Case of Petrous Apicitis After COVID-19 Infection

Clinical Correspondence Case of Petrous Apicitis After COVID-19 Infection Wissam B. Nassrallah, PhD, Lyne Noel de Tilly, MD, Jonathan A. Micieli, MD P etrous apicitis (PA) is typically associated with Gradenigo syndrome, a clinical triad of otitis media, facial pain, and abducens palsy usually from infection although less than half of the patients present with all 3 symptoms.1 Streptococcus pneumoniae, hemophilus influenzae, pseudomonas, staphylococcus, tuberculosis, and fungal infections typically affect the middle ear initially and then progresses to PA.1 Thus, the treatment for PA is usually an antibiotic targeting the offending organism. We present a novel case of PA after SARS-CoV-2 infection. A 32-year-old man was referred for new binocular double vision worse when looking left. He had a history of COVID-19 that manifested with headache, nasal congestion, and sore throat. SARS-CoV-2 infection was confirmed with a rapid antigen test. After 1 week, his nasal congestion and sore throat resolved, but the headache persisted. The pain was located mainly on the left. Two weeks after his initial symptoms, he developed new double vision. He presented to the emergency room and had a CT/CTA of the head and neck that showed no abnormality, including no erosive skull base lesion. He also had an MRI of the brain without contrast that was reported as normal. Bloodwork was performed and included CBC, electrolytes, ESR, CRP, HbA1c, and lipid panel that were normal. His headache intensified behind his left eye, and he was referred to neuro-ophthalmology for further evaluation. The neuro-ophthalmology assessment revealed a visual acuity of 20/20 in each eye and pupils were equal and reactive. There was a complete limitation of abduction in the left eye, and ocular ductions were otherwise full. He had reduced sensation to light touch in the left V1 distribution and mildly reduced corneal sensation in the left eye. The remainder of the trigeminal nerve function was normal. There were no conjunctival injection, proptosis, or eyelid changes. His optic nerves appeared normal in both eyes. The pain and limitation of abduction in the left eye was believed to be related to an orbital or cavernous sinus lesion. He underwent MRI Faculty of Medicine (WBN), University of British Columbia, Vancouver, Canada; Division of Neuroradiology (LNdT), Department of Medical Imaging, St. Michael’s Hospital, University of Toronto, Toronto, Canada; Department of Ophthalmology and Vision Sciences (JAM), University of Toronto, Toronto, Canada; and Kensington Vision and Research Centre (JAM), Toronto, Canada. The authors report no conflicts of interest. Address correspondence to Jonathan A. Micieli, MD, Kensington Vision and Research Centre, 340 College Street, Suite 501, Toronto, ON M5T 3A9, Canada; E-mail: [e-mail] e438 brain and orbits with contrast, and this showed altered marrow signal with associated enhancement in the left petrous apex and adjacent lateral clivus/dorsum sellae (Fig. 1). Both the fifth and sixth cranial nerves appeared radiologically normal. He underwent a workup for inflammatory and infectious etiologies and the following tests were normal or negative: ANA, ANCA, VDRL, ACE, IgG4, NMO, MOG-IgG, and TSH. He underwent a lumbar puncture that showed normal protein, cell count, and glucose. CT of the chest, abdomen, and pelvis was normal. Treatment with prednisone 1 mg/kg was initiated. His headache promptly responded within 48 hours, and his eye movements gradually improved. At the 1-month follow-up, the sixth nerve palsy was improved, but not resolved. The prednisone was tapered over 2 months, and the sixth nerve palsy and reduced V1 sensation resolved at the 3-month follow-up. At that time, there was no limitation of eye movements, and he was orthophoric. He remained symptom-free with a normal examination at the 6-month follow-up (Fig. 2). There has been an increase in the number of ophthalmoparesis cases described in the literature after SARS-CoV-2 infection. These case reports have shown that the affected population covers a wide age range, and that many of them are otherwise healthy individuals.2 Here, a 32-year-old male patient developed an abducens nerve (CN VI) and trigeminal nerve (CN V) palsy in temporal relation to COVID-19. CN VI runs over the superomedial surface of the petrous apex before entering the Dorello canal, and CN V runs over the surface of the petrous apex and leaves an impression on the anteriorlateral surface called the Meckel cave. The MRI finding of altered marrow signal with associated enhancement in the left petrous apex is consistent with CN VI and CN V being affected given their proximity to the petrous apex. Furthermore, the ophthalmic branch of CN V runs in the lateral wall of the cavernous sinus which given the increasing headache behind the patient’s left eye and the MRI finding of mild asymmetry of the left cavernous sinus is consistent with the cavernous sinus involvement demonstrated on the MRI. The most common cause of PA is bacterial and consists of streptococcus pneumoniae, hemophilus influenzae, pseudomonas, staphylococcus, tuberculosis, and fungal infections which typically affect the middle ear and then progresses to PA.1 Thus, the treatment for PA is usually an antibiotic targeting the offending organism.3 Our patient Nassrallah et al: J Neuro-Ophthalmol 2024; 44: e438-e439 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence FIG. 1. MRI. Axial T1 image (A) and fat suppressed axial T1 image postgadolinium administration (B) demonstrate low signal in the left petrous apex and adjacent lateral clivus and moderate enhancement in the same region (white circles). FIG. 2. MRI. Axial T1 image (A) and fat suppressed axial T1 image postgadolinium administration (B) after treatment demonstrate restauration of the expected marrow signal and resolution of the marrow enhancement (white circles). had no signs of bacterial infection, and the lumbar puncture did not show signs of meningitis. Normally, if antibiotic therapy fails, complications may develop, and surgical intervention is the next step.3 In this case, the PA was either caused directly by SARS-CoV-2 infection or was idiopathic, of which there is no report in the literature. Furthermore, prednisone was given to treat the inflammation, which was believed to be the underlying mechanism induced by the virus. The treatment also coincided with the headache resolution and the CN VI palsy gradually improving. Therefore, no surgical intervention was necessary. As of now, the pathophysiological mechanism behind SARS-CoV-2 infections leading to PA or any other ophthalmological manifestations is unclear. It is unknown whether these conditions arise from the virus directly causing damage, aggravating an underlying condition, or whether the body’s own immune response to the virus is responsible. Tolosa–Hunt syndrome, described as a unilateral headache with restricted eye movements, is idiopathic and believed to be due to nonspecific inflammation in the cavernous sinus.4 Perhaps this case of PA may have a similar mechanism. One study shows that SARS-CoV-2 can directly infect microglia cells, leading to an M1-like proinflammatory response.5 This may be the underlying mechanism of inflammation in this case, but the reason as to why this would be localized to the petrous apex and the cavernous sinus remains unclear. This case adds an additional neuro-ophthalmic manifestation to SARS-CoV-2 viral infection. The patient tolerated prednisone well, with apparent resolution of symptoms, suggesting this was a manifestation of an inflammatory response to either an underlying infection, or perhaps a parainfectious or autoimmune response. It is also advised to perform a thorough review of systems of any patient with SARS-CoV-2 infection because symptoms could manifest in any organ including the eye and its visual and oculomotor pathways. Nassrallah et al: J Neuro-Ophthalmol 2024; 44: e438-e439 STATEMENT OF AUTHORSHIP Conception and design: J. A. Micieli; Acquisition of data: J. A. Micieli, L. Noel de Tilly; Analysis and interpretation of data: J. A. Micieli, W. B. Nassrallah, L. Noel de Tilly. Drafting the manuscript: J. A. Micieli, W. B. Nassrallah; Revising the manuscript for intellectual content: J. A. Micieli, W. B. Nassrallah. Final approval of the completed manuscript: J. A. Micieli. REFERENCES 1. Talmor G, Vakil M, Tseng C, Svider P, Ying M, Eloy JA. Petrous apicitis: a systematic review and case presentation. Otol Neurotol. 2022;43:753–765. 2. Sen M, Honavar SG, Sharma N, Sachdev MS. COVID-19 and eye: a review of ophthalmic manifestations of COVID-19. Indian J Ophthalmol. 2021;69:488–509. 3. Gadre AK, Chole RA. The changing face of petrous apicitis-a 40year experience: the changing face of petrous apicitis. Laryngoscope. 2018;128:195–201. 4. Amrutkar C, Burton EV. Tolosa-hunt syndrome. In: StatPearls. StatPearls Publishing, 2022. Available at: https://www.ncbi. nlm.nih.gov/books/NBK459225/. 5. Jeong GU, Lyu J, Kim KD, et al. SARS-CoV-2 infection of microglia elicits proinflammatory activation and apoptotic cell death. Microbiol Spectr. 2022;10:e0109122. e439 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.