Objective: To present an individual with multifocal myoclonus after COVID-19 infection with resolution of bilateral MRI hyperintensities following corticosteroids use.

Background: Myoclonus after Covid-19 infection has been seen as both an isolated symptom or with other neurologic deficits (1) and most studies showed favorable responses to symptom therapies and or corticosteroids (2,3).

Method: a 62 year old male presented with gait ataxia and new onset generalized tonic clonic seizure after COVID-19 infection. Brain MRI showed changes in left posterior frontal convexity compatible with subacute infarct [figure 1]. Levetiracetam was started for seizure prevention. Patient later developed myoclonus in the cervical musculature. Myoclonic movements progressed to distal muscle groups of the right leg despite using clonazepam. Prolonged video EEG did not show epileptiform correlations. Sodium valproate was added with no symptom relief. Repeat brain MRI showed new multifocal non-enhancing bilateral hyperintensities. CSF analysis showed mild lymphocytosis, minimally elevated protein and was also remarkable for high titration anti-GAD 65. Five days of methylprednisolone 1 gr/day resulted in only subtle improvement. IVIG 2 mg/kg was also given over 5 days with poor response. Brain biopsy of a superficial lesion in the right frontal lobe showed mild reactive astrocytic gliosis. Methylprednisolone 1 gram daily was re-started.

Results: Shortly after the second-term IV methylprednisolone started, myoclonic movements gradually resolved and the patient became symptom free within one week. Repeat MRI of the brain showed significant resolution in bilateral lesions [figure 2].

Conclusion: recent studies suggested a possible role for cytokine-mediated hyperinflammatory mechanisms based on the elevated interleukin levels in CSF(4,5 ). Our study suggests the possible role of neuronal autoantibodies in myoclonus after COVID-19 infection, and it shows  resolution of chronic and subacute  MRI hyperintensities after corticosteroid treatment. Brain autopsy studies on a limited group of COVID_19 non-survivors showed nonspecific changes (6). Our study combines neuroimaging, CSF analysis, electrophysiological and brain tissue biopsy findings which may be helpful in expanding our knowledge about the pathogenesis of post-COVID myoclonus.

References: 1- Anna Francesca Guerra, Ilaria Martinelli, Vittorio Rispoli, Matteo Marcacci, Francesco Cavallieri, Silvia Nizzoli, Franco Valzania, Paolo Ventura, Stefano Meletti, Antonello Pietrangelo. Ataxia-Myoclonus Syndrome in Patients with SARS-CoV-2 Infection. The Canadian Journal of Neurological Sciences. October 2021, 14:1-2.

2- Aatma Ram, Hafiz Jeelani, Dilpat Kumar, Heeren Patel. Generalized myoclonus associated with COVID-19 infection. BMJ Case Reports. 2021 Jul 22;14(7).

3- Victoria Ros-Castelló, Carmen Quereda, José López-Sendón, Iñigo Corral. Movement Disorder Clinical Practice. Volume7, Issue8. November 2020; Pages 983-984.

4- Lorenzo Muccioli, Francesca Rondelli, Lorenzo Ferri, Giada Rossini, Pietro Cortelli, Maria Guarino. Subcortical Myoclonus in Coronavirus Disease 2019: Comprehensive Evaluation of a Patient. Movement Disorders Clinical Practice. Volume 7. Issue 8. November 2020.

5- Andrea Pilotto, Silvia Odolini, Stefano Masciocchi, Agnese Comelli, Irene Volonghi, Stefano Gazzina, Sara Nocivelli, Alessandro Pezzini, Emanuele Focà, Arnaldo Caruso, Matilde Leonardi, Maria P Pasolini, Roberto Gasparotti, Francesco Castelli, Nicholas J Ashton, Kaj Blennow, Henrik Zetterberg, Alessandro Padovani. Steroid-Responsive Encephalitis in Coronavirus Disease 2019. Annual of Neurology. August 2020. 88 (2):423-427.

6- Tim Coolen, Valentina Lolli, Niloufar Sadeghi, Antonin Rovai, Nicola Trotta, Fabio Silvio Taccone, Jacques Creteur, Sophie Henrard, Jean-Christophe Goffard, Olivier Dewitte, Gilles Naeije, Serge Goldman, Xavier De Tiège. Early postmortem brain MRI findings in COVID-19 non-survivors. Neurology. October 06, 2020; 95.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/refractory-myoclonus-after-covid-19-with-resolution-after-corticosteroids-a-case-report-with-brain-biopsy-and-serial-neuroimaging/