A year ago this month, the coronavirus disease presented itself in Wuhan, China, as an aggressive viral pneumonia. Initially, little was known regarding the functional changes associated with the disease. As it spread to the U.S. and caseloads grew exponentially, symptoms revealed that the disease attacked numerous organ systems, including the nervous system.
A case study
As described in “A Case Report of Coronavirus Disease 2019 Presenting with Tremors and Gait Disturbance,” a 46-year-old male (let’s call him John) was brought to the hospital with complaints of a severe cough, fever, muscle pain, progressive shortness of breath, sore throat, and night sweats. Before being brought in, John was treated by his primary care physician with a course of amoxicillin-clavulanate. After seven days of treatment, John presented with tremors and had trouble walking. No other symptoms were present, such as nausea, fever, vomiting, diarrhea, constipation, chest, or abdominal pain. Before entering self-quarantine, he told the medical staff that several of his co-workers displayed flu-like symptoms.
According to the report, John’s blood pressure was 130/87, his temperature was 97.9º Fahrenheit, his pulse rate was 108 beats per minute, his respiratory rate was 22 breaths per minute, and his blood oxygenation level was at 96%. His respiratory evaluation confirmed he had clear and equal breaths while his neurologic exam revelated his mental status was unimpaired. Doctors ruled out the presence of dysarthria, aphasia, or neglect. Still, his cranial nerves exam detected irregular incidental episodes of two or more fast eye movements (saccadic intrusions) despite John being able to closely follow moving objects (smooth pursuit).
When John laid down, he presented with a generalized tremor and a postural tremor in all his extremities. His heel-to-shin assessment was non-dystaxic, although tremulous, and there was a bilateral intention tremor. During his motor exam, he had normal tone and durability in all his upper and lower extremities. His chart stated he had a wide-based gait with instability with no dysmetria, pronator drift, or truncal ataxia.
A computed tomography of the head and CT angiogram did not find anything out of the ordinary. A chest radiograph revealed that John’s lungs were clear while an MRI showed hyperintense foci in the bifrontal subcortical and deep white matter on scattered T2-weighted, fluid-attenuated inversion recovery.
A course of action
John was treated with a medication called propranolol, a beta-blocker used to treat tremors for 40 years. With this course of action, John reported a moderate recovery from symptoms.
Tremors associated with COVID-19
Studies have shown that SARS-CoV-2 (the virus that causes COVID-19) can infiltrate the brain and spread to various areas. Based on a study of 214 COVID-19 patients in Wuhan, China, 36.4% of patients presented with neurological symptoms.
While similar neurologic manifestations, with postural and action tremors, have been reported with other viral infections, it is believed that this is the first known case of tremors as a result of COVID-19. Due to these findings, physicians should be attentive when diagnosing patients who present with unexplained neurologic symptoms, especially when early diagnosis helps prevent transmission.