Disclosures: Dylan J. Lewis, DO: No financial relationships or conflicts of interest

Case Diagnosis: Acute inflammatory demyelinating polyneuropathy (AIDP) associated leptomeningeal enhancement following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection

Case Description: A 69-year-old female with history of breast cancer and COVID-19 four weeks prior presented with seven days of dysesthesias, diminished sensation in a stocking-glove distribution, symmetric extremity weakness, and absent Achilles muscle stretch reflexes (MSRs). MRI brain and extensive laboratory studies were unremarkable. Lumbar puncture (LP) revealed albuminocytological dissociation. A diagnosis of AIDP was made and five days of intravenous immunoglobulin was initiated. She was discharged to acute inpatient rehabilitation. One week following, the patient developed worsening diplopia and weakness, urinary retention, fecal incontinence, absent MSRs, and a positive Lhermitte’s sign. MRI revealed leptomeningeal enhancement from T11-S1 and enhancement of L4-S1 nerve roots. Neurosurgery, neurology, and oncology were consulted. The patient was administered intravenous dexamethasone. Full-body imaging, LP, and tumor markers were negative for malignancy. LP continued to demonstrate increased protein. Following steroid initiation, there was minimal improvement and the patient was transferred to acute care for further evaluation and treatment.

Setting: Acute inpatient rehabilitation hospitalAssessment/

Results: A five-day course of plasma exchange was initiated, and the patient was noted to have increased sensation in distal lower extremities with improved strength. The steroid taper was continued, and comprehensive rehabilitation restarted. Electrodiagnostic studies are pending at the time of this report.

Discussion: There have been reported cases of AIDP associated with COVID-19. In AIDP, immune attack is directed at peripheral nerve myelin with secondary axonal loss, without enhancement of leptomeninges. This patient’s atypical presentation causes suspicion for meningeal-enhancement-associated AIDP with SARS-CoV-2, similar to a previously reported case.

Conclusion: It is possible that coronaviruses may be neurotropic, like poliovirus, leading to this unusual AIDP presentation. Lack of cells in the CSF argues against this hypothesis. Thus, the association between leptomeningeal enhancement and AIDP following SARS-CoV-2 infection warrants further investigation.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/acute-inflammatory-demyelinating-polyneuropathy-associated-leptomeningeal-enhancement-following-sars-cov-2-infection-a-case-report/