New-Onset Movement Disorders Associated with COVID-19

Abstract

Introduction: Movement disorders are increasingly described in hospitalized and milder cases of SARS-CoV-2 infection, despite a very low prevalence compared to the total patients.

Methods: We reviewed the scientific literature published in English, spanning from the initial descriptions of COVID-19 until January 25, 2021, in the PubMed/MEDLINE database.

Results: We identified 93 new-onset movement disorders cases (44 articles) from 200 papers screened in the database or reference lists. Myoclonus was present in 63.4% (n = 59), ataxia in 38.7% (n = 36), action/postural tremor in 10.8% (n = 10), rigid-akinetic syndrome in 5.38% (n = 5), oculomotor abnormalities in 20.4% (n = 19), catatonia in 2.1% (n = 2), dystonia in 1.1% (n = 1), chorea in 1.1% (n = 1), functional (psychogenic) movement disorders in 3.2% (n = 3) of the reported COVID-19 cases with any movement disorder. Encephalopathy was a common association (n = 37, 39.78%).

Discussion: Comprehensive neurophysiological, clinical, and neuroimaging descriptions of movement disorders in the setting of SARS-CoV-2 infection are still lacking, and their pathophysiology may be related to inflammatory, postinfectious, or even indirect mechanisms not specific to SARS-CoV-2, such as ischemic-hypoxic brain insults, drug effects, sepsis, kidney failure. Cortical/subcortical myoclonus, which the cited secondary mechanisms can largely cause, seems to be the most common hyperkinetic abnormal movement, and it might occur in association with encephalopathy and ataxia.

Conclusion: This brief review contributes to the clinical description of SARS-CoV-2 potential neurological manifestations, assisting clinical neurologists in identifying features of these uncommon syndromes as a part of COVID-19 symptomatology.

Highlights: - Movement disorders are probably uncommon neurological manifestations in SARS-CoV-2 infection;- Myoclonus is the most reported movement disorder associated with COVID-19, its clinical complications or pharmacological management;- The pathophysiology is yet not well-understood but can include systemic inflammation, autoimmune mechanisms, or hypoxia.

Keywords: COVID-19; SARS-CoV-2; ataxia; chorea; movement disorders; myoclonus; opsoclonus; parkinsonism.

Figure 1

Prisma flowchart for a systematic review of articles on new-onset movement disorders and COVID-19 from PubMed database on January 25, 2021. Search criteria used: “COVID-19” OR “SARS-CoV-2” OR “Coronavirus Disease 2019” OR “2019 n-CoV” OR “2019 Novel Coronavirus” AND (“movement disorders” OR “myoclonus” OR “ataxia” OR “parkinsonism” OR “Parkinson’s disease” OR “chorea” OR “dystonia” OR “myoclonus” OR “catatonia” OR “tremor”).

Figure 2

COVID-19-associated new-onset movement disorders: case counts in the reported original articles sample. A scale measuring total case counts ranges from 0 to 17 and is visually represented using a color scale ranging from light green to dark blue.

Figure 3

The bar plots’ numbers depict the Bayesian binomial posterior proportion of the described movement disorders or associated phenomenology to the total number of described cases (N = 93) in the reviewed articles. The error bar reflects the error in the posterior estimates. Data source: extracted from individual patients, original articles.

Figure 4

Posterior beta densities from the Bayesian zero-inflated Poisson (ZIP) regressions. The thick segments indicate 50% intervals, while the thinner outer lines indicate 90% intervals. The points in the above plot indicate the posterior medians. Data source: extracted from individual cases, original articles.