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| LETTER TO THE EDITOR |
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| Year : 2022 | Volume
: 15
| Issue : 2 | Page : 258-259 |
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Bell's palsy as a presenting feature of COVID-19
Richa Agarwal1, Mohit Agarwal2, Alka Tripathi1, Vijeta Bajpai3
1 Department of Ophthalmology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
2 Department of Paediatrics, Kilkari Child Care, Gorakhpur, Uttar Pradesh, India
3 Department of Anesthesiology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
| Date of Submission | 05-Feb-2021 |
| Date of Decision | 12-Oct-2021 |
| Date of Acceptance | 06-Nov-2021 |
| Date of Web Publication | 29-Jun-2022 |
Correspondence Address:
Dr. Richa Agarwal
27-M, Kilkari Child Care, Daudpur, Gorakhpur - 273 001, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_38_21
How to cite this article:
Agarwal R, Agarwal M, Tripathi A, Bajpai V. Bell's palsy as a presenting feature of COVID-19. Oman J Ophthalmol 2022;15:258-9 |
To the Editor,
The ongoing coronavirus disease 2019 (COVID-19) pandemic has affected many people worldwide which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It mainly causes respiratory symptoms.[1] However, recent studies have also revealed several neurological symptoms associated with this infection. Anosmia, ageusia, encephalitis, encephalopathy, cerebrovascular complications, myelitis, and Guillain–Barré syndrome are among the neurological manifestations reported in many patients.[2] We report a case of COVID-19 who developed peripheral facial palsy as its first symptom.
A 19-year-old male was not able to close the right eye completely for 4 days associated with progressive right-sided labial commissure deviation. No history of any systemic illness was recorded. On examination, he had right-sided lagophthalmos, involuntary drooling, and ipsilateral labial commissure deviation. He did not have fever, dyspnea, odynophagia, ear pain, dermatomal pain, face swelling, skin rash, cough, myalgias, anosmia, ageusia, or diplopia. No recent history of respiratory infection or SARS-CoV-2 epidemiological context was reported. On neurological examination, he exhibited right peripheral facial nerve palsy. The remaining examination revealed no abnormalities, including signs of other cranial neuropathies. The blood tests and C-reactive protein level were both normal. Probable Bell's palsy Grade 4 (House–Brackmann grading system[3]) was assumed. Corticosteroid therapy (10-day tapering prednisolone course, starting at 60 mg/day) and prophylactic acyclovir was initiated. He was also prescribed lubricating eyedrops and lid taping during sleep.
The patient returned after 5 days with low-grade fever, anosmia, and ageusia. His real-time reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 came out to be positive. He was eventually diagnosed with confirmed COVID-19 infection complicated with Bell's palsy. The patient was started on symptomatic treatment with antipyretics and corticosteroid and antiviral therapy was continued. The patient was also advised to undergo self-isolation. On follow-up after 14 days of isolation, there was complete recovery of facial paralysis and he tested negative on RT-PCR for SARS-CoV-2.
Idiopathic facial paralysis (also called Bell's palsy) is the most common cause of facial nerve paralysis.[4] It can also be associated with infections most commonly herpes simplex and herpes zoster viruses. The exact pathogenesis of Bell's palsy remains unclear, but its association with neurotropic herpes virus is thought to be related to its axonal spread and viral replication leading to inflammation and demyelination.[4] Reactivation of virus may be provoked by stress or trauma or may be due to super infection by a heterotypic virus. Current treatment options include corticosteroids possibly associated with antiviral agents.
Neurological manifestations of COVID-19 have been reported to have an incidence of 36.4%.[2] Thus far, impairment of taste and smell, dizziness, and headache have been reported as common symptoms in COVID-19.[2] Recently, reports of significant neurological associations have emerged, including Guillain–Barré syndrome, encephalopathy, and strokes.[2] Cranial nerve manifestations associated with COVID-19 have been reported in 2 patients, 1 of whom had Miller Fisher syndrome and the other presenting with polyneuritis cranialis.[5] Coronaviruses can cause nervous tissue injuries through several known mechanisms like direct infection injury, hypoxia, angiotensin converting enzyme 2 receptors, and immune injury. Cranial neuropathies may be related to immune-mediated injury from proinflammatory cytokines rather than direct viral neutrophism.[5]
Cases of COVID 19 complicated with facial nerve palsy have been reported but not as a presenting feature. This case presented as a case of Bell's palsy who subsequently developed symptoms of COVID 19 infection. This case suggests a possible association between isolated cranial neuropathies and COVID-19.
Acknowledgment
All the authors made substantial contributions to the conceptualization, design of work, data acquisition, validation, drafting the work, or revising it critically. All the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects presented in the article.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.  |
| 2. | Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020;77:683-90. |
| 3. | Eviston TJ, Croxson GR, Kennedy PG, Hadlock T, Krishnan AV. Bell's palsy: Aetiology, clinical features and multidisciplinary care. J Neurol Neurosurg Psychiatry 2015;86:1356-61. |
| 4. | House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7. |
| 5. | Gutiérrez-Ortiz C, Méndez-Guerrero A, Rodrigo-Rey S, San Pedro-Murillo E, Bermejo-Guerrero L, Gordo-Mañas R, et al. Miller Fisher syndrome and polyneuritis cranialis in COVID-19. Neurology 2020;95:e601-5. |
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