Editors' note: COVID-19 presenting with ophthalmoparesis from cranial nerve palsy

Dr. Dinkin et al. reported 2 cases with MRI confirmation of cranial nerve inflammation within several days of systemic symptoms of the novel coronavirus disease 2019 (COVID-19). Both patients tested positive for SARS-CoV-2 by PCR from a nasal swab, and both were treated with hydroxychloroquine (one also with intravenous immunoglobulin), with mild short-term improvement. The authors suggest the inflammatory cranial neuropathies could have been because of a postviral immune-related response. Dr. Machado wonders whether the cranial neuropathies could have resulted from direct viral invasion, given their onset shortly after the viral symptoms started. As noted by Gutierrez-Ortiz et al. (Dinkin et al., reference 2 below) 2 patients developed evidence of cranial nerve inflammation and autoimmune neuropathy within 3–5 days of COVID-19 symptom onset. Each of these 4 cases highlight the accelerated time course of inflammatory cranial neuropathies after systemic manifestations of COVID-19, which seems to be more rapid than has been typically reported for variants of Guillain-Barre syndrome after other infectious illnesses. These observations may also support that there is an asymptomatic phase of this viral infection during which an immune response may be generated. Dr. Dinkin et al. reported 2 cases with MRI confirmation of cranial nerve inflammation within several days of systemic symptoms of the novel coronavirus disease 2019 (COVID-19). Both patients tested positive for SARS-CoV-2 by PCR from a nasal swab, and both were treated with hydroxychloroquine (one also with intravenous immunoglobulin), with mild short-term improvement. The authors suggest the inflammatory cranial neuropathies could have been because of a postviral immune-related response. Dr. Machado wonders whether the cranial neuropathies could have resulted from direct viral invasion, given their onset shortly after the viral symptoms started. As noted by Gutierrez-Ortiz et al. (Dinkin et al., reference 2 below) 2 patients developed evidence of cranial nerve inflammation and autoimmune neuropathy within 3–5 days of COVID-19 symptom onset. Each of these 4 cases highlight the accelerated time course of inflammatory cranial neuropathies after systemic manifestations of COVID-19, which seems to be more rapid than has been typically reported for variants of Guillain-Barre syndrome after other infectious illnesses. These observations may also support that there is an asymptomatic phase of this viral infection during which an immune response may be generated.