Background: Since the outbreak of the COVID-19 pandemic, there has been a growing need to fully  understand all the possible clinical features of the epidemic, which often presents with unusual manifestations, 
especially in children.
Methods: In this report, we describe the case of a child with a COVID-19 infection and suffering  exclusively from vertigo and fever.
Results: Altogether, considering the clinical manifestation, laboratory tests and imaging, given the  patient’s positivity to SARS-CoV-2 infection and its neurotropic potential, we assumed that the child had  COVID-19-induced Vestibular Neuritis, which, in consideration of the spontaneous improvement of symptoms,  did not require any therapeutic adjustments, apart from the natural compensation of the central nervous system.
Conclusions: This case suggests the importance of having an index of suspicion for a COVID-19 infection  in pediatric patients presenting with vertigo and adds valuable information to the limited literature on  COVID-19 presentation and management in children.

Giannantonio S, Scorpecci A, Montemurri B, Marrone S, Campagnola C, et al. (2020) A Case of COVID-19 Induced Vestibular Neuritis in a Child. Ann Otolaryngol Rhinol 7(4): 1249.

In December 2019, a new Coronavirus, first called 2019-nCov and then SARS-CoV-2 for Severe Acute Respiratory SyndromeCoronavirus-2, was identified in Wuhan, China [1]. SARS-CoV-2 has rapidly spread, causing the current COVID-19 (Coronavirus Disease 2019) pandemic, which as of November 1, 2020 has already killed 1.2 million people worldwide, with a recent further acceleration of new cases in the European region [2].

Consequently, understanding the clinical manifestations of such pandemic has been a priority for the scientific world ever since. Pneumonia appears to be the most frequent and the most serious manifestation of a COVID-19 infection, presenting as fever, cough, dyspnea, and bilateral infiltrates on chest imaging [3]. However, as in the case of other viral respiratory infections, COVID-19 may occur with other clinical features (such as conjunctivitis, fatigue, myalgia), and proved to have neurotropic properties, as some Authors advocate that it may cause neurological manifestations, ranging from headache and loss of smell and taste, to confusion and disabling strokes [4,5].

Currently, little is known about the possible clinical implications of such infection on balance, and even less in the pediatric population.

In this report, we describe the case of a child with a COVID-19 infection and suffering exclusively from vertigo and fever.

A 13-year-old boy, previously healthy, complained of sudden onset of fever, giddiness and repeated vomiting in 20th October 2020. Due to the persistence and worsening of “unsteadiness”, he went to the emergency room of the “Bambino Gesù” Children’s Hospital in Rome, Italy, the day after the onset of symptoms; in accordance with anti-COVID surveillance protocols, he immediately performed a nasopharynx swab, which tested positive for SARS-Cov-2 infection. Admitted to the COVID ward with an initial diagnosis of dehydration, he then underwent further investigations: after 24 hours, the child had no longer fever, but continued to complain of asthenia, extreme fatigue, mild photophobia, headache, nausea and dizziness. He described his vertigo as objective, lasting most of the day, present in rest conditions but mostly worsened by the movement of the head to the left side. He has never had breathing difficulties, no hearing loss or tinnitus, no disturbances of smell or taste. All the inflammatory markers, including erythrocyte sedimentation rate, C-reactive protein, and ferritin, were within normal limits and so were the coagulation parameters, including d-dimer, fibrinogen, and platelet count. He had a blood pressure of 120/60 mmHg, heart rate 80/min, respiratory rate 26/min, 100% oxygen saturation on room air. Neurological consult demonstrated an intact cognition, no cranial nerve defects, intact fine finger movements and strength of upper limbs, except for the tendency to fall toward the left side. Vestibular examination, performed by the ENT specialist using Frenzel glasses, showed the presence of a spontaneous, horizontal-torsional grade III nystagmus with a rightward fast component, non-rhythmic, about 70 beats per minute, inexhaustible, visible even with visual fixation, although weaker. No further positioning maneuvers were performed due to the finding of spontaneous nystagmus. Transient-evoked acoustic otoemissions were bilaterally present, while it was not possible to perform pure tone audiometry due to problems of environmental disinfection. A brain MRI ruled out any acute findings. Serology (IgG, IgM) and Polymerase Chain Reaction (PCR) for the main neurotropic viruses (HSV-1 and 2, CMV, EBV, and Adenovirus) gave negative results. During the 6 days of hospitalization, the general conditions of the child gradually improved, with a clear spontaneous reduction of the vertiginous symptoms. By day 6, the boy had spontaneous grade I-II nystagmus, a strong reduction of unsteadiness, no more nausea or vomiting.

Altogether, considering the clinical manifestation, laboratory tests and imaging, the most likely diagnostic hypothesis was a left Vestibular Neuritis probably caused by SARS-CoV-2 infection, which, in consideration of the spontaneous improvement of symptoms, did not require any therapeutic adjustments, apart from the natural compensation of the central nervous system.

Although not rare in absolute terms, the prevalence of balance disorders in children is low, ranging between 0.7% and 15% in general pediatric population [6,7]. Vestibular Neuritis (VN), defined as benign, self-limited vestibular imbalance, represents one of the most common causes of vertigo in children, especially among adolescents, accounting for about 16% of overall pediatric dizziness [8]. The clinical findings in these patients are consistent with sudden, severe rotatory vertigo, lasting from few hours to few days, associated with nausea and vomiting, without hearing loss. On examination, they would demonstrate hypofunction of the affected labyrinthine canal, typically with a spontaneous horizontal-torsional nystagmus beating away from the lesion side, associated with unsteadiness characterized by a falling tendency toward the lesion side. In adults, abnormal head impulse test for the involved semicircular canals, ipsilesional caloric paresis, decreased responses of vestibular-evoked myogenic potentials during stimulation of the affected ear can also be detected [9,10]. Despite a faster and better recovery with respect to the adults, affected children often represent a diagnostic challenge, due to their inability to explain the characteristics of the experienced symptoms and the scarce reliability of vestibular tests in younger patients. A diagnosis of VB is largely based on the clinical presentation of an acute, sustained vestibular syndrome, since there are no specific diagnostic tests. Yet, even in the patient with the typical pattern of spontaneous nystagmus observed in VN, brain imaging is indicated when the patient has unprecedented headache, negative head impulse test, severe unsteadiness, or no recovery within 1 to 2 days. With respect to the therapeutic aspect, although a role of steroids and vestibular rehabilitation has been advocated, VN often has a spontaneous resolution in children and their overall prognosis seems to be better than that in adults [11]. Recovery from VN is generally due to a combination of peripheral restoration of labyrinthine function, somatosensory and visual substitution, and central compensation [12].

With respect to the etiopathogenesis, VN occurs most of the times subsequently or concurrently to a viral upper respiratory infection resulting in a post-viral inflammatory disorder affecting predominantly the superior vestibular portion of the eighth cranial nerve [11]. Many Authors advocate the role of type 1 Herpes Simplex Virus (HSV-1) as the main cause of VN [12,13], either through a reactivation of a latent infection of the vestibular ganglia or through autoimmune and microvascular ischemic insults to the vestibular labyrinth [14].

Also SARS-Cov-2 is proved to invade the central nervous system, causing neurological disorders such as headache, dizziness and impaired consciousness, acute cardio-vascular disease, meningitis/encephalitis, acute necrotizing hemorrhagic encephalopathy, and acute Guillain–Barré syndrome [15]. Though the underlying neurotropic mechanisms of the new coronavirus are yet to be fully established, it has been hypothesized that SARSCoV-2 may affect the central nervous system through two direct mechanisms, which is hematogenous dissemination or neuronal retrograde dissemination [5].

Since serology and PCR have both ruled out a current or previous infection by one of the main neurotropic viruses, given the patient’s positivity to SARS-CoV-2 infection and its neurotropic potential, we assumed that the child had COVID19-induced VN. In conclusion, this case suggests the importance of having an index of suspicion for a COVID-19 infection in pediatric patients presenting with vertigo and adds valuable information to the limited literature on COVID-19 presentation and management in children.

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11.T Tahara, T Sekitani, Y Imate, K Kanesada, M Okami. Vestibular neuronitis in children. Acta Otolaryngol Suppl. 1993; 503: 49–52.

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13. V Arbusow, P Schulz, M Strupp, M Dieterich, A von Reinhardstoettner, E Rauch, et al. Distribution of herpes simplex virus type 1 in human geniculate and vestibular ganglia: implications for vestibular neuritis. Ann Neurol. 1999; 46: 416–419.

14. Brandt T, Dieterich M, Strupp M. Vertigo and dizziness: common complaints. London: Springer; 2005.

15. Pranusha Pinna, Parneet Grewal, Julianne P Hall, Tachira Tavarez, Rima M Dafer, Rajeev Garg, et al. Neurological manifestations and COVID- 19: experiences from a tertiary care center at the Frontline. J Neurol Sci. 2020; 415: 116969.