A Woman With COVID-19 Infection and Quadriparesis

A 36-year-old 8-month pregnant female presented to the hospital with severe weakness and fever for 2 days. She was diagnosed having COVID-19 infection.

She underwent an emergency cesarean section and was intubated in the prone position; this situation lasted for over 6 weeks. The patient was extubated and improved, and she had generalized weakness, more severe in the right upper extremity.

Examination revealed normal mentation and cranial nerves. There was profound weakness; this was more severe in the lower extremities, more distally than proximally, and in the proximal right arm. She was areflexic. Sensory examination showed decreased vibration sense in the toes. She had decreased pinprick in the right upper extremity, particularly in the outer aspect of the forearm and the second and third digits.

What is the Most Likely Diagnosis?

This patient appears to have had an ICU neuropathy and possible myopathy. She also appears to have a compression of the brachial plexus, likely from positioning during intubation.

What is the Next Step?

An EMG showed a sensorimotor neuropathy with denervation potentials, mainly in the distal muscles, and small polyphasic motor units in the proximal muscles. There was also denervation mainly in muscles innervated by the right upper trunk and of the brachial plexus.

Motor Nerve Conduction Studies

Nerve/Sites	Muscle	Latency ms	Ref. ms	Amplitude mV	Ref. mV	Velocity m/s	Ref. m/s
R Median-APB _Wrist	_APB	_4.5	≤4.40	_3.7	_4.0	₄₉
R Ulnar-ADM Wrist	ADM	3.1	≤3.3.0	_4.6	26.0	₆₁
L Peroneal-EDB Ankle	EDB	4.9	≤6.50	2.9	≥2.0
Fib head	_EDB			_5.3		₄₄	≥44.0
Pop fossa	EDB			5.0		43	≥44..0
L Tibial-AH
Ankle	_AH	_NR	≤5.80	_NR	≥4.0
Pop fossa	AH	NR		NR			≥41.0