Case:
A 45-year-old female with no past medical history presented to the emergency department with onset of progressive nausea, slurred speech, and difficulty walking due to imbalance for 10days prior to arrival. She had her first dose of Sinopharm COVID-19 vaccine two weeks prior to her presentation. She reported some difficulty walking at initiation, but then had difficulty speaking and showed dysmetric movements in her left limbs which prompted her to come to the emergency department. She denied headache, unilateral weakness, vision changes, cough, fever, shortness of breath, chest pain or neck pain. She denied any COVID-19 contacts. Her initial vital signs were normal with oxygen saturation of 99% in room air. The physical exam was significant for dysarthria, incoordination, trouble reaching for items in left hand and imbalance. On exam she was significantly ataxic and her symptoms were more prominent on her left side. Her examination revealed mild horizontal nystagmus to left, dysdiadochokinesia, moderate appendicular ataxia, left dysmetria with finger-nose testing, and inability to stand unassisted. The patient was alert and oriented. Her motor force was 5/5 in upper and lower extremities with no pronator drift. No meningeal signs on exam. The initial laboratory work including CBC, TSH, ESR, CRP, urinalysis and urine drug screen were obtained and all were essentially normal. As acute cerebellitis could be related to various etiologies, she underwent different investigations. Brain MRI was taken with and without contrast from the head and neck. The MRI image showed a bilateral hyper intense lesion in both cerebellums which was more prominent in the left middle cerebellar peduncle (MCP) along with a fade enhancement in the same region and no cervical lesion (Figure 1). A lumbar puncture (LP) revealed an elevated protein level of 90 mg/dl with 10 WBCs with a lymphocyte predominance of 80%. CSF analysis revealed a positive COVID PCR and negative oligoclonal band (OCB). Accordingly, the most probable diagnosis was viral cerebellitis secondary to COVID-19 infection. Chest CT-scan and oropharyngeal COVID-19 PCR were negative. Infectious disease prescribed Remdicivir therapy along with 5grams of methylprednisolone. The LP was repeated after the completion of treatment and CSF COVID PCR was negative this time with no cells and a protein level of 38mg/dl. Since symptoms didn’t improve significantly, she remained hospitalized for 10 days more and treatment with 7.5 liter of plasmaphereses was performed with some improvement in neurological symptoms. The patient was provided with a walker for her ataxia at discharge and was scheduled to receive physiotherapy at home.