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Título

Parkinson’s Disease emerged during acute COVID-19 illness: a case report

RESUMO

Case Report

A 47-year-old female was evaluated in an outpatient setting with a complaint of asymmetrical rigidity, rest tremor and slowness. She had been hospitalized two months prior due to mild COVID-19, notably with anosmia and ageusia. The motor symptoms were noticed by the patient on the third day of hospitalization, with progressive worsening.
She has a medical history of chronic constipation and was taking multivitamins and pantoprazole. She lives in an urban area and works at a hospital laundry. She declined psychiatric or cognitive problems. Her family history was negative for neurological disorders.
On MDS-UPDRS part III she scored 37 points, presenting bradykinesia grade 4 in the right upper limb (LUL), grade 3 in the right lower limb (RUL) and grade 1 in LUL. She had unilateral grade 2 rest tremor in RUL, bilateral postural and intention tremor, and unilateral grade 2 rigidity in LUL.
The rest of the neurological exam was unremarkable. Laboratory assessment and brain MRI were normal. Functional study with SPECT with TRODAT showed bilateral putamen reduced captation, with right and left basal ganglia/occipital relation of 0.39 and 0.58, respectively (reference value: 1.98 ± 0.24). She was started on levodopa/benserazide 100/25mg TID. After 1 month, she noticed an improvement with a slight objective reduction of the MDS-UPDRS part III to 34 points (8.1% decrease). An increase in medication was considered, but the patient did not desire dose modification.

Discussion

Numerous neurological symptoms have been described in acute and long COVID-19. Among the theories involving the invasion of the CNS, there are the hematogenous route and axonal transport through the olfactory neuroepithelium.
To date, only three COVID-19-related parkinsonism cases have been reported. Same as our patient, two of them presented hyposmia. The SPECT with TRODAT was also abnormal in all three cases, and the motor symptom onset ranged between 10 and 32 days after PCR-confirmed diagnosis.

Final commentary

Although a latent hypokinetic rigid syndrome may be unmasked in the context of great stress or infection, possibly by depleting compensatory mechanisms, the acute presentation during viral illness may implicate a more direct causal relation. Thus, this case could represent either one of secondary parkinsonism, with a more benign prognosis, or of a neurodegeneration exacerbated or even triggered by COVID-19. Follow-up will help differentiate between the two scenarios.

Palavras Chave

COVID-19, parkinsonism

Área

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