Can COVID-19 accelerate neurodegeneration?
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Herein, authors report a case with rapidly progressive parkinsonism during the COVID-19 pandemic.

A 67-year-old right-handed man was referred for movement disorders centers 4 months after the COVID-19 pandemic get started in Iran. In March 2020, he had had several episodes of falls after changing position from sitting to standing, dry mouth and skin, tachycardia, and constipation, then bradykinesia was added to his symptoms and he received levodopa/carbidopa 600/150mg which caused hallucination and the patient did not take it anymore.

At that time, systemic evaluation, chest CT, and SARS-CoV-2 PCR were negative. His neurological examination showed intact cognition, eye movements were normal, he had mild bilateral action tremor on his hands, severe rigidity on limbs, severe generalized bradykinesia, and pizza sign, and he could not walk without support, and while walking his gait was wide-based. Sensory and motor examination was unremarkable; he did not have appendicular ataxia.

Besides, he had orthostatic hypotension, and his systolic pressure dropped (systolic blood pressure 30 mmHg and diastolic 20 mmHg) after changing position from lying to sitting, he could not stand for three minutes to check blood pressure. Brain MRI including DWI sequence did not show any abnormalities, and routine laboratory tests came back negative. The electroencephalogram was normal. EMG-NCS did not show any abnormal findings, and paraspinal muscle needle EMG did not reveal continuous muscle activity. CSF RT-QuIc for sporadic Creutzfeldt-Jakob (SCJ) and 14.3.3 proteins were negative.

An autoimmune panels including Glutamate Receptors, DPPX, AMPA1/2 (GluR1/GluR2), LGI1, CASPR2, GABA RB1/2, Amphiphysin, Recoverin, PNMA2 (Ma2/Ta), AGNA (Sox1), Anti CRMP5 (CV2), titin, Ri/ ANNA-2, Zic4, Yo/PCA-1, GAD65, Hu/ANNA-1, and PCA-Tr (DNER) were checked on CSF and blood, and all were negative. Work-ups for malignancy including whole-body scan, chest and abdominal CT scan did not show any pathology. SARS-CoV-2 PCR has been checked several times during the last four months but was negative. He received Levodopa/benserazide 150/37.5 mg and gradually increased to 300/75 mg and lead to mark improvement, and he could walk with a cane afterward, but urge incontinence was added to his symptoms.

Brain MRI was done again and did not show any change from the previous one. After four months due to malaise, SARS-CoV-2 PCR has been checked and was positive; therefore, the patient took conservative management at home and recovered. He did not experience anosmia or respiratory symptoms. But his parkinsonism got worsened subsequently, and he could not walk independently. In addition, he suffered from hallucination and cognitive decline. Laboratory workups including inflammatory markers (CRP, ESR, blood count, etc) did not show any abnormalities. Unfortunately, after two months in January 2021, he had a cardiac arrest and died.

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