Neurological Complications during Treatment of Middle East Respiratory Syndrome

Kim, Jee-Eun; Heo, Jae-Hyeok; Kim, Hye-ok; Song, Sook-hee; Park, Sang-Soon; Park, Tai-Hwan; Ahn, Jin-Young; Kim, Min-Ky; Choi, Jae-Phil

A triple antiviral regimen was initiated. He began to complain of dyspnea on hospital day (HD) 2, and his respiratory deterioration then progressed very rapidly. Antimicrobial therapy was added to his treatment regimen. He was intubated, and a mechanical ventilator was added on HD 10. Acute respiratory failure was followed by ARDS, septic shock, and multiorgan dysfunction syndrome. His respiratory status began to improve on HD 16, and he was taken off the mechanical ventilator on HD 28. The patient remained drowsy and exhibited bilateral ptosis up to 31 h after the administration of the sedative midazolam was stopped on HD 25. A neurological examination revealed complete external ophthalmoplegia and mild limb ataxia. Weakness was also suspected in all four limbs [Medical Research Council (MRC) grade 4]. Nystagmus, sensory changes, and oropharyngeal or facial palsy were not observed. Deep tendon reflexes were decreased in all limbs. The results of brain magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) studies were normal, including a negative CSF MERS-CoV RT-PCR assay. An electroencephalogram exhibited diffuse slow-wave activity. Nonspecific results were obtained in laboratory studies performed at the onset of neurological symptoms, including in assays to determine the glucose, thiamine, blood gas, ammonia, electrolyte, and creatinine levels. He was diagnosed with Bickerstaff's encephalitis (BBE) overlapping with Guillain-Barré syndrome (GBS). IgM/IgG anti-GQ1b and IgM/IgG anti-GM1 antibody titers were analyzed on HD 39, and all were negative. The findings of nerve conduction studies performed on HD 46 were normal. His neurological complications began to improve on HD 30, and he had fully recovered by approximately HD 60 (Fig. 1) .