COVID19-associated new-onset movement disorders: a follow-up study

Journal of Neurology https://doi.org/10.1007/s00415-023-11661-x ORIGINAL COMMUNICATION COVID19‑associated new‑onset movement disorders: a follow‑up study Susanne A. Schneider1 · Soaham Desai2 · Onanong Phokaewvarangkul3 · Elena Cecilia Rosca4 · Jirada Sringean3 · Pria Anand5 · Gary Álvarez Bravo6 · Francisco Cardoso7 · Anna M. Cervantes‑Arslanian5 · Harshad Chovatiya2 · David Crosiers8,9 · Femke Dijkstra8,9 · Conor Fearon10 · Francisco Grandas11 · Eric Guedj12 · Antonio Méndez‑Guerrero13 · Muhammad Hassan14 · Joseph Jankovic15 · Anthony E. Lang10 · Karim Makhoul15 · Lorenzo Muccioli16 · Sarah A. O’Shea17 · Vahid Reza Ostovan18 · Javier Ricardo Perez‑Sanchez11 · Ritesh Ramdhani19 · Victoria Ros‑Castelló20 · Christina Schulte21 · Priyank Shah22 · Lars Wojtecki21,23 · Pramod Kumar Pal24 Received: 5 February 2023 / Revised: 5 March 2023 / Accepted: 6 March 2023 © The Author(s) 2023 Abstract Background Neurological symptoms are common manifestation in acute COVID-19. This includes hyper- and hypokinetic movement disorders. Data on their outcome, however, is limited. Methods Cases with new-onset COVID-19-associated movement disorders were identified by searching the literature. Authors were contacted for outcome data which were reviewed and analyzed. Results Movement disorders began 12.6 days on average after the initial onset of COVID-19. 92% of patients required hospital admission (mean duration 23 days). In a fraction of patients (6 of 27; 22%; 4 males/2 females, mean age 66.8 years) the movement disorder (ataxia, myoclonus, tremor, parkinsonism) was still present after a follow-up period of 7.5 ± 3 weeks. Severe COVID-19 in general and development of encephalopathy were risk factors, albeit not strong predictors, for the persistence. Conclusions The prognosis of new-onset COVID-19-associated movement disorder appears to be generally good. The majority recovered without residual symptoms within several weeks or months. Permanent cases may be due to unmasking of a previous subclinical movement disorder or due to vascular/demyelinating damage. Given the relatively low response rate of one third only and the heterogeneity of mechanisms firm conclusions on the (long-term) outome cannot, however, be drawn. Keywords COVID · Sars-CoV2 · Movement disorder · Long covid · Outcome · Myoclonus ataxia · Parkinsonism Introduction Severe acute respiratory syndrome coronavirus 2 (SARSCoV2, 2019-nCoV) emerged in December 2019 and spread into a worldwide pandemic. More than 641 million people worldwide have been verifiably infected with Sars-CoV-2 (as of November 2022). About 10–30% of COVID-19 patients develop neurological symptoms in the acute phase, including a broad range of new-onset movement disorders [1]. Among these, ataxia and myoclonus are the most common manifestation; however, parkinsonism, dystonia, chorea and other movement disorders may also occur [2]. Little is * Susanne A. Schneider Extended author information available on the last page of the article known about the outcome of these patients, as most case reports were published relatively soon after the occurrence of symptoms. Long-term data are lacking. As a mission of the International Parkinson and Movement Disorders Society (MDS) Infection-Related Movement Disorder (IRMD) Study Group, we therefore collected detailed clinical information and outcome data of COVID-19-associated movement disorder cases. Methods We searched the literature using PubMed and Medrxiv, the preprint server for health sciences, to identify cases of COVID-19-associated new-onset movement disorders published until February 2022. We used the (combination of) 13 Vol.:(0123456789) Journal of Neurology search terms: movement disorder; parkinsonism/Parkinson’s disease; dystonia; chorea; tics; myoclonus; SARSCoV2, and COVID-19. Further articles were identified by cross-referencing. The authors were contacted and asked to provide follow-up information using a standardized questionnaire. Additional cases were also accepted, including by submission of data via a publicly available page on the website of the International Parkinson Disease and Movement Disorders Society (https://www.movementdisorders. org/COVID-19-Pandemic-MDS/COVID-19-Repository- Submissions.htm). Results Reports of 81 patients with new-onset movement disorders were identified (63 ataxia/myoclonus, 8 parkinsonism, 6 chorea, 3 dystonia, other movement disorders), the authors of which were contacted by email. Information was received on 27 patients (8 female, 19 male) who were included in the final analysis (20 with ataxia/myoclonus [3–12], 3 with a parkinsonian syndrome [13–15], 1 with chorea [16], 1 with tremor, 1 with limb tremor and gait ataxia [17]), yielding an overall response rate of 33.3%. (Fig. 1) Submissions were received from the US, Spain, India (5 cases each), Germany (4 cases), Canada (2 cases), Pakistan (2 cases) and Italy, Fig. 1  Identification of cases 13 Belgium, France and Iran (1 case each). None of the cases had been vaccinated against COVID-19. The clinical information is summarized in Table 1. Briefly, the mean age at movement disorder onset for the whole group was 56.8 ± 12.6 years. Severity of the COVID-19 infection ranged from mild to severe requiring hospital admission in all but two cases (92.6%; exceptions: one case with ataxia myoclonus and one with parkinsonism) with a mean cycle threshold score of 8.6 (data available for 18 patients) (with high scores indicating a low concentration of viral genetic material which is typically associated with a lower risk of infectivity). The movement disorder developed an average of 12.6 ± 9.21 days after the initial onset of COVID-19 (information available for 24 patients). It was still persistent in six cases (four males, two females, mean age 66.8 years) after a mean duration of follow-up of 53 ± 23 days. Clinical details of these six cases are presented in Table 2. Briefly, their movement disorders manifested as ataxia, myoclonus, myoclonus-ataxia, tremor and parkinsonism. The movement disorder resolved in the remaining 21 patients within several weeks. The mean duration of hospital admission was 22.9 ± 23.8 days for all cases (19.6 days for those who recovered vs 34.7 days for those with a persistent movement disorder). Oxygen supply was required in 51.8% of cases (56% of those admitted). Patients with an akinetic rigid syndrome stayed longer (48.3 ± 40 days) than patients Journal of Neurology Table 1  Clinical description of the study cohort (n = 27) Movement Disorder Number of patients Age Sex (M/F) Days of Hospital Stay Days Between COVID and movement disorder Myoclonus Myoclonus-Ataxia 7 5 58.7 ± 13.1 3/4 57.2 ± 12.4 4/1 20.4 ± 12.1 12.2 ± 8.1 Ataxia 5 53.2 ± 11.4 3/2 16.2 ± 10.2 Opsoclonus-MyoclonusAtaxia Hypokinetic rigid syndrome Tremor Serotonin Syndrome Limb tremor and gait ataxia Chorea 3 46.3 ± 13.0 3/0 3 1 1 1 1 56 ± 7.5 62 66 78 58 2/1 1/0 1/0 1/0 1/0 Follow Up# [weeks] (...truncated)