We read with interest the case report by Della Corte et al. detailing a 12-year-old male with neuro-COVID presenting with drowsiness, memory impairment, prosopagnosia, myoclonus, and other neurological symptoms, all of which resolved following treatment with intravenous immunoglobulins (IVIG). While the case is noteworthy, we raise several concerns. The claim that this is the first pediatric case of SARS-CoV-2–associated myoclonus is questionable, as earlier reports have described similar presentations. Furthermore, the patient exhibited signs of Quadri spasticity, clonus, and a positive Babinski sign, suggesting involvement of the pyramidal tract—findings that were not fully explored in the original report. Discrepancies exist between the described clinical findings and the supplementary video data, particularly regarding limb involvement. Essential diagnostic details, such as video-EEG, spinal MRI, inflammatory markers (e.g., interleukin-6, D-dimer), and the exclusion of venous sinus thrombosis, are missing. The delayed initiation of a neurological work-up also raises concerns. While the report is significant for being the first to link prosopagnosia with pediatric neuro-COVID, other key neurological features were insufficiently addressed, limiting the strength and interpretation of the study’s conclusions.
We eagerly read the article by Della Corte et al. [1] about a 12 years old male with neuro-COVID manifesting with drowsiness, memory impairment, lassitude, difficulty in recognising familiar faces and positive and negative myocloni in the face and the limbs. Clonazepam and steroids were ineffective regarding the myocloni but administration of Intravenous Immunoglobulins (IVIG) was followed by complete resolution of the myolconi and the other neurological and neuropsychological deficits within one month [1]. The study is appealing but raises concerns which require discussion.
We do not agree with the statement that the index patient is the first pediatric patient in whom SARS-CoV-2 associated myoclonus was diagnosed [1]. Also Wiegand et al. claimed to have reported first pediatric patient with opsoclonus myoclonus syndrome [2]. Myoclonus syndrome in this patient was already known previously but exacerbated during a SARS-CoV-2 infection [2]. The third patient is a 4 months old SARS-CoV-2 positive female with opsoclonus, that completely resolved upon application of steroid and IVIG [3].
The index patient obviously also had quadrispasticity as tendon reflexes were generally increased and as there was foot clonus. The patient obviously also had prosopagnosia (face blindness) as detected on repeated neuropsychological testing.
According to the supplementary video 1 the index patient had a positive, spontaneous Babinsky sign on the right side. The discrepancy between the description of the neurological exam in the text and the video should be solved.
According to video 2 the index patient also had cloni of the left upper limb [1]. Were serial EEGs recorded and did any of them ever disclose focal, paroxysmal activity? Missing is a video-EEG recording to reliably confirm or exclude seizure activity.
Missing is the exact latency between onset of the SARS-CoV-2 infection respectively the positive PCR for SARS-CoV-2 and the onset of neuro-COVID.
Missing is an MRI of the spinal cord with contrast medium. As cerebral imaging, Electroencephalography (EEG) and Cerebrospinal Fluid (CSF) investigations were non-informative, it is conceivable that at least the myocloni of the limbs were triggered by a spinal lesion.
Missing is the information about blood chemical values such as interleukin-6 and coagulation parameters, such as the D-dimer. Since Venous Sinus Thrombosis (VST) can be a complication of a SARS-CoV-2 infection [4], it is crucial that VST is appropriately excluded or confirmed by providing the D-dimer and a Magnetic Resonance Venography (MRV). VST can go along without headache and can go undetected on routine MRI. VST may manifest exclusively with neuropsychological deficits [5].
It is not comprehensible why it took >1 month before work-up of neuro-COVID was initiated.
Overall, the study has limitations which challenge the results and their interpretation. The index patient is obviously the first in whom prosopagnosia was reported as a manifestation of a SARS-CoV-2 infection but not the first with myocloni as a manifestation of neuro-COVID. Several neurological manifestations, such as quadrispasticity, tremor respectively cloni and a pyramidal tract lesion were not appropriately addressed.
Conflict of Interest
The authors declare no conflicts of interest.
Funding
No funding was received.
Author Contribution
Josef Finsterer: Design, literature search, discussion, first draft, critical comments:
Informed consent: was obtained
The study was approved by the institutional review board
Della Corte, M. et al. "Neuropsychiatric syndrome with myoclonus after SARS-CoV-2 infection in a paediatric patient." Clinical Neurology and Neurosurgery, vol. 213, 7 Jan. 2022, p. 107121. https://doi.org/10.1016 /j.clineuro.2022.107121.
Wiegand, S. et al. "Immunotherapy responsive SARS-CoV-2 infection exacerbating opsoclonus myoclonus syndrome." Multiple Sclerosis and Related Disorders, vol. 50, May 2021, p. 102855. https://doi.org/10.1016/j. msard.2021.102855.
Heald, D.L. et al. "Opsoclonus after COVID-19 in an infant." Pediatric Neurology, vol. 117, Apr. 2021, p. 34. https://doi.org/10.1016/j.pediatrneurol.2020.12.009.
Abbas, Z. and Chaudhary, A. "COVID-19 associated coagulopathy resulting in cerebral venous thrombosis and pulmonary embolism." Cureus, vol. 13, no. 11, 15 Nov. 2021, p. e19602. https://doi.org/10.7759/cureus.19602.
Stephen, M. et al. "Cerebral venous sinus thrombosis in a patient with delirium secondary to COVID-19." Canadian Medical Association Journal, vol. 194, no. 1, 10 Jan. 2022, pp. E15–E16. https://doi.org/10.1503/cmaj.211745.
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