Coronavirus disease 2019‐associated worsening and improvement of ataxia and gait in a patient with multiple system atrophy

Dear Editor,

Patients with Parkinson's disease (PD) are reported to experience worsening of motor and non‐motor symptoms with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. ¹ However, until now, the impact of coronavirus disease 2019 (COVID‐19) on the clinical features of other types of parkinsonism remains to be elucidated. We report a patient with multiple system atrophy (MSA) presenting with COVID‐19‐associated worsening of his neurological symptoms and improvement to his baseline neurological status.

A 64‐year‐old man initially visited the movement disorders clinic for evaluation of progressive gait difficulty that developed over the past year. On neurological examination, mild saccadic hypermetria and dysarthria were noted. A mild postural tremor was seen in bilateral upper extremities. Rigidity and bradykinesia were present in all limbs, with the latter slightly more prominent in the right upper and lower extremities. Limb ataxia was present on performing finger‐to‐nose and heel‐to‐shin, of which the latter was found to be more prominent. Although the patient was found to have a moderate degree of postural instability, he was able to ambulate independently. A review of systems was positive for urinary incontinence and dizziness, and his orthostatic vital signs were later confirmed to meet the criteria for orthostatic hypotension. His past medical history was positive for hypertension, diabetes mellitus and atrial fibrillation. Axial T2‐weighted images of brain magnetic resonance imaging showed the hot cross bun sign and pontocerebellar atrophy (Fig. 1a,b). Dopamine transporter imaging showed a dopaminergic deficit most prominent in the left putamen (Fig. 1c). According to the current diagnostic criteria for MSA, we concluded that the patient had probable MSA of the cerebellar type. ²

Figure 1.

Radiological findings of the patient. Axial T2‐weighted images show (a) pontocerebellar atrophy, the hot cross bun sign, middle cerebellar hyperintensities and (b) dilation of the fourth ventricle. (c) Dopamine transporter imaging shows significant striatal dopaminergic depletion, most prominent in the left putamen. (d) High‐resolution computed tomography of the chest shows multifocal ground‐glass opacities and consolidations most notable in the right lung.

One month later, the patient was admitted to SoonchunhyangUniversity Seoul Hospital in Seoul, South Korea for rapid worsening of his neurological symptoms, including slurred speech, clumsiness and gait difficulty, developing over the past week. He was initially started on levodopa/benserazide 100/25 mg/day, for possible symptomatic benefit. The patient was admitted for further observation and on the day of admission, developed a fever of 38.1°C with mild respiratory symptoms, including dyspnea, cough and sputum. Real‐time reverse transcription polymerase chain reaction test for the qualitative detection of nucleic acid from SARS‐CoV‐2 was carried out on the patient's nasopharyngeal and oropharyngeal swab specimens, and were found to be positive. High‐resolution computed tomography scan of the chest showed multifocal patchy lesions in bilateral lungs (Fig. 1d), compatible with findings of COVID‐19. The COVID‐19 infection itself was only mild, both clinically and radiologically. The patient was briefly put on 3 L of oxygen (through nasal prong), with an oxygen saturation level of 96~97%. He was given daily intravenous remdesivir 100 mg/day for 5 days and dexamethasone 6 mg/day for 10 days. Although the patient's respiratory symptoms gradually improved over the course of a month, his neurological symptoms, including dysarthria, limb ataxia and gait ataxia with postural instability, were found to worsen in the first 2 weeks. Features of parkinsonism including rigidity and bradykinesia were found to be relatively unchanged. He could neither stand nor even walk with assistance during this period while he received treatment for COVID‐19. However, the patient's neurological status was found to gradually improve to baseline, and he was ultimately discharged 6 weeks after admission.

All procedures performed were carried out in accordance with national law and the Helsinki Declaration of 1964 (in its present revised form). Informed consent was obtained from the patient.

To the best of our knowledge, this is the first documented report of a patient with MSA infected by SARS‐CoV‐2. Initially, abrupt worsening of his neurological symptoms with COVID‐19 were concerning, as a recent report suggested that COVID‐19 in patients with PD might result in poor prognosis, such as rapid clinical decline leading to sudden death. ³ A report of a patient with PD with only mild COVID‐19 related abnormalities on chest computed tomography was found to result in a fatal course. However, we found the present patient with MSA to experience only mild respiratory symptoms, and undergo only transient worsening and return to baseline neurologically. Therefore, based on the present case, we presume that COVID‐19 itself does not appear to lead to long‐lasting worsening motor symptoms in MSA. Furthermore, the present case suggests that the prognosis of parkinsonian patients infected with COVID‐19 might vary. It remains unclear whether such a difference of clinical outcomes in PD and MSA is due to primary brain pathology or secondary pathology as a result of COVID‐19 infection. Therefore, more reports are required to address this issue.

The current case suggests that clinicians should consider the possibility of SARS‐CoV‐2 infection when patients with parkinsonism present with acute worsening of their motor symptoms. To date, little is known about the precise mechanism of how COVID‐19 could induce such worsening. One possibility is that infection could accelerate the pathology of alpha‐synucleinopathies. ⁴ However, the present patient only showed transient worsening of neurological symptoms, giving rise to the possibility of factors such as psychological stress or reduced physical activity as a cause. ⁵ The present case might provide clinicians with an initial glimpse into the association between COVID‐19 and multiple system atrophy. Future observations regarding worsening of neurological symptoms and signs in PD and MSA are required in this era of COVID‐19 pandemic.

Disclosure statement

The authors declare no conflict of interest.

Park JE, Kwon K‐Y. Coronavirus disease 2019‐associated worsening and improvement of ataxia and gait in a patient with multiple system atrophy. Geriatr. Gerontol. Int. 2021;21:591–593. 10.1111/ggi.14184