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.