Dizziness in SARS-CoV2: A Red Flag to Clinicians
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A 61 years old man, a known hypertensive, presented with a history of fever, loss of appetite and progressive difficulty in breathing of one week. His nasopharyngeal swabs for COVID-19 using reverse transcriptase polymerase chain reaction (RT-PCR) tested positive and the chest x-ray showed bilateral infiltrates. Initial investigations revealed increased d-dimer, ferritin, lactate dehydrogenase and international normalized ratio (INR) of 1.04 and thrombocytosis. His ECG was normal.

In view of severe COVID-19 pneumonia, he was started on low molecular weight heparin 60 mg subcutaneously twice a day, methylprednisolone 40 mg twice daily, remdesivir 200mg followed by 100 mg once a day for five days started on the third day.

The patient remained alert, afebrile, hemodynamically stable and showed progressive improvement and his oxygen requirements were gradually tapered to maintain an oxygen saturation of 94-96%. On the fourth day, he complained of dizziness which was initially treated symptomatically with rest and oral betahistine. The d-dimer levels showed a decreasing trend on day 4 reducing to 441.36 ng/ml FEU by the tenth day.

The dizziness did not subside and the symptoms gradually progressed to increasing ataxia and mild right hemiparesis by the tenth day. The CT scan of the brain showed right cerebellar infarct and CT angiogram of the cerebral vessels was normal, except for a hypoplastic right vertebral artery. Aspirin 150 mg daily along with statins was added. The weakness had improved well with persisting gait ataxia at the time of discharge.

This case highlights the importance of having a low threshold to investigate for the possibility of a stroke in patients with COVID-19 reporting seemingly innocuous symptoms like dizziness and loss of balance. The case also brings to the foreground the occurrence of stroke in patients with moderate to severe COVID-19 in spite of administering therapeutic doses of LMWH and downward trend of d-dimer levels, thereby suggesting other possible pathogenic mechanisms.

Source: https://www.japi.org/x2648454/dizziness-in-sars-cov2-a-red-flag-to-clinicians
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