Subacute dystonia heralding Covid-19 in a PD patient

Summary of observations

In the middle of the COVID-19 pandemic in Italy, we evaluated a 58-year-old woman with PD diagnosed when she was 50 years old, preceded by anosmia since a few years before. PD slowly and progressively worsened. She was treated with dopaminergic drugs and clozapine was introduced due to levodopa-induced hallucinations. In recent years, antiparkinsonian treatment consisted of levodopa/benserazide and clozapine administration. On April 12, 2020, she showed a slightly high temperature (37.2 °C), slurred speech, and confusion. In the following hours, the patient presented severe and sustained spasms of arms and legs. We arranged a session of telemedicine consulting with the patient. She showed sustained dystonic posturing of the upper and lower extremities, reported as persistent in the “off” and in the “on” med condition. She was advised to increase the daily dose of levodopa (from 400 to 600) and clozapine (from 25 to 50 mg). The clinical suspect of COVID-19 was confirmed by the positive nasopharyngeal swab test for SARS-CoV-2. The infection had a mild course with fever never exceeding 37.5 °C and temperature dropping after a few days. She never presented respiratory distress or other complications. No therapy for viral infection was prescribed. She reported a rapid improvement of neurological conditions. At the end of the quarantine period, she was evaluated at the Movement Disorder Clinic. The UPDRS III score in on status was 32/108 and no dystonic spasms of the limbs were present.