Pediatric SARS-CoV-2-Related Diplopia and Mesencephalic Abnormalities

Abstract

Objective: This case report describes a patient with mesencephalic MRI signal abnormality and diplopia, possibly associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Methods: We describe a boy with binocular diplopia and nystagmus. The pattern of serology positivity and negative direct research of SARS-CoV-2 RNA in our patient allowed us to consider novel coronavirus as the trigger of possible immune-mediated phenomena against the central nervous system.

Results: During hospitalization, blood tests revealed a recent SARS-CoV-2 infection. MRI revealed hyperintensity of the mesencephalic tegmentum and periaqueductal region, consistent with an inflammatory lesion of the midbrain tegmentum. Viral and bacterial molecular screening on cerebrospinal fluid and isoelectrofocusing analysis, anti-myelin oligodendrocyte glycoprotein, anti-aquaporine-4, and anti-N-methyl-d-aspartate antibodies were negative. The patient was treated with steroids and immunoglobulin therapy with complete remission of neurologic symptoms.

Discussion: This report expands the spectrum of pediatric COVID-19-associated neurologic symptoms and highlights a possible isolated neurologic COVID-19-related symptom.

Figure. Brain MRI Findings at the Onset and Follow-up

Sagittal (A.a) and axial (A.b) fluid attenuated inversion recovery (FLAIR) images at admission showing hyperintensity of the midbrain tegmentum (arrows) consistent with an inflammatory lesion. Sagittal (B.a) and axial (B.b) FLAIR images after 1 month showed a reduction of midbrain lesions. Sagittal (C.a) and axial (C.b) FLAIR images acquired after 4 months showed complete resolution of signal changes.