A case series of vestibular symptoms in positive or suspected COVID-19 patients
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Le Infezioni in Medicina, n. 1, 117-122, 2021
CASE REPORTS 117
A case series of vestibular symptoms
in positive or suspected COVID-19
patients
Srikrishna Varun Malayala1, Gisha Mohan2, Deepa Vasireddy3, Paavani Atluri4
1
Temple University Health System, Philadelphia, Pennsylvania, USA;
2
Physicians for American Healthcare Access, Philadelphia, Pennsylvania, USA;
3
Pediatric Group of Acadiana, Lafayette, Louisiana, USA;
4
Bay Area Hospital, Coos Bay, Oregon, USA
SUMMARY
Respiratory symptoms are the most common presen- The pathophysiology of vestibular neuritis induced
tation of an acute COVID-19 infection, but thrombo- by COVID-19 is similar to any other viral infection.
embolic phenomena, encephalopathy and other neu- Whether in the inpatient or outpatient settings, CO-
rological symptoms have been reported. VID-19 should be considered in the differential diag-
With these case series, we present multiple presentations nosis for patients presenting with these symptoms,
of COVID-19 induced vestibular symptoms namely diz- irrespective of the presence of respiratory symptoms
ziness, vertigo and nystagmus. The patients reported in or hypoxia.
this case series are from different parts of the world, be-
long to different age groups and had manifested these Keywords: COVID-19, vestibular neuritis, vertigo, diz-
symptoms in different periods of the pandemic. ziness.
n INTRODUCTION quiring imaging to be supported with exclusion
of other similar disorders [3].
T he Covid-19 pandemic outbreak still remains
a major global challenge for physicians and
patients. The spectrum of the disease and organ
The accumulating evidence from Wuhan pub-
lished case series confirmed 8% of COVID-19
patients reported dizziness. Another study from
involvement is still not fully known and evolving. Wuhan reports 16.8% confirmed cases of COV-
The symptoms vary between asymptomatic to se- ID-19 causing vestibular symptoms [2, 4]. Though
vere multiorgan complications [1]. the mechanism by which COVID-19 causes ves-
Vestibular neuritis is an inner ear disorder as- tibular neuritis is unclear, it could be due to its
sociated with symptoms such as sudden, severe effect on individual cranial nerves similar to its
vertigo, dizziness, balance problems, nausea and pathogenesis in causing anosmia, optic neuritis or
vomiting. It is a result of 8th cranial nerve disorder a result of vasculitis or vasculopathy.
following a viral infection leading to inflamma- We compiled a case series of six patients who had
tory changes of the nerve [2]. It is a benign con- distinct symptoms of different severities diag-
dition and usually self-limiting but the recovery nosed eventually with vestibular neuritis. Some
time can vary from days to months. Diagnosis of the neurological manifestations that have al-
is usually based on symptomatology seldom re- ready been identified are delirium, anosmia,
headache, corticospinal tract signs, dizziness,
stroke, encephalopathy, encephalitis but as de-
Corresponding author scribed in our case series vestibular neuritis can
Srikrishna Varun Malayala also be their initial presentation [5-7]. The partici-
E-mail: Srikrishna.Malayala@tuhs.temple.edu pant in case 2 was admitted and treated by the118 S.V. Malayala, G. Mohan, D. Vasireddy, et al.
primary author in Delaware, United States. The She described it as “persistent” vertigo in every
participant in case 4 is an American female but position, though she was not able to explain the
on an extended trip to Europe (country was kept direction in which movement made it worse.
anonymous per her request). Rest of the partici- She seemed to be in severe distress from her nau-
pants are from Iran, Brazil, Canada and Switzer- sea, non-bilious non bloody vomiting, and severe
land and they volunteered to discuss their clinical vertigo. Nystagmus, positioning maneuvers like
presentation through a telephone interview. Dix Hallpike, gait could not be attempted because
of her distress. The cranial nerve exam did not
Case 1 show defects.
A 31-year-old Persian female, resident of Iran Her urine toxicology and rest of the laboratory
presented with runny nose, sweating, fever and parameters were completely within normal lim-
lethargy. She did not report shortness of breath, its. Computed Tomography (CT) scan of the head
loss of taste or loss of smell. She had a known showed no acute pathology. A CT chest/abdo-
exposure to a COVID-19 contact. Diagnosis of men and pelvis without contrast showed multifo-
COVID-19 infection was confirmed with PCR of cal, bilateral, peripheral, ill-defined, ground-glass
nasal swab. She received symptomatic treatment opacifications, features consistent with acute CO-
and was advised home quarantine. VID-19 pneumonia. Acute cerebrovascular attack
About thirteen days after the initial infection, she was also considered a differential but the MRI of
developed dizziness and vertigo that worsened the brain did not show any acute findings.
on any head movement and would get better on She was admitted to the hospital with acute ves-
lying still. The symptoms were associated with tibular neuritis as the admission diagnosis and
lack of appetite and fatigue. She denied earache, she was offered symptomatic management with
tinnitus, hearing loss or unsteady gait. She denied anti-emetics and meclizine as needed. When she
any other history of similar illness, recent upper was found to be positive for COVID-19 infec-
respiratory tract infection or recent trauma. tion through a nasal Polymerase Chain Reaction
She seeked medical attention due to worsening (PCR), she was started on oral hydroxychloro-
symptoms. On examination her vital signs were quine and azithromycin (which was the standard
within normal limits, systemic examination and of treatment for acute COVID-19 infection). The
neurological examination by her physician did acute phase reactants, coagulation parameters
not reveal any abnormalities. Audiometric exami- and other inflammatory markers were within
nation and Magnetic Resonance Imaging (MRI) normal limits.
scan of the brain did not reveal any underlying With no improvement in the symptoms, she was
pathology. A diagnosis of COVID-19 induced ves- subsequently treated with intravenous steroids.
tibular neuritis was made after excluding other She also required vestibular rehabilitation from
diagnoses. She was prescribed dimenhydrinate physical and occupational therapy while she
but her symptoms still persisted despite conser- remained inpatient. The symptoms were quite
vative measures. Subsequently she was given 60 persistent and refractory to this treatment and it
mg prednisone that was tapered over the next ten took almost a week for her to recover and become
days. With this therapy, her symptoms improved asymptomatic. She was eventually discharged
and gradually resolved over the next six weeks. home after a prolonged eight-day stay in the hos-
pital.
Case 2
A 29-year-old Hispanic female residing in Dela- Case 3
ware, USA, presented to the emergency room in A 63-year-old Caucasian female with a known
April 2020 with sudden onset of severe vertigo, medical history of aplastic anemia, mitral valve
nausea and vomiting two days prior to arrival. prolapse with regurgitation, celiac disease, and
She was working at a chicken plant in the local ru- motion sickness, presented with a runny nose
ral community, which had a huge cluster of CO- and would feel out of breath with activity. She did
VID-19 infections. She denied tinnitus, hearing not report fever, chills, cough, wheezing or chest
loss or unsteady gait. She described the vertigo at pain. Given the past history of aplastic anemia,
rest and it worsened with any type of movement. she took over-the-counter iron pills for shortnessVestibular symptoms in COVID-19 patients 119 of breath with no improvement. She is a resident a slight improvement in her vision post cessation of the United States but in Europe on a trip when of steroids. the symptoms developed. The symptoms devel- Several weeks later, she developed a high-grade oped in March 2020 when there were no reported fever, pain and swelling of her joints and a non- COVID-19 cases. itchy erythematous rash all over her chest and Due to lack of improvement despite a few days abdomen eight hours following the intake of 2 of symptomatic management, the PCR on nasal g amoxicillin/clavulanic acid for a dental proce- swab for the SARS-CoV-2 test was performed in dure. Tmax was 102F, not associated with chills an ambulatory setting. It was positive for COV- and rigors. She did not report lymphadenopathy ID-19 and she was advised home quarantine. or pedal edema. Symptoms self-resolved after About four weeks after the initial episode, she de- 48hrs. Five months after her positive COVID-19 veloped twitching of her left eye and left cheek, test, she was tested for COVID-19 immunoglobu- non-bloody diarrhea, generalized weakness, pal- lin G (IgG) antibodies and was found to be nega- pitations, sleep disturbances, decreased appetite, tive. skin rash, anosmia, and dysgeusia. The twitch- ing was involuntary, initially involving the left Case 4 eye which then progressed to the left side of the A previously healthy 35-year-old Canadian fe- face. No pain, loss of sensation or numbness were male presented to the hospital with a 4-day his- reported. There were 8 to 10 painful, red skin le- tory of dizziness, lightheadedness and loss of bal- sions around 3 mm in size over perioral area. She ance describing it as a “drunk like feeling”. She was clinically diagnosed with herpes labialis. She works as a television producer and reportedly also developed purple discoloration at the base of worked with people on a cruise ship during the her fingers and whitish discoloration at her fin- COVID-19 outbreak in March 2020. She started gertips with temperature changes. She continued noticing the symptoms a week after that. Her conservative management with ample hydration, symptoms were aggravated with caffeine intake antipyretics, and over-the-counter aspirin, multi- and staring at laptop screens and alleviated by ly- vitamins, and calcium supplements. She gradual- ing down. These symptoms were associated with ly had some clinical improvement over a 4-week fatigue, nausea, crackling sound like perception period. She was tested for COVID-19 every week with loud voices in the right ear. She denied fever, until she was negative on the 58th day. headache, vomiting, diarrhea and earache. No ab- A week post being tested negative for COVID-19, normalities in facial sensations were reported. she suddenly developed chills and vomiting. She She sought medical attention due to worsening woke up in the middle of the night with dizziness, of symptoms. On examination her vitals were a sense of the room spinning and an unsteady within normal limits, systemic examination and gait. She did not have tinnitus or hearing loss. neurological examination did not reveal any ab- She immediately sought medical attention and normalities. No abnormalities were revealed on the physical examination showed a strong nys- routine blood tests. However, she was never test- tagmus to the right. Dix-Hallpike maneuver was ed for COVID-19 infection as she did not meet the performed, and she was confirmed to have ver- “testing criteria” around that time, as she was not tigo and was diagnosed with post-viral vestibular hospitalized. She was treated with betahistine and neuritis. She was treated initially with meclizine, vestibular therapy but her symptoms persisted antiemetics, and Cawthorne vestibular rehabili- even after that for a while. Her symptoms gradu- tation exercises. Due to lack of symptomatic im- ally improved over the next 10 weeks. She was provement she was subsequently given 60 mg tested for COVID-19 antibodies (IgG and IgM) in prednisone with a gradual taper over the next 10 September which turned out to be negative. days. On the 10th day of prednisone, the patient noticed a sudden onset of flashes and floaters in Case 5 the left eye. A slit-lamp examination diagnosed A 71-year-old Brazilian female with a history of Posterior Vitreous Detachment (PVD) of the left obesity developed sudden onset lightheadedness, eye. PVD was attributed to an increase in intraoc- a sense of loss of balance between May 24th 2020 ular pressure with the use of steroids. There was and May 31st 2020. The severity of symptoms had
120 S.V. Malayala, G. Mohan, D. Vasireddy, et al.
progressively worsened and the episodes would and negative inflammatory markers excluded
last her about 15 to 20 minutes. She also devel- other differential diagnoses [9]. The history, pre-
oped nausea and could perceive a white noise senting clinical signs and symptoms, exposure to
resembling sound. On 1st June she was evalu- or confirmation of Covid-19 confirmed the pre-
ated by her primary care physician who advised sumptive diagnosis of vestibular neuritis second-
admission to the hospital for further testing. On ary to COVID-19.
June 2nd 2020 she tested negative for COVID-19 An antigen test on an upper respiratory specimen
via nasal PCR. She was kept admitted over the obtained by nasopharyngeal or oropharyngeal
next 4 days for monitoring of symptoms. A repeat swab is preferred for initial diagnostic testing.
nasal PCR swab was obtained on June 4th 2020 Nucleic Acid Amplification Tests (NAAT) such as
which was resulted 2 days later as being posi- RT-PCR that detect Viral Ribonucleic Acid (RNA)
tive for COVID-19. She did not have any further are considered as the gold standard test at pres-
episodes during her hospital stay and was dis- ent [10]. There are several factors that can lead
charged on the day of the positive test result to to a false negative RT-PCR result in a COVID-19
quarantine at home. About 6 days post hospital infected patient. Multiple regions of the viral ge-
discharge, the patient redeveloped the symptoms nome should be targeted to avoid target region
of nausea, vomiting, “buzzing noise” sensation and primer mismatches. Precision in sample col-
and dizziness and had intermittent episodes of it lection affects the obtained sample. The exposure
over a duration of a month. time to the virus and the viral load in the patient
are also pertinent factors [11-13]. Antibody tests
Case 6 should not be utilized in diagnosing an acute CO-
A 57-year-old female residing in Switzerland had VID-19 infection as antibody development may
an exposure to COVID-19 at her workplace. 5-day take upto 2 weeks [14-18]. Total antibody testing
post exposure she had tested negative to COVID-19 could be more sensitive than IgM or IgG alone for
via nasal PCR. 7 days post exposure she developed early detection [14].
sudden onset dizziness. The episodes were inter- The severity of COVID-19 disease symptoms is
mittent and recurred. She also developed accom- attributed to the marked inflammatory response
panying nystagmus 3 days later. During the course following the virus entry into the host cell. The
of her illness as her symptoms progressively wors- effects of SARS-CoV-2 on the neuronal tissue
ened in intensity, she also developed nausea and could be due to a direct infection of the central
non-bloody non bilious vomiting. nervous system or related to a vascular damage
She was evaluated by an Ear, Nose and Throat caused by vasculitis or vasculopathy, similarly
(ENT) physician and was diagnosed with ves- to the mechanism described for Varicella Zoster
tibular neuritis. She was prescribed meclizine, Virus (VZV) and Human Immunodeficiency Vi-
ondansetron, and diazepam. Due to minimal im- rus (HIV). The other members of the coronavirus
provement of symptoms her physician prescribed family have a history of invading the neurologi-
her a five-day course of steroid which brought cal system resulting in optic neuritis, encephalitis,
about symptomatic relief. encephalomyelitis [19, 20]. The invasion of SARS-
COV2 within CNS is through binding to the An-
giotensin Converting Enzyme (ACE) receptors
n DISCUSSION
once the viruses have gained entry into the CNS,
These cases confirm the diagnosis of vestibular they appear advancing by axonal transport [20].
neuritis by excluding other possible differential Evidence about the virus shows that COVID-19
diagnoses. Our cases had either known or sus- can affect the central nervous system resulting in
pected exposure to or confirmation of COVID-19. neurological symptoms similar to other members
They lacked other neurologic signs and symp- in the coronavirus family [21]. The neurological
toms (dysarthria, dysphagia, weakness, sensory symptoms of COVID-19 vary from dizziness,
loss, or facial droop). There were no abnormalities headache, and impaired consciousness to severe
in imaging studies thus excluding the possibility symptoms like encephalopathy, encephalomyeli-
of an acute vascular event in the central nervous tis, ischemic stroke and intracerebral hemorrhage,
system [8]. Lack of abnormalities in blood tests anosmia, dysgeusia and neuromuscular diseases.Vestibular symptoms in COVID-19 patients 121
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