TOPIC: Signs and Symptoms of Chest Diseases
      TYPE: Fellow Case Reports
      INTRODUCTION: Unilateral diaphragm paralysis is most commonly discovered incidentally on chest radiograph. Although most cases are secondary to trauma or surgery about 20% are idiopathic or viral in etiology (1,2). Herpes zoster and HIV have been the most commonly reported viral etiologies in the literature (3). To the best of our knowledge, unilateral diaphragm paralysis secondary to COVID-19 has not been reported. We present a rare case of symptomatic unilateral diaphragm paralysis after a mild COVID-19 infection.
      CASE PRESENTATION: A 50-year-old male with no significant medical or surgical history presented for evaluation of persistent exertional and positional dyspnea one month after COVID-19 infection. Initial symptoms from COVID-19 were loss of taste and smell, dyspnea, and myalgias, however after two weeks all symptoms had resolved with the exception of dyspnea. The patient noted significant positional component prompting sleeping in an upright position. Chest radiograph revealed a new elevated right hemidiaphragm. Fluoroscopy confirmed paralysis with paradoxical motion of right hemidiaphragm with inspiration. Pulmonary function testing showed a nonspecific pattern with a significant decrease in forced vital capacity (FVC) of 27% with supine positioning, as well as normal diffusion capacity (DLCO), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP). Evaluation for other potential causes including CT of the chest and neck were unrevealing. Overnight polysomnogram to evaluate for central apneas or hypoventilation with desaturation was obtained. After three months follow up from initial presentation his symptoms were improving. Consistent with common practice the current plan is to observe for at least 12 months in hopes of spontaneous recovery before consideration of more advanced therapies including surgical plication.
      DISCUSSION: The far reaching effects and outcomes of COVID-19 are still being evaluated, however there appears to be a strong inflammatory process capable of affecting nearly every organ system. Multiple case reports and series have evaluated peripheral nerve pathology including cranial nerve palsies and Guillain-Barre syndrome (GBS) (4,5). The pathophysiology of these neurological abnormalities including "molecular mimicry" or small vessel vasculitis posits a potential pathway for unilateral diaphragm paralysis (6).
      CONCLUSIONS: As with other viral induced peripheral neuropathies there is a strong likelihood of recovery after resolution of infection. In regards to our patient, we remain optimistic for recovery while providing appropriate supportive care.
      REFERENCE #1: 1. Kokatnur L, Rudrappa M. Diaphragmatic Palsy. Diseases. 2018;6(1):16. Published 2018 Feb 13. doi:10.3390/diseases6010016
      REFERENCE #2: 2. Crausman RS, Summerhill EM, McCool FD. Idiopathic diaphragmatic paralysis: Bell's palsy of the diaphragm?. Lung. 2009;187(3):153-157. doi:10.1007/s00408-009-9140-z
      REFERENCE #3: 3. Ricoy J, Rodríguez-Núñez N, Álvarez-Dobaño JM, Toubes ME, Riveiro V, Valdés L. Diaphragmatic dysfunction. Pulmonology. 2019;25(4):223-235. doi:10.1016/j.pulmoe.2018.10.0084. Dinkin M, Gao V, Kahan J, et al. COVID-19 presenting with ophthalmoparesis from cranial nerve palsy. Neurology. 2020;95(5):221-223. doi:10.1212/WNL.00000000000097005. Codeluppi L, Venturelli F, Rossi J, et al. Facial palsy during the COVID-19 pandemic. Brain Behav. 2021;11(1):e01939. doi:10.1002/brb3.19396. Fotuhi M, Mian A, Meysami S, Raji CA. Neurobiology of COVID-19. J Alzheimers Dis. 2020;76(1):3-19. doi:10.3233/JAD-200581
      DISCLOSURES: No relevant relationships by Robert Trentacosta, source=Web Response