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CASE REPORT
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 25-26

Opsoclonus-myoclonus syndrome in a COVID-19-positive pregnant patient – A rare case report


Department of Anaesthesiology, ABVIMS and DR. RML Hospital, New Delhi, India

Date of Submission05-Jan-2022
Date of Acceptance14-Mar-2022
Date of Web Publication20-May-2022

Correspondence Address:
Dr. Priyanka Singh
Department of Anaesthesiology, ABVIMS and DR. RML Hospital, Baba Kharak Singh Marg, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jica.jica_1_22

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  Abstract 

In the present time of severe acute respiratory syndrome coronavirus-2 pandemic, there are various systemic complications reported as its sequelae. We hereby report a rare presentation of opsoclonus-myoclonus syndrome as a neurological complication in a COVID-19-positive pregnant patient posted for emergency cesarean section.

Keywords: COVID-19, myoclonus, opsoclnus, parainfectious, pregnancy


How to cite this article:
Kakkar A, Singh P, Kaur M D, Kumar A. Opsoclonus-myoclonus syndrome in a COVID-19-positive pregnant patient – A rare case report. J Ind Coll Anesth 2022;1:25-6

How to cite this URL:
Kakkar A, Singh P, Kaur M D, Kumar A. Opsoclonus-myoclonus syndrome in a COVID-19-positive pregnant patient – A rare case report. J Ind Coll Anesth [serial online] 2022 [cited 2022 Jul 1];1:25-6. Available from: https://www.jicajournal.in//text.asp?2022/1/1/25/345591


  Introduction Top


Opsoclonus-myoclonus syndrome (OMS), also known as opsoclonus-myoclonus-ataxia syndrome (OMAS), is a neuroinflammatory disorder of paraneoplastic and idiopathic etiology. It is well described in young children (Kinsbourne syndrome) of paraneoplastic origin. Adult-onset OMAS is mostly of idiopathic (parainfectious) in etiology.[1] Literature shows very few reported cases of OMAS in pregnancy.[2],[3],[4] We hereby report a case of OMAS in pregnancy as a neurological sequel of severe acute respiratory syndrome coronavirus-2 (SARS Co-V 2) (COVID-19) infection. To the best of our knowledge, this is the first reported case of OMS as neurological complication in COVID-19-positive pregnant patient.


  Case Report Top


A 26-year-old primigravida female with no comorbidities presented at 36 weeks of gestation with a history of nausea, vomiting, and loose stools for the past 4 days, followed by abnormal rapid, irregular eye movements and jerky limb movements for the past 2 days. These were later accompanied with dizziness, balance, and gait abnormalities. There was no history of fever, cold, cough, shortness of breath, and chest pain. General examination and vitals were found to be normal. Neurological examination revealed jerky to and fro movement of both eyes suggestive of opsoclonus with involuntary abnormal jerky movements present in all four limbs suggesting myoclonus. The patient was able to stand with support and had a wide base (truncal swaying) gait. The motor power was 5/5 in all four limbs. Deep tendon reflexes were normal. Rest neurological examination was grossly normal. Routine blood investigations and thyroid profile were normal and viral markers (HIV, anti HbsAg and anti HCV) were found to be negative. Brain magnetic resonance imaging (MRI) revealed no significant finding. Based on history and examination, a provisional diagnosis of opsoclonus-myoclonus-ataxia syndrome was made, the cause of which to be further evaluated. On further obstetric examination, fetal movements were found to be less, and patient had a nonreassuring nonstress test. Hence, the patient was planned for an emergency cesarean section, and a sample for reverse transcriptase–polymerase chain reaction (RTPCR) for COVID-19 was sent before surgery.

The surgery was done under general anesthesia with rapid sequence induction. All protective precautions were taken during surgery as per the COVID-19 protocol in view of the unknown COVID status of the patient. A fresh stillborn baby was delivered. Intraoperative course was uneventful and the patient was extubated at the end of surgery.

Postoperatively, the patient was started on bablet clonazepam 0.5 mg per day, tablet levetiracetam 1 g per day, and tablet Dexamethasone 12 mg per day as a treatment for OMS. A slight improvement in abnormal movements was observed post termination of pregnancy on the 2nd postoperative day. On day 2, cerebrospinal fluid (CSF) tap and electroencephalogram (EEG) were done, which were reported normal. RTPCR report for COVID19 sent before surgery came out to be positive on postoperative day 2, and hence, the patient was shifted to dedicated COVID ward for further management.


  Discussion Top


Adult-onset OMS is mostly an immune-mediated disease of paraneoplastic or idiopathic origin. The etiology of opsoclonus-myoclonus syndrome includes paraneoplastic, parainfectious, toxic-metabolic, and idiopathic causes.[1] A variety of viral infections such as HIV, Epstein–Barr virus, rotavirus, and West Nile virus have been associated with OMS. The novel coronavirus SARS-CoV-2 is another addition to the list, as the association of this syndrome with COVID-19 infection has been recently reported in the literature.[5],[6],[7] The OMS is one of the many neurological complications reported in COVID-19 infection such as stroke, seizures, encephalopathy, Guillain–Barre syndrome. Antimicrobiological treatment and immunotherapy is the mainstay in treating parainfectious OMS. In addition, as symptomatic treatment, regardless of OMS origin, antiepileptic drugs (levetiracetam and valproic acid) and benzodiazepines (clonazepam and nitrazepam) could be helpful for myoclonus-opsoclonus treatment.[2]

The relationship between OMS and pregnancy is unclear. Previously reported cases[2],[3],[4] raise the possibility that pregnancy influences the appearance of OMS and suggest the role of antigen within Mullerian epithelium of sexual organ as inciters of immune reaction responsible for OMS.[2] In our patient, CSF examination, MRI brain, EEG, HIV, antinuclear antibodies, metabolic functions (hemogram, hematocrit, thyroid, renal and hepatic function tests, glucose, and electrolytes), and all other investigations which could be done during the short stay in our intensive care unit were normal, leaving us with two probable causes of these neurological manifestations pregnancy or COVID-19. The fact that there was slight improvement noted in the symptoms as the pregnancy ended is supporting the observations seen in previously reported few cases,[2],[3],[4] although we cannot ignore the possibility of these movement disorders as one of the neurological manifestations of concomitant COVID-19 infection detected in the patient by RT PCR test. After excluding some of the well-known causes of OMS, the highly likely association of this syndrome with the pregnancy or its parainfectious nature (COVID-19) is concluded and hence needs further evaluation. This case is one of the additions to the limited literature available.


  Conclusion Top


Our case adds to the increasing list of novel neurologic manifestations occurring in the setting of COVID-19. Physiological change to immune system regulation during pregnancy might also be a probable cause of OMS in this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Oh SY, Kim JS, Dieterich M. Update on opsoclonus-myoclonus syndrome in adults. J Neurol 2019;266:1541-8.  Back to cited text no. 1
    
2.
Koziorowska-Gawron E, Koszewicz M, Bladowska J, Ejma M, Budrewicz S. Opsoclonus-myoclonus syndrome with severe clinical course and beneficial outcome: A case report. Medicine (Baltimore) 2021;100:e25261.  Back to cited text no. 2
    
3.
Koide R, Sakamoto M, Tanaka K, Hayashi H. Opsoclonus-myoclonus syndrome during pregnancy. J Neuroophthalmol 2004;24:273.  Back to cited text no. 3
    
4.
Goto T, Yonemitsu M, Araki Y, Yamaguchi Y. Case of Opsoclonus-Myoclonus Syndrome (OMS) developing during pregnancy. Nihon Naika Gakkai Zasshi 1999;88:344-6.  Back to cited text no. 4
    
5.
Sanguinetti SY, Ramdhani RA. Opsoclonus-myoclonus-ataxia syndrome related to the novel coronavirus (COVID-19). J Neuroophthalmol 2021;41:e288-9.  Back to cited text no. 5
    
6.
Shah PB, Desai SD. Opsoclonus myoclonus ataxia syndrome in the setting of COVID-19 Infection. Neurology 2021;96:33.  Back to cited text no. 6
    
7.
Emamikhah M, Babadi M, Mehrabani M, Jalili M, Pouranian M, Daraie P, et al. Opsoclonus-myoclonus syndrome, a post-infectious neurologic complication of COVID-19: Case series and review of literature. J Neurovirol 2021;27:26-34.  Back to cited text no. 7
    




 

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