Case presentation:
A 48-year-old male, previously healthy, was admitted with vomiting,
cough and diarrhea, his chest X-ray showed bilateral lower zone
infiltrates (figure A), nasopharyngeal swab was positive for COVID-19.
He also complained of binocular diplopia more pronounced on looking to
the left that stared a day after his initial manifestation, he had no
loss of smell or taste.
On examination, there was a clear limitation of abduction in the left
eye with left gaze. Right, upper and lower gazes were intact, as well as
convergence (figure B). Other cranial nerve examination was unremarkable
including visual acuity, pupillary reflexes and fundoscopy.
General examination was unremarkable, and patient had vitals and oxygen
saturation within normal limits without supplemental oxygen. The patient
first underwent Computed Tomography with venography (CTV) and mass
lesions with increased intracranial pressure and cerebral venous
thrombosis was ruled out.
Magnetic Resonance Imaging (MRI) of the head with contrast was done
(figure C & D), and it showed no evidence of any intracranial mass
lesions, nor enhancement involving the nerve or its course. A lumbar
puncture was performed and showed the cerebrospinal fluid (CSF) to have
a normal opening pressure and was acellular, with negative cultures,
normal protein, and glucose level. Tuberculosis acid fast bacilli,
polymerase chain reaction (PCR) and culture were negative.
Autoimmune screen was also negative and an HBA1c was 5.2%. The patient
was treated with hydroxychloroquine, azithromycin, and ceftriaxone as
per our local protocol at that time. He also used an eye cover which
helped with his diplopia. By day 10, his 6th nerve
palsy has improved remarkably and was discharged to home isolation and
outpatient follow up.