PMC8741194_01
Brain magnetic resonance imaging (MRI) and electrophysiological tests. (A) Chest computed tomography detected possible COVID-19 pneumonia on admission. (B) Axial brain MRI diffusion weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) images on admission. No abnormalities were detected. (C) Nerve conduction study on the 6th day from onset (i.e., hospital day 2). The motor nerve conduction study revealed a slight reduction in compound muscle action potential amplitudes and no conduction block with an apparent increase of stimulation threshold. The orthodromic sensory nerve conduction study showed a reduction in sensory nerve action potentials. F-wave examination exhibited no responses in the upper and lower extremities. CMAP, compound muscle action potential; SNAP, sensory nerve action potential. (D) Blink reflex test on day 7 (i.e., hospital day 3) showed bilateral loss of both R1 and R2 with bilateral trigeminal nerve stimulation. (E) Median nerve somatosensory evoked potential testing on day 6 (i.e., hospital day 2). P13/14 and N18 were normally evoked, whereas N20 was lost. These results suggested interruption of the somatosensory pathway in the brainstem. Ai, the ipsilateral earlobe. CPc and CPi, the centroparietal electrode contralateral and ipsilateral to the stimulation, respectively. C2S, the spinous process over the second cervical spine. Fz, the midline frontal electrode. NC, non-cephalic reference on the contralateral shoulder. (F) Standard 12-lead electrocardiography on admission (day 5) demonstrated inverted T-waves in leads I, II, aVF, and V1-V6. (G) Transthoracic echocardiography on admission (day 5). Images in end-diastole (left) and end-systole (right) revealed segmental wall motion abnormalities with apical akinesis (arrows) and hyperkinesis in the basal segments, which was compatible with Takotsubo cardiomyopathy.
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Coma Scale (GCS), E1V1M1] with blood pressure of 152/114 mmHg, heart rate of 120 beats per minute, and body temperature of 33.2 C. Chest computed tomography (CT) detected bilateral pneumonia, presumably caused by COVID-19 (Figure 1A). Brain magnetic resonance imaging (MRI) detected no significant abnormalities (Figure 1B). F-wave examination showed no responses in the upper and lower extremities (Figure 1C). During median nerve somatosensory evoked potential testing, normal P13/14 and N18 were detected, whereas N20 was lost (Figures 1D,E). On the other hand, electrocardiography showed deep T-wave inversions in multiple leads (Figure 1F). Transthoracic echocardiography showed apical akinesis with preserved basal function and a depressed ejection fraction of ~50%, consistent with the diagnosis of TCM (Figure 1G).
Clinical course. Clinical and treatment course. The horizontal axis represents the day from onset. BNP, B-type natriuretic peptide; CK, creatine kinase; EOM, extraocular movement; GCS, Glasgow Coma Scale; IVIG, intravenous immunoglobulin therapy (400 mg/kg/day for 5 consecutive days); IVMP, intravenous methylprednisolone pulse therapy (1 g/day for 3 consecutive days); mRS, modified Rankin scale (0, no symptoms; 1, no significant disability; 2, slight disability, able to look after own affairs without assistance, but unable to carry out all previous activities; 3, moderate disability, require some help, but able to walk unassisted; 4, moderately severe disability, unable to attend to own bodily needs without assistance, and unable to walk unassisted; 5, severe disability, require constant nursing care and attention, bedridden, incontinent); NAd, noradrenaline administration; PE, plasma exchange; TnI, troponin I.
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For BBE, two cycles of intravenous methylprednisolone pulse therapy (IVMP, 1 g/day for 3 consecutive days) and intravenous immunoglobulin therapy (IVIG, 400 mg/kg/day for 5 consecutive days) were simultaneously started on day 6 (i.e., hospital day 2) because sustained hemodynamic instability did not allow for plasmapheresis (Figure 2). She became able to obey some commands although it was hard to open her eyes actively because of external ophthalmoplegia (GCS, E1VTM6) on day 24 (Figure 2).