Opsoclonus-Myoclonus in COVID-19 Infection. A Known Clinical Presentation in New Disease

Photo and Video Essay Section Editors: Melissa W. Ko, Dean M. Cestari, Peter Quiros, Kimberly M. Winges, MD MD MD MD Opsoclonus–Myoclonus in COVID-19 Infection. A Known Clinical Presentation in New Disease Tonse A. Kini, MBBS, Zain Guduru, MD A 39-year-old healthy woman with no known medical history, postpartum after delivery of a healthy baby, tested positive for COVID-19 when she developed respiratory distress that required intubation. After stabilization of her respiratory status, she was extubated. She was then noted to have multidirectional rapid eye movements and spontaneous jerking movements in the extremities. Ataxia was unable to be demonstrated because the patient was unable to follow commands during the acute phase of the illness. Rest of neurologic and ophthalmologic examination was unremarkable. Initial laboratory work, MRI of the head with and without contrast, full-body computed tomography scan, and serum paraneoplastic panel were unremarkable; infectious workup was negative (except COVID-19), and the patient was diagnosed with post–COVID-19 opsoclonus–myoclonus syndrome after ruling out other toxic, metabolic, and alternate infectious etiologies. Myoclonus improved with valproic acid (10 mg/kg/d), and opsoclonus resolved gradually over the next few days; she was discharged home (see Supplemental Digital Content, Video, http://links.lww.com/WNO/A574). A para infectious etiology for opsoclonus–myoclonus ataxia syndrome has been previously described with bacterial and viral infections. Positive, negative, and stimulus-induced myoclonus has been described in the literature, and the myoclonus could be generalized or isolated. COVID-19 has recently emerged as an etiology for this rare and interesting movement disorder (1). Cases have been reported in the literature recently, suggesting overall good prognosis and improvement of symptoms over few weeks. Treatment tried includes antiepileptic agents such as valproic acid, levetiracetam, steroids, and even intravenous immunoglobulin with variable response (2). The exact pathogenesis remains unknown, but owing to response to steroids, IVIG is believed to be autoimmune with target on Purkinje cells in the cerebellum (3). Other theories suggested include direct CNS invasion of virus or secondary to hypoxic insults from pulmonary disease (4). Video legend: involuntary, chaotic, and multidirectional conjugate saccadic ocular movements suggestive of opsoclonus. Multifocal, sudden, brief involuntary jerking movements suggestive of myoclonus are noted in extremities. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: T. A. Kini; b. Acquisition of data: Z. Guduru; c. Analysis and interpretation of data: A. Kini. Category 2: a. Drafting the manuscript: T. A. Kini; b. Revising the manuscript for intellectual content: Z. Guduru. Category 3: a. Final approval of the completed manuscript: Z. Guduru. REFERENCES 1. Emamikhah M, Babadi M, Mehrabani M, Jalili M, Pouranian M, Daraie P, Mohaghegh F, Aghavali S, Zaribafian M, Rohani M. Opsoclonus-myoclonus syndrome, a post-infectious neurologic complication of COVID-19: case series and review of literature. J Neurovirol. 2021;27:26–34. 2. Shah PB, Desai SD. Opsoclonus myoclonus ataxia syndrome in the setting of COVID-19 infection. Neurol. 2021;96:33. 3. Connolly AM, Pestronk A, Mehta S, Pranzatelli MR, Noetzel JM. Serum autoantibodies in childhood opsoclonus-myoclonus syndrome: an analysis of antigenic targets in neural tissues. J Pediatr. 1997;130:878–884. 4. Koralnik IJ, Tyler KL. COVID-19: a global threat to the nervous system. Ann Neurol. 2020;88:1–11. Department of Neurology (TAK, ZG), University of Kentucky, Lexington, KY. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the full text and PDF versions of this article on the journal’s Web site (www. jneuro-ophthalmology.com). Address correspondence to Tonse A. Kini, MBBS, T 740, S Limestone, Lexington, KY 40536; E-mail: [e-mail] e526 Kini and Guduru: J Neuro-Ophthalmol 2022; 42: e526 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.