Superior Divisional Palsy of the Oculomotor Nerve as a Presenting Sign of SARS-CoV-2 (COVID-19)

Although COVID is a predominantly respiratory disease, recent studies demonstrate variable and atypical presentations with multiorgan involvement. Neurological manifestations involving cranial nerves and the peripheral nervous system are more frequently being described. Although mechanisms are still under investigation, several studies demonstrate the neuroinvasive potential of COVID via angiotensin-converting enzyme 2 (ACE2) receptor interactions and postulate this mechanism to be the route of COVID central nervous system (CNS) infection. We present the rare case of a purely superior divisional palsy of the left oculomotor nerve in a 46-year-old woman with no medical history in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, confirmed by magnetic resonance imaging (MRI) findings of asymmetrical thickening and enhancement of the left oculomotor nerve. With this report, we hope to increase clinical suspicion for oculomotor nerve palsies as a manifestation of SARS-CoV-2 infection and also to inspire further studies investigating neurological manifestations of COVID.