Acute Onset Bilateral Ptosis in an Asymptomatic COVID Patient

Abstract

Sixty-five-year old man, known hypertensive with previous history of cerebrovascular accident presented to the Emergency Department with complaints of acute onset ptosis for the last 7 h. Onset of ptosis was sudden and was not associated with waxing and waning of symptoms. Examination revealed bilateral ptosis with no other neurological deficits. Differentials of acute cerebrovascular accident, myasthenia, and neurotoxic envenomation were considered. Magnetic resonance imaging stroke protocol was done which revealed an acute mid brain infarct. Real-time polymerized chain reaction test for corona virus disease 19 (COVID-19) done in view of the pandemic situation was positive. Acute onset bilateral ptosis is an infrequent presentation to any emergency room. Prompt diagnosis and evaluation of the various differentials is of utmost significance in improving the patient outcome. Ptosis occurs due to paresis of levator palpebrae superioris (LPS) and Mullers muscle. In this patient, isolated ptosis with papillary sparing probably occurs due to the involvement of caudal sub nucleus of oculomotor nucleus. Ischemic events especially stroke is emerging as complication of COVID-19. COVID-19 is associated with hypercoagulopathy and the elevation of d-dimer and fibrinogen, leading to potential complications like acute stroke. COVID-19 infection may not always present with the typical respiratory symptoms and atypical presentations are incrementing. However, the patient had risk factors for stroke and a causal relationship with coronavirus infection remains conjectural.