Professor, Vice-Chair Faculty Affairs H. Ben Taub PMR, Baylor College of Medicine Houston, Texas, United States
Case Diagnosis: Severe ulnar and median neuropathies
Case Description: This is a case of a 39-year-old female presenting for NCS/EMG. Four months prior, she was intubated with COVID-19 pneumonia and required bilateral upper extremity restraints while in the ICU. She developed right hand weakness and numbness in fingers and medial forearm without any significant swelling. On examination, she had claw hand with marked atrophy of her right hand thenar eminence and intrinsic musculature. She had 5/5 strength of right upper extremity except for 1/5 strength of thumb abduction, thumb opposition, finger abduction, and MCP flexion. She had diminished sensation to her right hand and medial forearm. Reflexes were 1+ bilaterally. Electrodiagnostic evidence was most consistent with severe right median (distal to the innervation of FCR and proximal to FDS) and ulnar (distal to FDP and proximal to dorsal ulnar cutaneous branch) neuropathies.
Discussions: The neurologic implications of SARS-CoV-2 infection remain incompletely defined. Studies have suggested the possibility of direct viral interaction with neurologic ACE2 receptors or autoimmunity to peripheral nerve glycoproteins due to cross-reactivity with SARS-CoV-2 gangliosides. Additionally, COVID-19 patients with severe illness often have multi-organ failure, prolonged immobility, and increased use of paralytics, high-dose steroids, and restrictive positioning, all factors that increase risk for nonspecific critical illness myopathy/polyneuropathy. In this case, it is notable that the NCS/EMG was not suggestive of a generalized myopathy or polyneuropathy that would support a picture of CIM/CIP. Instead, the cause of nerve injury remains unclear as it localized proximal to the wrist restraints and was unilateral. Other possibilities include retrograde denervation, compression during a proning session, or potentially, the SARS-CoV-2 infection increased the risk for developing this neuropathy.
Conclusions: With the ongoing pandemic, the continued accumulation of knowledge regarding neurologic complications can have significant implications in the treatment of COVID-19 patients.