Case Presentation: A 60-year-old female with a history of ulcerative colitis, hypertension and paternal history of Huntington’s disease was diagnosed with mild COVID 19 infection in September 2021. Three weeks later, she started noticing that she was clumsy, and dropping things. She then started having jerky, spasmodic, involuntary movements of her head, upper extremities, and voice. The cadence of her speech was unpredictable. She had trouble eating. She was often confused intermittently. Then, she developed involuntary spasmodic contractions of her lower extremities, causing ambulatory dysfunction. She subsequently presented to the Emergency Room. Her vitals were unremarkable. Her speech displayed aspects of adductor spasmodic dystonia. Her cardiopulmonary exam and abdominal exam were normal. She was unable to move intermittently due to acute stiffening of her muscles. Her motor strength, sensory exam and reflexes were normal. She occasionally appeared to have elements of ballism and chorea, but these were more consistent with dystonia on careful exam. She failed to show any significant response to Cogentin and Benadryl in the Emergency Department. During hospital stay, she developed partial left abducens nerve palsy as well. Patient’s initial evaluation included CBC, BMP, LFT, TSH, ceruloplasmin, antigliadin, anti-endomysial, antiphospholipid antibodies, and autoimmune screen, all of which were normal. Her MRI brain, MRA head and EEG showed no abnormality. Lumbar puncture showed WBC 4, Glucose 65 mg/dl and protein 30 mg/dl. CSF Meningitis/encephalitis panel, CSF culture, CSF Lyme Screen and CSF pathology were negative. CSF ACE, CSF myelin protein, the Mayo Movement disorder serology and paraneoplastic disorder panel is pending at the time of this submission.Amantadine provided no relief. She was then treated with IVIG and 1g Solumedrol for 5 days for possible postinfectious autoimmune dystonia related to COVID 19 infection. She had partial relief in her symptoms and was stable enough to be discharged to rehab after a 10-day hospital stay.

Discussion: Movement disorders are now increasingly recognized even after mild cases of COVID 19 infection. The most prevalent disorder reported is myoclonus. Other neurologic manifestations reported include ataxia, oculomotor dysfunction, acute polyneuropathy, and encephalopathy. Dystonias are rare. Chorea is characterized by rapid, unpredictable, contractures affecting limbs, trunk and face with variable speed and direction, leading to the “dance-like” nature, whereas dystonia is characterized by more sustained or intermittent muscle movements and postures. The mechanism is still unknown, however direct neuro-invasion of the brainstem using the angiotensin (ACE2) receptors has been proposed. Other possible mechanisms leading to neurologic involvement include hypoxia, inflammatory cytokines, and autoimmune response. We treated our patient with IVIG based on published reports of good treatment response of other para-infectious movement disorders to IVIG.

Conclusions: COVID 19 disease can cause para- or post-infectious movement disorder. Different mechanisms, including autoimmune, have been postulated. A variety of clinical manifestations like myoclonus, oculomotor dysfunction, ataxia and encephalopathy have been described. Dystonias are rare but could be a crippling manifestation of this syndrome. IVIG and high dose steroids may help.