Director, Moss Rehab Electrodiagnostic Center Moss Rehab Elkins Park, Pennsylvania, United States
Case Diagnosis: Sciatic neuropathy with total axon loss likely attributed to a small clot affecting the vasa nervorum to the sciatic nerve in the proximal thigh in the setting of COVID-19 infection.
Case Description: 67-year-old female with recent COVID-19 pneumonia, septic shock and prolonged ICU stay was referred for electrodiagnosis of the right leg to rule out peroneal neuropathy. She reported numbness in the right foot, lateral leg, weakness and occasional pain. Sensation to light touch was absent in the right distal lateral leg, dorsum, plantar and lateral foot and decreased in the proximal lateral leg and medial foot. Reflexes were brisk in the knees and absent at ankles with absent Babinski response on the right. Muscle strength was 4-5/5 in the upper limbs and left lower limb, 0/5 in the right ankle and 3/5 in knee and hip flexion with normal hip abduction and adduction.
Discussions: The peroneal and tibial compound muscle action potentials were unobtainable. Increased insertional activity and fibrillation potentials or positive sharp waves were present in sciatic muscles. Concurrent axon loss peripheral polyneuropathy in the lower limbs and patchy myopathic process of the pelvic and shoulder girdle muscles was present likely related to long intensive care stay.
Conclusions: The pathogenesis of hypercoagulability in COVID-19 is incompletely understood but has been a well-documented phenomenon and likely caused this patient’s focal ischemia of the sciatic nerve with total axon loss. Prognosis for recovery of function is poor. This diagnosis should be considered in patients with concern for radiculopathy, plexopathy or peripheral neuropathy following acute intensive care stays and especially in the setting of the current global COVID-19 pandemic. Initiation of therapeutic-level anticoagulation remains controversial but should be considered for critically ill patients diagnosed with COVID-19 infection.