Resident Physician Schwab Rehabilitation Hospital Chicago, Illinois, United States
Case Diagnosis: pan-brachial plexopathy of the right upper extremity following COVID-19 infection
Case Description: A 53 year-old male with history of diabetes with HgA1C 10.5 and recent 50-day hospitalization due to COVID-19 infection is admitted to acute inpatient rehabilitation for critical illness myopathy due to COVID-19 viral pneumonia. The patient was intubated for 27 days with a prone positioning protocol and noted right upper extremity weakness and paresthesia after extubation. He noted some improvement in the distal muscles of his right hand over time, but continues to experience difficulty with shoulder abduction, elbow flexion, and elbow extension. He was referred to the EMG clinic for evaluation of a possible brachial plexus injury.
Discussions: Physical examination revealed muscle strength of 0/5 for right shoulder abduction, elbow flexion, elbow extension, wrist extension, and finger extension. Right finger flexion was 4/5 and finger abduction was 2/5. Grip strength was decreased on the right. Muscle stretch reflexes were absent at the right biceps and triceps. The left upper extremity exam was normal. The NCS/EMG revealed an axonal upper trunk, posterior cord, and lateral cord brachial plexopathy as well as median neuropathy at the wrist and chronic peripheral neuropathy in the first dorsal interosseous muscle.
Conclusions: The novel COVID-19 has brought on many medical challenges. One major complication is the development of pneumonia with acute respiratory distress syndrome (ARDS) requiring intubation. Prone positioning is used to improve ventilation for the management of ARDS. Injury to the brachial plexus may result from prone positioning due to the compression and stretching of the brachial plexus when shoulders are posteriorly displaced in abduction and external rotation. Brachial plexus injuries should be considered in patients undergoing prone positioning.