Concurrent tonic pupil and trochlear nerve palsy in COVID-19
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CASE REPORT
Concurrent tonic pupil and trochlear nerve palsy in COVID-19 Carlos M. Ordás 1
&
Javier Villacieros-Álvarez 1 & Ana-Isabel Pastor-Vivas 2 & Álvaro Corrales-Benítez 2
Received: 24 July 2020 / Revised: 19 August 2020 / Accepted: 28 August 2020 # Journal of NeuroVirology, Inc. 2020
Abstract Since COVID-19 was first reported, different neurological complications have been acknowledged, but their description is constantly evolving. We report a case of concurrent tonic pupil and trochlear nerve palsy in this context. A 62-year-old man reported a 5-day history of binocular vertical diplopia and blurred vision in his left eye, noticing that his left pupil was dilated. He had suffered a flu-like syndrome 2 weeks before. Clinical exam showed a right trochlear nerve palsy and a left mydriatic pupil. MRI, X chest ray, and analytical results were normal. Antibodies for SARS-CoV-2 were positive (low IgM and high IgG titers). Antiganglioside antibodies were negative. A 0.125% pilocarpine test confirmed Adie’s pupil diagnosis. The patient was treated with a tapered prednisone dose with resolution of his diplopia but no change in Adie’s pupil. This is the first case reporting Adie’s pupil as a postinfectious manifestation of COVID-19. An immune-mediated mechanism is presumed. Keywords COVID-19 . Adie’s pupil . Tonic pupil . Trochlear palsy . Postinfectious syndrome
Introduction
Case report
Since COVID-19 was recognized as a new disease in December 2019, different neurological symptoms have been reported such as headache, dizziness, consciousness impairment, and anosmia (Asadi-Pooya and Simani 2020). More recently, some cases of Guillain-Barre syndrome (GBS), mono or polyneuritis cranialis, and complete Miller-Fisher syndrome have broadened the neurological spectrum (Scheidl et al. 2020; Gutiérrez-Ortiz et al. 2020). Here, we report a case of a fourth cranial mononeuropathy coexisting with a contralateral tonic pupil developing 2 weeks after a SARS-CoV-2 infection. To our knowledge, this is the first case of tonic pupil reported in this particular context.
A 62-year-old man with an antecedent of hypertension attended our hospital reporting a 5-day history of binocular vertical diplopia and blurred vision in his left eye, noticing that his left pupil was dilated. No pain with ocular movements nor impairment in color vision was noticed. Three weeks prior, he had suffered a flu-like syndrome, including symptoms such as high fever, myalgia, intense coughing, and asthenia for 10 days. The general examination was normal. The neuroophthalmological exam revealed that ductions were apparently full and no evident ocular misalignment was found in primary gaze position, but an alternate cover test showed a subtle right hypertropia. Vertical diplopia was also noticed, which worsened in left gaze and was maximum at the down-and-left position, where right hypertropia was more evident in the alternate cover test. A double Maddox rod test revealed an excyclotorsion of the right eye, which was supported by a worsening of the dipl
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