COVID-19-associated vestibular neuritis in an infant

Neurologic manifestations of COVID-19 infection vary from undetectable to profound and may include dizziness, headache, cognitive and sensory deficits, seizures, Guillain–Barré syndrome, and death.¹ Moreover, evidence is mounting to suggest that postinfection neurologic impairment from COVID-19 may be longstanding or possibly permanent.² One such neurologic manifestation of COVID-19 is vestibular neuritis, a benign self-limited condition that classically presents with vertigo, nausea, and gait imbalance.³ There have been reported cases of COVID-19-associated nystagmus as the result of vestibular neuritis in adults.⁴ Cases in adolescents are less described, with a few reports of COVID-19-associated nystagmus in children⁵ and 1 reported nystagmus case in a 2-month-old baby resulting from fatal acute hemorrhagic necrotizing encephalitis.⁶ Here we report a rare case of COVID-19-associated postviral nystagmus in an infant as the result of vestibular neuritis.

A 9-month-old African-American female presented to the Emergency Department after her mother noted several episodes of conjugate horizontal nystagmus over the preceding hour. Additionally, she reported 2 weeks of staring spells, head-waving motions, and loss of balance compared with baseline. The medical history was significant for COVID-19 infection 2–3 weeks prior as well as 5 independent ear infections over the past 4 months. The child was born at full term and was developmentally advanced for age as she was able to walk several steps unassisted at 9 months. She had no history of seizure or neurologic disorder. On presentation, she was afebrile with a white blood cell count of 18.7 thousand cells per microliter. The patient was admitted to the pediatrics service with neurology and ophthalmology consults.

Physical and neurologic examinations were normal for age except for a large head with mildly short philtrum. On ophthalmic examination, the child's pupils were equal, round, and reactive without relative afferent pupil defect. She was orthophoric in all directions of gaze. Every 1–4 minutes she was observed to have brief episodes of horizontal jerk nystagmus lasting 4–5 beats, with fast phase noted in both directions at times. The remainder of the ocular examination was reassuring with no visualized anterior or posterior pathology. Magnetic resonance imaging brain with and without contrast material demonstrated reactive upper cervical lymph nodes but was otherwise normal with clear mastoid air cells, mastoid antra, and tympanic cavities. The child was discharged the following evening with plans for close follow-up. Lumbar puncture was not performed because the patient remained afebrile.

On 3-day outpatient follow-up with ophthalmology, the nystagmus was still present but less frequent, now occurring 12–15 times per day. Streak retinoscopy demonstrated mild hyperopia with +1.00 sphere bilaterally, with the remainder of the ophthalmic examination again normal. A tentative diagnosis of postviral COVID-19-induced vestibular neuritis was made, and the patient was scheduled for additional follow-up with ophthalmology and neurology. On subsequent neurology visits, the patient underwent electroencephalography to rule out epilepsy, but the findings were normal and did not support the diagnosis of seizure. Two months after admission, the patient's nystagmus episodes had resolved, and neurology findings supported the diagnosis of postviral vestibular neuritis.

To our knowledge, postviral vestibular neuritis in an infant following COVID-19 infection has not been described previously. While this case was self-limited, another reported case of COVID-19-associated nystagmus in a newborn was the result of fatal acute hemorrhagic necrotizing encephalitis.⁶ We therefore recommend that COVID-19-associated nystagmus should be taken seriously, with appropriate examination, imaging, and follow-up for optimal diagnosis and care. It is important to point out that while the timing of viral infection with onset of vestibular neuritis is suggestive of an association, a causative effect cannot be proven. As COVID-19 becomes ubiquitous and seemingly here to stay, we expect frequent and widespread infections with additive lasting neurologic effects to lead to more such cases.

Footnotes and Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this correspondence.