Case Presentation: A 40-year-old healthy woman, presented with two weeks of cough, nasal congestion, sore throat, intermittent fevers, fatigue, and myalgia but no weakness. She tested positive for the SARS-Cov-2. Physical exam showed no neurologic deficit. Two weeks later, respiratory symptoms were improving but she developed sudden, leg pain, numbness, and weakness. She described it as a “pain crisis”. Neurological exam showed bilateral symmetrical, non-ascending lower extremity weakness and normal, symmetric reflexes. She had normal magnetic resonance imaging of the brain and spine, spinal fluid analysis, serum studies including creatinine kinase and C-reactive protein. She had elevated Lactate Dehydrogenase , low serum copper (72.9 (ref:80.0–155.0 ug/dL) and low vitamin B6 (14.6 (ref:20.0–125.0 nmol/L)). A diagnosis of SARS-Cov-2 associated peripheral neuropathy was considered. We pursued empiric treatment with intravenous steroids (1000mg methylprednisolone for three days); followed by a total of 2g/kg of IVIG given over five days. Pain management with gabapentin and ketorolac. We replaced copper and vitamin B6. Six weeks later, she reported improvement and was closer to baseline, but she endorsed residual, exertional, mild bilateral lower extremity pain, numbness, and weakness.
Discussion: Previous reports showed various neurological manifestations in about 36.4% of patients infected with SARS-Cov-2. However, peripheral neuropathy was only reported once before. Treatment of SARS-Cov-2 associated neuropathy has included corticosteroids and IVIG. Our patient saw the most symptomatic improvement with gabapentin. In our case, the preserved reflexes, lack of ascending pattern, sudden onset of symptoms, and normal CSF argued against Guillain-Barre Syndrome. Copper deficiency can result in myelopathy but not peripheral neuropathy, so is unlikely the sole explanation.
Conclusions: Awareness and early detection of neurological manifestations of SARS-Cov-2 can result in improved clinical outcomes for patients. Documenting this case study will increase the limited medical literature on SARS-Cov-2 peripheral neuropathy.