A 48-year-old man with a history of asymptomatic HIV infection, with normal CD-4 count and undetectable viral load, for which he received treatment with antiviral therapy (dolutegravir, abacavir, lamivudine) was referred to the outpatient clinic of the Radboud University Medical Centre because of the onset of jerky movements that had emerged after the resolution of symptoms related to COVID-19. His only other medication was pantoprazole. On day 1, this patient developed a fever and a concomitant headache but with minimal cough. On day 7, the general practitioner treated him with amoxicillin for 5 days. Symptoms gradually resolved except for persistent fatigue. On day 13, he developed involuntary jerky movements and clumsiness of his trunk and limbs during the course of several hours. The jerks were present at rest but worsened with movement, causing considerable disability. Gait had become insecure. Following the initial subacute onset, his complaints did not progress any further. A nasopharyngeal swab tested positive for SARS-CoV-2 by polymerase chain reaction (PCR on day 16). PCR was not repeated.\nNeurological examination on day 20 revealed a normal consciousness with fully intact cognitive functions. Eye movements showed saccadic intrusions and hypermetric saccades, but no opsoclonus. There was facial jerking. Examination of the cranial nerves was otherwise unremarkable. There were generalized myoclonic jerks of the trunk and limbs, particularly involving the hands, which were present at rest but that clearly worsened both posturally and with action (). The myoclonus was not stimulus sensitive to touch, and there was no startle response to a loud acoustic stimulus. Except for some lapses in the legs upon rising from a chair, there was no convincing negative myoclonus. Motor examination further revealed clear cerebellar ataxia of the arms and legs (hypermetria) and an ataxic gait (). There was no paresis or sensory deficit. Deep tendon reflexes were normal, and plantar responses were unremarkable.\nAn extensive laboratory work-up, including thyroid function test and celiac disease screening, cranial magnetic resonance imaging (MRI) with gadolinium, and extensive cerebrospinal fluid (CSF) analysis, revealed no abnormalities (Table ). PCR for SARS-CoV-2 in CSF on day 35 was negative. SARS-CoV-2 serology on day 62 was positive.\nNo immunotherapy was given, but symptomatic treatment with levetiracetam was initiated, which alleviated the myoclonus within several days. Functional disability also diminished considerably. Repeat neurological examination several weeks later (day 62) showed that both the myoclonus and the ataxia had improved, but recovery was not yet complete ().
A 26-year-old female patient with a past medical history of obesity, post-traumatic stress disorder, depression, and exercise-induced asthma presented to the emergency department with sudden onset of headache, vomiting, and right-sided numbness, and tingling. The patient underwent computed tomography (CT) angiography of the head and neck, which were unremarkable, and no vertebral artery dissection was seen. She was discharged with the diagnosis of migraine.\nShe developed worsening of her symptoms at home, presenting again to the emergency department with increasing right-sided numbness, weakness, and dysarthria. Vital signs were stable with no fever. The patient reported no respiratory symptoms and denied any recent head trauma or chiropractic neck manipulation. The neurological exam was significant for right-sided weakness, dysarthria, right-sided dysmetria, and gait ataxia. Chest X-ray showed no acute infiltrates. Magnetic resonance imaging (MRI) of the brain showed an acute right cerebellar infarct with the involvement of the right cerebellar peduncle (Figure ). Magnetic resonance angiography of the head revealed narrowing of the right superior cerebellar artery (Figure ). An echocardiogram with a bubble study was performed, as well as a part of a stroke workup, which showed a PFO. The lower extremity venous doppler ultrasound was negative for deep venous thrombosis. The laboratory test results are shown in Table .\nThe patient was screened for COVID-19 with a nasopharyngeal reverse transcription polymerase chain reaction due to increased reports of stroke in young patients nationwide, and the test came back as positive, to our surprise. Standard stroke treatments, including aspirin, clopidogrel, and high-intensity statins, were initiated for the patient. Enoxaparin for deep venous thrombosis prophylaxis was also prescribed.