Brachial plexopathy as a complication of COVID-19

Abstract

COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.

Keywords: infections; neurological injury; neuromuscular disease; pain (neurology); peripheral nerve disease.

Figure 1

D-dimer levels in the patient over the course of his hospitalisation. The black arrow indicates the first appearance of the microthrombotic rash. Reference range: 0–229 ng/mL.

Figure 2

Livedoid, retiform purpura of the left hand and forearm (A) on day 24, (B) on day 45 (day of initial neurological consultation) and (C) on day 50 (day following EMG/NCS). (D) The rash did not involve the left upper arm, despite weakness of these muscle groups. EMG, electromyography; NCS nerve conduction study.

Figure 3

MRI reveals diffuse left brachial plexitis (A: coronal T2 STIR 20 mm reformat) with denervation enhancement and oedema of the left serratus anterior (B: coronal T1 with gadolinium). STIR, short tau inversion recovery.