ICU-Acquired Weakness Complicated With Bilateral Foot Drop After Severe COVID-19: Successful Rehabilitation Approach and Long-Term Follow-Up

Abstract

Coronavirus disease 2019 (COVID-19) is associated with muscle and nerve injuries as a consequence of prolonged critical illness. We report here a case of intensive care unit-acquired weakness (ICU-AW) with bilateral peroneal nerve palsy after COVID-19. A 54-year-old male with COVID-19 was transferred to our hospital. He was treated by mechanical ventilation and veno-venous extracorporeal membrane oxygenation (VV-ECMO), from which he was successfully weaned. However, by day 32 of ICU admission, he had developed generalized muscle weakness with bilateral foot drop and was diagnosed with intensive care unit-acquired weakness complicated with bilateral peroneal nerve palsy. Electrophysiological examination showed a denervation pattern in the tibialis anterior muscles, indicating that the foot drop was unlikely to recover immediately. Gait training with customized ankle-foot orthoses (AFO) and muscle-strengthening exercises were started as part of a regimen that included a stay in a convalescent rehabilitation facility and outpatient rehabilitation. Seven months after onset, he returned to work, and 18 months after onset, he had improved to the same level of activities of daily living (ADLs) as before onset. Outcome prediction by electrophysiological examination, appropriate prescription of orthoses, and continuous rehabilitative treatment that focused on locomotion contributed to the successful outcome in this case.

Keywords: ankle-foot orthosis; bilateral peroneal nerve palsy; coronavirus disease 2019; electorophysiological examination; polyneuropathy.

Figure 1. Clinical course during the acute hospitalization period

Dexamethasone was continued and tocilizumab was started on day 1. The patient was intubated on day 9. In view of his poor respiratory status, he was kept under deep sedation using dexmedetomidine, propofol, and midazolam. Rocuronium bromide was also administered. Mobilization was started on day 32. After being weaned from mechanical ventilation, swallowing assessment and training were provided by a speech therapist. He was able to shift from enteral nutrition to an oral diet on day 47. His food intake was normal by the time of discharge. On day 40, his MRC-SS (0-60, none to full) was low at 28. At discharge, he had improved muscle strength in the upper limbs and in the proximal muscles of the lower extremities, his MRC-SS had improved to 34, and his FIM score was 74. ADL, activities of daily living; AFO, ankle-foot orthoses; DEX, dexmedetomidine; FIM, Functional Independence Measure; GS, grip strength; HFNC, high-flow nasal cannula; L, left; MRC-SS, Medical Research Council sum score; MDZ, midazolam; MV, mechanical ventilation; OT, occupational therapy; PT, physical therapy; R, right; ROC, rocuronium bromide; ST, speech therapy; VV-ECMO, veno-venous extracorporeal membrane oxygenation

Figure 2. Chest computed tomography on admission

Chest computed tomography showed ground-glass shadows and consolidation in both lungs.