key: cord-256375-f4vrcjr1
authors: Cabrera Muras, Antonio; Carmona‐Abellán, María del Mar; Collía Fernández, Alejandra; Uterga Valiente, Juan María; Antón Méndez, Lander; García‐Moncó, Juan Carlos
title: Bilateral Facial Nerve Palsy associated with COVID‐19 and Epstein‐Barr Virus co‐infection
date: 2020-09-30
journal: Eur J Neurol
DOI: 10.1111/ene.14561
sha: 
doc_id: 256375
cord_uid: f4vrcjr1

A 20‐year‐old male, with no relevant previous medical history, was admitted due to bilateral facial weakness. Two weeks before, he noticed odynophagia and fever of 39ºC without cough. He associated significant asthenia with headache, myalgia, nausea, and vomiting and he was treated with levofloxacin 500mg qd for 7 days. One week after, during an initial improvement of the respiratory symptoms, he presented acute right facial weakness. He was diagnosed with right peripheral facial palsy and was treated with prednisone 60 mg/24h with a tapering schedule.

peripheral facial palsy and was treated with prednisone 60 mg/24h with a tapering schedule. The following week he noted left facial weakness and was referred again to the emergency room. On 

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This patient presented with severe bilateral facial palsy, evidence of SARS-CoV-2 infection preceded by upper respiratory symptoms, and evidence of coinfection with EBV. Interestingly, he had odynophagia but did not have the typical dry cough of COVID-19.

Bilateral facial palsy is a rare entity, accounting for 0.3 to 2% of all peripheral facial palsies [1] .

There are several conditions identified as potential causes, including infections (Lyme disease, EBV, HIV), inflammatory disorders (sarcoidosis), tumoral (brainstem tumors), and idiopathic (bilateral Bell's palsy). EBV infection is responsible for 0.5%-7.5% of peripheral facial palsies, and up to 35% are bilateral [2, 3] . This patient had serological evidence of recent EBV infection, although PCR for EBV in the CSF was negative.

Both viruses may have played a role in this patient. Co-infection with SARS-CoV-2 is not rare. A recent study showed that 20.7% of a sample of 116 specimens positive for SARS-CoV-2 were also positive for 1or more additional pathogens, among which EBV was not studied [4] .

There are several reports of Guillain-Barré Syndrome (GBS) associated with COVID-19 infection [5] , of which 7 had facial diplegia (8 including ours), an incidence higher than the 3% reported in GBS [1] . One of the reported patients had isolated bilateral facial palsy and was interpreted as a variant of GBS know as bifacial weakness with paresthesias [6] . Our patient also meets the criteria (bifacial symmetrical weakness, absence of limb, neck or ocular weakness, and infectious disease in the previous 3 days to 6 weeks and albumino-cytological dissociation in CSF), although he did not have paresthesias.

The fact that PCR in the CSF was negative for both EBV and SARS-CoV-2 may suggest and indirect, immune-mediated mechanism rather than a direct, viral-induced damage.

SARS-CoV-2 infection should be suspected in patients with facial palsy or any suspicion of GBS in the times of COVID-19 pandemics since it may be the presenting feature in patients with mild respiratory symptoms. Co-infection with other pathogens should be considered as may require specific therapy.

Bilateral Facial Paralysis: A 13-Year Experience

Neurological picture. Bilateral facial nerve palsy associated with Epstein-Barr virus infection

Bilateral facial nerve palsy associated with Epstein-Barr virus infection with a review of the literature

Rates of Co-infection Between SARS-CoV-2 and Other Respiratory Pathogens

Guillain-Barre Syndrome Associated with SARS-CoV-2

Isolated facial diplegia in Guillain-Barre syndrome: Bifacial weakness with