IJCRR - 14(1), January, 2022
Date of Publication: 03-Jan-2022
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Post Covid Lower Limb Axonal Neuropathy - A Case Report
Author: Yashasvi Shukla, Dhara Sharma, Khanjan Patel
Abstract:Introduction: The spectrum of neurologic complications subsequent to novel coronavirus 2 (SARS-Cov-2) infection is broad. COVID-19, caused by the infection with the SARS-Cov-2, is a pandemic affecting the whole globe with periods of exacerbations and remissions. Neurological manifestations occur in about 36.4% of patients infected with SARS-Cov-2. Case Report: Here reported case is of 37- year- old female who was clinically diagnosed with post covid lower limb axonal neuropathy after 50 days of covid 19 infection. A survey on neurological manifestations was specially designed to address 10 neurological manifestations of COVID-19: headache, altered sensation, nausea and vomiting, sudden hemiparesis (stroke), numbness and paresthesia, vertigo, ataxia, seizure, encephalitis/meningitis, Guillain-Barr\? Syndrome (GBS), and myelitis. Conclusion: Physical rehabilitation playing a significant part in treating balance, strength and returning to independence is known worldwide.
Keywords: Axonal Neuropathy, Post Covid Complication, Physiotherapy, Nerve Conduction Velocity test, Balance, Strength
COVID-19, caused by the infection with the SARS-Cov-2, is a pandemic affecting the whole globe with periods of exacerbations and remissions. The spectrum of neurologic complications subsequent to novel coronavirus 2 (SARS-Cov-2) infection is broad. Neurological manifestations occur in about 36.4% of patients infected with SARS-Cov-2 and span several domains within the central and peripheral nervous system.1,2 One of those is sub-acute peripheral neuropathy. Here reported case is of 37-year-old female who was clinically diagnosed with post covid lower limb axonal neuropathy after 50 days of covid 19 infection.
This healthy 37-years-old female got tested positive with covid 19 in early May 2021. After 25 days of infection, she felt swelling over right eye for which she consulted an ophthalmologist who gave her 5 dose of methylprednisolone IV daily for choroidal thickening. After 2 weeks she felt sudden numbness in her both lower limbs which not only made her ambulation difficult but also lead to domestic fall once. Consequently, she consulted an orthopedic surgeon who further commented L5-S1 disc bulging with haemangioma based on MRI. Blood reports were suggestive of reduced haemoglobin 9.5gm/dl along with reduction in P.C.V, M.C.V., M.CH. M.C.H.C. with values 30.8%, 60.5%, 18.7%, 30.8% respectively. Furthermore, NCV finding concluded axonal motor neuropathy.
The patient had no co-morbidity hence diabetic neuropathy was ruled out. Furthermore, since the patient developed manifestations after covid 19 infection, Guillain Barre Syndrome was first on our differential list. Ascending flaccid paralysis, areflexia but in contrast our patient had involvement of lower back, lower limb till distal thigh. Moreover, patient had an acute presentation which goes against the chronic course of multiple sclerosis with no demyelinating lesions on MRI- brain and spinal cord. Considering nutritional neuropathy, a classic B12 deficiency scenario presents with chronic fatigue and neurological symptoms like tingling, numbness and loss of balance, Despite the Methylcobalmine injections of 1000mcg/ml for 5 doses there was no relief in pain, but the numbness went down to 50% as stated by patient. Hyperreflexia in knee can be seen due to corticospinal tract involvement, vibration, and proprioception is involved too, which was absent in this case. Cauda Equina can present with lower limb hyperreflexia, radiating pain and fecal incontinence which is classic in cauda equine but was absent in this patient, neither the MRI spine suggested any nerve root damage or compression.
On assessment, the patient had pain that was sharp and stabbing in nature and radiated posterolaterally downwards originating from the buttocks that giving her a sensation of heavy limb. According to Oxford grading for Manual Muscle Testing, on right side grade 1 in tibialis anterior, grade 2 in hamstrings, grade 1 in gluteus and the rest had grade 3, whereas on left side these muscles were grade 3. The clinical picture came out to be of post covid lower limb axonal neuropathy. Physiotherapy was aimed to reduce pain, stimulate paretic muscles, strengthen them and hence make the patient independent. Exercises were started in form of mechanical strengthening of bilateral lower limbs in form hip flexion, extension, abduction and back extension, electrical muscle stimulator and fast brushing for weak muscles like tibialis anterior
On progression after 15 days of exercise patient did all the above-mentioned exercises with 1kg of weight along with dynamic and static balance training, gait training with verbal and audio cueing from a therapist and visual biofeedback from a mirror while training. Furthermore, pain was reduced to NPRS 2 at rest which was 8 initially.
Peripheral neuropathy represents a spectrum of diseases with different etiologies, of which the commonest are certain co-morbidities like diabetes and can also be genetically inherited. Survey on neurological manifestations was specially designed for COVID-19 patients by researchers which addressed 10 neurological manifestations of COVID-19: headache, altered sensation, nausea and vomiting, sudden hemiparesis (stroke), numbness and paresthesia3,4 vertigo, ataxia, seizure, encephalitis/meningitis, Guillain-Barré Syndrome (GBS), and myelitis. Neurological manifestations were later confirmed by a thorough review of all available patient records.5 Peripheral neuropathies are the commonest neurological conditions having an incidence of 77/100,000 per year and a prevalence of 1–12% in all age groups and up to 30% in older people.3 Physical rehabilitation playing a significant part in treating balance, strength and returning to independence is known worldwide.
This case study of post-Covid Axonal Neuropathy gives an insight into the disease, its complication and challenges. It as well demonstrates the contradictions of diagnosis, the detailed prognosis and its management. Persistent monitoring, early interventions and meticulous plan of management are the key components to expedite the recovery.
Authors sincerely thank the patient for her cooperation and adherence towards rehabilitation throughout the entire period of assessment and Khyati College of Physiotherapy for aiding with specific instruments when needed. The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to the authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
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CONFLICT OF INTEREST:
Authors declare they have no conflict of interest.
Dr Yashasvi and Dr Dhara conceived and conceptualized the idea. Dr Yashasvi, Dr Dhara and Dr Khanjan were involved with the analysis of the facts, differential diagnosis and backing it up with a theoretical framework. Dr Yashasvi drafted the manuscript. Dr Dhara reviewed the manuscript.
Bureau B, Obeidat A, Dhariwal M, Jha P. Peripheral Neuropathy as a Complication of SARS-Cov-2. Cureus. 2020Nov 12;12(11)
Iltaf S, Fatima M, Salman S, Salam J, Abbas S. Frequency of Neurological Presentations of Coronavirus Disease in Patients Presenting to a Tertiary Care Hospital During the 2019 Coronavirus Disease Pandemic. Cureus. 2020 Aug 12(8)
Lehmann H, Wunderlich G, Fink G, Sommer C. Diagnosis of peripheral neuropathy. Neurological Research and Practice. 2020;2(1).
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurology. 2020;77(6):683.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061.