised sudden sensorineural hearing loss during COVID-19 widespread

BACKGROUND

Sudden sensorineural hearing loss (SSNHL) is commonly encountered in otolaryngologic practice. SARS-CoV-2 infection is typically marked by respiratory symptoms although neurologic manifestations of the disease have also been described.

OBJECTIVE

We want to measure the incidence and clinical aspects of persons exhibiting in otolaryngology clinic (OC) with SSNHL during the COVID-19 widespread and in the constant interval of previous year.

METHODS

We retrospectively inspected the medical information for admissions to OC in Eskisehir, Turkey, during the COVID-19 widespread to describe the patients SSNHL. Clinical knowledge was saved for each subject and corresponded with that of SSNHL subjects demonstrating in 2019.

RESULT

Between 1 April and 30 September 2020, 68 patients admitted to OC for SSNHL; in 2019, there were 41 subjects, for an incidence rate ratio of 8.5 per 100.000 (95% CI 1.02-2.92) for the 2020 cohort. Of the 2020 group, forty-one patients (60.3%) presented with active or recent symptoms consistent with COVID-19 infection, compared with four (9.8%) in 2019 (p < 0.001). Furthermore, subjects in 2020 group were younger (-15.5 years, p = 0.0141) than 2019 group and demonstrated prolonged interim (+1.7 days, p < 0.001) between SSNHL initiation and OC petition.

CONCLUSION

We detected increased incidence of SSNHL during the COVID-19 widespread compared to the same interval of the prior year; 60.3% of subjects confronting with SSNHL had signs that were harmonious with COVID-19.

Can isolated sudden sensorineural hearing loss (SSNHL) and idiopathic acute facial paralysis (Bell's palsy) be symptoms of COVID-19?

OBJECTIVES

The symptoms of COVID-19 at the time of presentation mainly include fever, cough, respiratory distress and myalgia. On the other hand, as neurological symptoms, disruption of taste and smell and cerebrovascular pathologies are well-known, whereas other neurological symptoms and signs are being newly recognized. Sudden-onset sensorineural hearing loss (SSNHL) and idiopathic acute facial paralysis (Bell's palsy) are otologic emergencies that are frequently encountered by otorhinolaryngology specialists. Although there are many articles describing SSNHL and Bell's palsy in the literature, the literature describing their relationship to COVID-19 is limited. In our study, we aimed to present the neuro-otologic relationship of SSNHL and Bell's palsy with COVID-19.

MATERIAL AND METHODS

The pretreatment real-time oronasopharyngeal PCR tests, COVID-19 symptomatology and COVID-19 infection statuses of patients who presented to our clinic with isolated SSNHL and Bell's palsy between April 2020 and April 2021 were questioned, and the data of the patients were collected. Throughout their treatment, the patients were followed-up in terms of COVID-19 infection. This is a prospective study. Moreover, to observe the change in the incidence, the data of patients visiting between January 2019 and January 2020 were also collected. The data of the patients were statistically analyzed using SPSS.

RESULTS

The study included a total of 177 patients. The SSNHL group consisted of 91 patients, and the Bell's palsy group consisted of 86 patients. Neither group showed a statistically significant difference in comparison to the year without the pandemic in terms of the patient numbers (incidence), sex, age, morbidity, response to treatment or social habits. There was a statistically significant difference in age only in the Bell's palsy group, but this difference was not medically significant.

CONCLUSION

As a result of our study, we did not observe a relationship between COVID-19 and cases of SSNHL and Bell's palsy. It is recommended to apply standard otologic treatment to isolated SSNHL and Bell's palsy patients whose association with COVID-19 is not determined.

Neurological Manifestations of Coronavirus Disease 2019: A Comprehensive Review and Meta-Analysis of the First 6 Months of Pandemic Reporting

Background: There is growing evidence that SARS-Cov-2 infection is associated with severe neurological complications. Understanding the nature and prevalence of these neurologic manifestations is essential for identifying higher-risk patients and projecting demand for ongoing resource utilisation. This review and meta-analysis report the neurologic manifestations identified in hospitalised COVID-19 patients and provide a preliminary estimate of disease prevalence.

Methods: MEDLINE, Embase and Scopus were searched for studies reporting the occurrence of neurological complications in hospitalised COVID-19 patients.

Results: A total of 2,207 unique entries were identified and screened, among which 14 cohort studies and 53 case reports were included, reporting on a total of 8,577 patients. Central nervous system manifestations included ischemic stroke (n = 226), delirium (n = 79), intracranial haemorrhage (ICH, n = 57), meningoencephalitis (n = 13), seizures (n = 3), and acute demyelinating encephalitis (n = 2). Peripheral nervous system manifestations included Guillain-Barrè Syndrome (n = 21) and other peripheral neuropathies (n = 3). The pooled period prevalence of ischemic stroke from identified studies was 1.3% [95%CI: 0.9–1.8%, 102/7,715] in all hospitalised COVID-19 patients, and 2.8% [95%CI: 1.0–4.6%, 9/318] among COVID-19 patients admitted to ICU. The pooled prevalence of ICH was estimated at 0.4% [95%CI: 0–0.8%, 6/1,006].

Conclusions: The COVID-19 pandemic exerts a substantial neurologic burden which may have residual effects on patients and healthcare systems for years. Low quality evidence impedes the ability to accurately predict the magnitude of this burden. Robust studies with standardised screening and case definitions are required to improve understanding of this disease and optimise treatment of individuals at higher risk for neurologic sequelae.

One Year on: An Overview of Singapore's Response to COVID-19-What We Did, How We Fared, How We Can Move Forward

Background—One year has passed since the first COVID-19 case in Singapore. This scoping review commemorates Singaporean researchers that have expanded the knowledge on this novel virus. We aim to provide an overview of healthcare-related articles published in peer-reviewed journals, authored by the Singapore research community about COVID-19 during the first year of the pandemic. Methods—This was reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) protocol. It included healthcare-related articles about COVID-19 published between 23 January 2020 and 22 January 2021 with a Singapore-affiliated author. MEDLINE, Embase, Scopus, Web of Science, CINAHL, PsycINFO, Google Scholar, and local journals were searched. The articles were screened independently by two reviewers. Results—The review included 504 articles. Most of the articles narrated the changes to hospital practice (210), while articles on COVID-19 pathology (94) formed most of the non-narrative papers. Publications on public health (61) and the indirect impacts to clinical outcomes (45) were other major themes explored by the research community. The remaining articles detailed the psychological impact of the pandemic (35), adaptations of medical education (30), and narratives of events (14). Conclusion—Amidst a resurgence of community cases involving variant COVID-19 strains, the resources from the research community will provide valuable guidance to navigate these uncertain times.

Evaluation of Acoustic Reflex Thresholds in COVID-19 Patients With Taste Disorders

OBJECTIVE

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can result in persistent loss of taste and smell. This study was performed to assess acoustic reflex threshold (ART) in patients with taste disorders caused by SARS-CoV-2.

MATERIAL AND METHODS

This retrospective study enrolled 11 patients (9 men, 2 women; average age = 22.3 years) with a history of COVID-19 and had complaints of taste disorder and sensitivity to loud sounds. The control group consisted of 13 healthy participants (10 men, 3 women; average age = 23.4 years). Anamnesis, neuro-otological, ear, nose and throat, and eye examinations, as well as a taste test, pure tone audiometry, speech discrimination test, and impedance audiometry were performed in all participants.

RESULTS

All participants in the study group had a negative taste test result. In addition, ART values were significantly higher in the study group than the control group at all frequencies.

CONCLUSIONS

SARS-CoV-2 could be a neurotropic virus that can cause facial nerve neuropathy.

A Cluster of Children with Facial Nerve Palsy in High Prevalence Area for COVID-19

OBJECTIVES

COVID-19 is a disease of varying presentation and neurological sequelae of the disease are being studied. Following a cluster of paediatric facial nerve palsy (FNP) cases in an area of South Wales with a high prevalence of COVID-19, we conducted an opportunistic study to determine whether there has been an increase in incidence of FNP and if there is an association between the FNP and COVID-19 in children.

STUDY DESIGN

A retrospective cohort study. Using the case series from 2020 and comparing it with previous years.

METHODS

We reviewed the incidence of FNP between 2015-2020 across two hospitals within the health board. The incidence was compared with that in 2020 including a cluster of six children in 14 weeks, presenting to the Royal Glamorgan Hospital between June and October.

RESULTS

There were 48 cases of children with FNP across both hospital within the study years. Seven (7) cases in 2020. The incidence was not statistically different in comparison to other years.Five out of six of these children in 2020 had antibody testing for COVID-19. All serology testing (100%) returned negative for SARS-CoV- 2 antibodies.In high prevalence area for COVID-19, cases of children with FNP have not shown a commensurate increase. we have found no causal link between COVID-19 and FNP in children. While this is a small study, larger cohort studies are needed to support this finding.

CONCLUSION

As new strains of COVID-19 are being reported in UK, South Africa and Brazil, physicians need to continue to be vigilant for consistent pattern of signs and symptoms, especially in children.

Guillain-Barré Syndrome Variant Occurring after SARS-CoV-2 Vaccination

Although SARS-CoV-2 vaccines are very safe, we report 4 cases of the bifacial weakness with paresthesias variant of Guillain-Barré syndrome (GBS) occurring within 3 weeks of vaccination with the Oxford-AstraZeneca SARS-CoV-2 vaccine. This rare neurological syndrome has previously been reported in association with SARS-CoV-2 infection itself. Our cases were given either intravenous immunoglobulin, oral steroids, or no treatment. We suggest vigilance for cases of bifacial weakness with paresthesias variant GBS following vaccination for SARS-CoV-2 and that postvaccination surveillance programs ensure robust data capture of this outcome, to assess for causality. ANN NEUROL 2021;90:315-318.

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

Purpose

Idiopathic facial palsy is called as Bell's palsy and reports showed that facial paralysis increased during COVID-19 pandemic period. There are many reports about the relationship between COVID-19 and facial paralysis but there is no prospective study. SARS-CoV-2 IgG and IgM antibodies increase in COVID-19. Our purpose is to investigate SARS-CoV-2 IgG + IgM antibody in the Bell's palsy.

Methods

Prospective cross-sectional study was planned. Patients with acute peripheral facial paralysis with no reason and diagnosed as Bell's palsy was included in the study. In order to investigate SARS-CoV-2 in the etiologies of these patients, SARS-CoV-2 IgM + IgG (total) test was studied. SARS-CoV-2 IgG + IgM was measured by using the ADVIA Centaur® test kit. Test reports result in index values and as nonreactive or reactive. The results were analyzed.

Results

Forty-one patients were included in the study. The average age of the patients was 41,7. 17 (41,4%) were female and 24 (58,6%) were male. 21 patients had left-sided; 20 had right-sided paralysis.

SARS-CoV-2 IgG + IgM values were measured two times of the patients. First control was in the first week of facial paralysis, 10 (24,3%) positivity was found. The average index of the positive patients were 6,74 (min.1,39–max.10) in the first control and 9,585 in the second control (min.8,7–max. 10).

Conclusion

We found that the SARS-CoV-2 IgM + IgG antibody test was positive in 24.3% of the patients with Bell's palsy. The results are higher than the seroprevalence studies conducted in asymptomatic individuals. Facial paralysis could be the only symptom of COVID-19 but further studies must be done.

A systematic review of Bell's Palsy as the only major neurological manifestation in COVID-19 patients

BACKGROUND

Bell's palsy is an acute idiopathic paralysis of the facial nerve. The disease is caused by many viruses like Herpes simplex virus-1, Varicella zoster, Epstein-bar virus, Cytomegalovirus, Usutu virus, Human immunodeficiency virus, etc. Literature has reported few cases of COVID-19 patients with Bell's palsy as the only major neurological manifestation indicating the possible role of another virus in the etiopathogenesis of Bell's Palsy. This paper aims to evaluate the reported cases of COVID-19 positive patients, presented with Bell's palsy as the only major neurological manifestation from March 2020 to December 2020, and to investigate the association of SARS-CoV2 and Bell's palsy.

MATERIALS AND METHODS

A systematic review of the published literature was performed using an electronic search in PubMed/Medline, Science Direct, Web of Science, Embase, J- STAGE, Google Scholar, China National Knowledge Infrastructure (CKNI) and Scopus databases, from March 2020 to Dec 2020 using keywords like 'COVID-19', 'SARS-CoV-2', 'Coronavirus', 'Bell's palsy', 'Facial nerve', 'First', 'Only',' Neurological', 'Manifestation'. The studies reviewed were case series and case reports regarding the subject.

RESULTS

Search strategy revealed thirteen articles from March 2020 to Dec 2020 with a total of 20 cases of COVID-19 with Bell's palsy as the only major neurological manifestation.

CONCLUSION

Evidence of Bell's palsy as the only major neurological manifestation in COVID-19 patients signifies an important clinical finding but robust research is needed to investigate their association and the exact mechanisms by which SARS-CoV2 causes Bell's Palsy.

Protracted COVID-19 during Treatment of Facial Palsy

Neurologic manifestations are increasingly reported as the coronavirus disease 2019 (COVID-19) pandemic continues. This is a report of a COVID-19 patient with Bell's palsy. Case Summary. A 52-year-old man with fever and malaise was tested positive for COVID-19. After a week, he developed right-sided peripheral facial palsy and was treated with corticosteroids in conjunction with antiviral treatment which resulted in complete recovery. Discussion. Concomitant treatment of corticosteroids and antiviral treatment can decrease morbidity in patients with COVID-19-related Bell's palsy.

Central and peripheral nervous system involvement by COVID-19: a systematic review of the pathophysiology, clinical manifestations, neuropathology, neuroimaging, electrophysiology, and cerebrospinal fluid findings

BACKGROUND

SARS-CoV-2 can affect the human brain and other neurological structures. An increasing number of publications report neurological manifestations in patients with COVID-19. However, no studies have comprehensively reviewed the clinical and paraclinical characteristics of the central and peripheral nervous system's involvement in these patients. This study aimed to describe the features of the central and peripheral nervous system involvement by COVID-19 in terms of pathophysiology, clinical manifestations, neuropathology, neuroimaging, electrophysiology, and cerebrospinal fluid findings.

METHODS

We conducted a comprehensive systematic review of all the original studies reporting patients with neurological involvement by COVID-19, from December 2019 to June 2020, without language restriction. We excluded studies with animal subjects, studies not related to the nervous system, and opinion articles. Data analysis combined descriptive measures, frequency measures, central tendency measures, and dispersion measures for all studies reporting neurological conditions and abnormal ancillary tests in patients with confirmed COVID-19.

RESULTS

A total of 143 observational and descriptive studies reported central and peripheral nervous system involvement by COVID-19 in 10,723 patients. Fifty-one studies described pathophysiologic mechanisms of neurological involvement by COVID-19, 119 focused on clinical manifestations, 4 described neuropathology findings, 62 described neuroimaging findings, 28 electrophysiology findings, and 60 studies reported cerebrospinal fluid results. The reviewed studies reflect a significant prevalence of the nervous system's involvement in patients with COVID-19, ranging from 22.5 to 36.4% among different studies, without mortality rates explicitly associated with neurological involvement by SARS-CoV-2. We thoroughly describe the clinical and paraclinical characteristics of neurological involvement in these patients.

CONCLUSIONS

Our evidence synthesis led to a categorical analysis of the central and peripheral neurological involvement by COVID-19 and provided a comprehensive explanation of the reported pathophysiological mechanisms by which SARS-CoV-2 infection may cause neurological impairment. International collaborative efforts and exhaustive neurological registries will enhance the translational knowledge of COVID-19's central and peripheral neurological involvement and generate therapeutic decision-making strategies.

REGISTRATION

This review was registered in PROSPERO 2020 CRD42020193140 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020193140.

Can COVID-19 Cause Peripheral Facial Nerve Palsy?

The aim of our study is to evaluate the relationship between peripheral facial paralysis and the patients who had a contact with a coronavirus disease 2019 (COVID-19) patient or had COVID-19. Patients with a history of contact with a COVID-19 patient or having COVID-19 disease, who were admitted to the emergency department for peripheral facial paralysis in the last 6 months, were included in the study. Facial paralysis grade at first presentation, treatment modality, treatment duration, post-treatment facial paralysis grade, and additional findings were analyzed. A total of 34 patients, 20 females and 14 males, were included into the study. Nasal-oropharyngeal reverse transcriptase-polymerase chain reaction (RT-PCR) was test taken from patients with a history of contact, and patients having COVID-19 disease were determined as positive in 5 and 3 patients, respectively. Peripheral facial paralysis was detected as an initial finding in 5 of these 8 patients, and paralysis developed in 7-12 days after the diagnosis of the COVID-19 disease in the remaining 3 patients. The grade of first admission paralysis did not change in one patient in the (+) group, while improvement was observed in all patients in the (−) group. Neuroinvasive potential of COVID-19 in the central and peripheral nervous system was reported in current literature. Our study indicates peripheral facial palsy can also be encountered during the clinical course of COVID-19 and should be considered a finding of this disease.

Case Report: Bilateral Palsy of the Vocal Cords After COVID-19 Infection

During the COVID-19 pandemic, adverse neurological effects have been described. In addition to unspecific neurological symptoms, cranial nerve deficits have appeared as part of SARS-CoV-2 infection. In this case report, we describe a 74-year-old patient who developed bilateral paralysis of the vocal cords some weeks following his dismissal in stable condition after COVID-19 pneumonia. After ruling out central lesions, peripheral tumors, and other possible causes, therapy was initiated with methylprednisolone, inhalations, and oxygen. The patient showed no improvement, so laterofixation after Lichtenberger was performed. The dyspnea worsened after several weeks, so a laser posterior cordectomy was performed with satisfactory outcome.

SARS-CoV-2 Induced Neurological Manifestations Entangles Cytokine Storm That Implicates For Therapeutic Strategies

The new coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can present with neurological symptoms and induce neurological complications. The involvement in both the central and peripheral nervous systems in COVID-19 patients has been associated with direct invasion of the virus and the induction of cytokine storm. This review discussed the pathways for the virus invasion into the nervous system and characterized the SARS-CoV-2 induced cytokine storm. In addition, the mechanisms underlying the immune responses and cytokine storm induction after SARS-CoV-2 infection were also discussed. Although some neurological symptoms are mild and disappear after recovery from infection, some severe neurological complications contribute to the mortality of COVID-19 patients. Therefore, the insight into the cause of SARS-CoV-2 induced cytokine storm in context with neurological complications will formulate the novel management of the disease and further identify new therapeutic targets for COVID-19.