A case of probable Parkinson's disease after SARS-CoV-2 infe
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A 45-year-old Israeli man was diagnosed with probable Parkinson's disease several months after being hospitalized with SARS-CoV-2 infection.

The Ashkenazi Jewish patient had no family history of Parkinson's disease and had not been exposed to neurotoxins or recreational drugs, said authors in a case report published in The Lancet Neurology.

The patient was hospitalized for dry cough and muscle pain and tested positive for SARS-CoV-2 on admission, the researchers reported. In the hospital, the patient had fatigue, shortness of breath, and chest pain, but no fever. He was treated for 3 days -- mostly with salbutamol for mild asthma symptoms, with no need for systemic drugs, oxygen, or ventilation -- and then isolated in a COVID-19 facility.

During the 3-week isolation period, the patient's handwriting became less readable. He had difficulty speaking and typing text on his mobile phone and experienced tremor episodes in his right hand. He continued to have these symptoms at home and eventually was admitted to the neurology department about 2 months after his initial positive COVID-19 test.

There, he had reduced facial expression and soft speech, moderate cogwheel rigidity in his neck and right arm, and moderate bradykinesia in his right extremities. Symptoms were milder on his left side. His gait was slow, with no right arm swing, and he showed no cognitive decline.

CSF showed six white blood cells, with normal glucose and protein. Anti­-SARS­-CoV-­2 immunoglobulin G was seen in serum but not CSF, and CSF was negative for SARS-CoV­-2. PET imaging showed decreased ­18F-fluorodopa uptake in both putamens -- more apparent on the left side. Genetic testing for LRRK2 mutations and full sequencing of GBA variants were negative, as were tests for other genes relating to Parkinson's.

The patient was diagnosed with parkinsonism, based on Movement Disorders Society Unified Parkinson's Disease Rating Scale criteria of probable Parkinson's disease, and treated with extended-release pramipexole (Mirapex), which led to quick improvement.

New symptoms emerged during the 9 days of his second hospitalization, including tremor in both legs, more on the right side than the left. At discharge, he still had unreadable handwriting, bradykinesia, and cogwheel rigidity, mostly on the right side. A 5-day high-dose course of methylprednisolone had no consistent effect. In a follow-up visit on June 29, he was treated with biperiden, which improved his tremor.

One issue to consider is that there may no relationship between the actual virus and Parkinson's disease. "COVID-19 infection may have been a stressor that brings previously subtle, unrecognized symptoms to a point of awareness," noted researchers.

Source: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(20)30305-7/fulltext
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