Objective: We report a case of myoclonus, tremor, and ataxia after COVID-19 infection with improvement in myoclonus after treatment with levetiracetam.

Background: Neurologic manifestations of COVID-19 are being increasingly reported, although movement disorders presentations have been surprisingly uncommon [1]. Currently reported movement disorders after COVID-19 include myoclonus [2-6], tremor [5], hypokinetic-rigid syndrome [7], tremor/ataxia [8], myoclonus/ataxia [9], and opsoclonus-myoclonus-ataxia [10]. Herein, we report a case of a patient with combined myoclonus, tremor, and ataxia after COVID-19 infection.

Method: A 49-year-old previously healthy man was diagnosed with COVID-19 December 2020 and 10 days later was hospitalized for 8 days for COVID-19 pneumonia, requiring supplemental oxygen and antibiotics. One day after discharge, he developed imbalance and vertigo that progressed over the next 6 days until he could no longer walk or stand without assistance. Around the same time, he also noted onset of bilateral hand kinetic tremor that prevented him from being able to write or feed himself, as well as a feeling of bilateral hand weakness that made it difficult to cut meat. He also experienced rapid whole-body jerks that would occur approximately 20 times daily. Upon presentation to our office 13 days after symptom onset, he was noted to have generalized positive myoclonus, postural and kinetic tremor, and ataxia. MRI brain with and without gadolinium and TSH and vitamin B12 levels were all normal. He was started on levetiracetam and titrated up to a dose of 500 mg twice daily and on follow-up 20 days later was noted to have improvement in his myoclonus, although his tremor and ataxia persisted.

Results: The pathology of movement disorders that develop after COVID-19 infection is still being established. While patients have previously been reported with tremor and ataxia or myoclonus and ataxia after COVID-19, ours is the first case reported of a patient with combined myoclonus, tremor, and ataxia.

Conclusion: As more movement disorders presenting after COVID-19 are reported, clinicians should be aware of combined movement disorders such as this case of myoclonus, tremor, and ataxia. We suggest that levetiracetam may be used to reduce myoclonus in patients with this presentation, but further study is needed to confirm its effectiveness in other patients.

References: 1. Geyer HL, Kaufman DM, Parihar, RK et al. Movement disorders in COVID-19: Whither art thou?. Tremor and Other Hyperkinetic Movements 2020. 10: 1–4. 2. Rábano-Suárez P, Bermejo-Guerrero L, Méndez-Guerrero A, et al. Generalized myoclonus in COVID-19. Neurology 2020. 95: e767–e772. 3. Khoo A, McLoughlin B, Cheema S, et al. Postinfectious brainstem encephalitis associated with SARS-CoV-2. J Neurol Neurosurg Psychiatry 2020. 91: 1013–1014. 4. Cuhna P, Herlin B, Vassilev K, et al. Movement disorders as a new neurological clinical picture in severe SARS-CoV-2 infection. Eur J Neurol 2020. 27: e88–e90. 5. Anand P, Zhou L, Bhadelia N, et al. (in press). Neurologic findings among inpatients with COVID-19 at a safety-net US hospital. Neurol Clin Pract 2020. 6. Anand P, Zakaria A, Benameur K, et al. Myoclonus in patients with coronavirus disease 2019: A multicenter case series. Crit Care Med 2020. 48: 1664–1669. 7. Méndez-Guerrero A, Laespada-García MI, Gómez-Grande A, et al. Acute hypokinetic-rigid syndrome following SARS-CoV-2 infection. Neurology 2020. 95: e2109–e2118. 8. Diezma-Martín AM, Morales-Casado MI, García-Alvarado N, et al. Tremor and ataxia in COVID-19. Neurologia 2020. 35: 409–410. 9. Schellekens MMI, Bleeker-Rovers CP, Keurlings PAJ, et al. Reversible myoclonus-ataxia as a postinfectious manifestation of COVID-19. Mov Disord Clin Pract 2020. 7: 977–979. 10. Sanguinetti SY, Ramdhani RA (in press). Opsoclonus-myoclonus-ataxia syndrome related to the novel coronavirus (COVID-19). J Neuro-Ophthalmology 2021.

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