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 38-year-old man was referred to our clinic with generalized jerks in his hands (see Supplementary video-). A week before, he had been discharged from the hospital after four days of hospitalization due to a positive nasopharyngeal RT-PCR test and evident involvement of his lungs. Four days after discharge, he developed fine jerks in his hands and could not write; three days later, he was referred to our clinic with progression and generalization of jerks. He had generalized myoclonus in upper and lower limbs and bizarre abnormal movements that diminished with distraction; he was also restless and seemed anxious. The rest of the neurological examinations were normal. Lab tests were unremarkable. Laboratory investigations and brain MRI scans were normal. CSF analyses, including cell count, protein, and autoimmune panel, were normal. Clonazepam (2 mg/day), levetiracetam (1000 mg/day), and IV methylprednisolone for 5 days (1 g/day) were started, resulting in partial improvement. After two weeks, myoclonus was resolved; functional movements improved with some residual deficits, but he was still suffering from anxiety.