Complications of COVID-19 , a case with both neurological and dermatological complications.

Recently, different complications and clinical manifestations of COVID-19 have been reported such as neurological or dermatological complications, We present a conrmed COVID-19 case of diplopia and ophthalmoplegia presenting skin lesions at the same time . Of the symptoms of COVID-19 , maculopapular exanthem , papulovesicular rash , urticaria , painful acral red purple papules , livedo reticularis lesions and petechiae .


Introduction
From the onset of the COVID-19 pandemic , various non-respiratory presentations have been reported, including dermatologic and neurologic presentations.
In this case report, a patient will be presented with both dermatologic and neurologic symptoms.
The lesions were mostly localized on the trunk . The development occurred before the onset of respiratory symptoms, and according to the majority of studies , lesions were not related to the severity of the disease . (2) Case Presentation In June, 2020, a 47-year-old man presented with fever and chills, cough, diarrhea, headache and then mild dyspnea . He was diagnosed with COVID-19 after a nasal swab for SARS-CoV-2 PCR was positive.
Laboratory test on admission showed increased D-dimer and in ammatory markers such as CPK, LDH, ESR and CRP.
In an outpatient setting , hydroxychloroquine started for the patient with a dose of 600 mg twice a day for one day, followed by 400 mg daily for four days . He was also treated with azithromycin and subcutaneous enoxaparin and naproxen 500 .
After 5 days, he returned with presentation of a rare hypersensitivity syndrome called baboon syndrome , erythrodermic non pruritic skin lesions in the inguinal area, axilla and also around his neck . This is considered as a nonimmediate hypersensitivity reaction, which is very rarely reported. (3,4) A therapy with antihistamine (hydroxyzine10) started for the patient and after 3 days, he presented with diplopia and ophthalmoplegia .
At referral to the neurologist, it was the 15 th day after the onset of his rst symptoms. The patient was awake and completely oriented, with normal language and speech examination. Cranial nerve examination showed right side 6 th nerve palsy leading to patient diplopia. All other cranial nerves were normal. Sensory motor and cerebellar examinations were normal. The only other abnormal exam was lost left side Achill re ex, which was compatible with a previous history of old left side S1 radiculopathy.
There was no papilledema or ptosis. He had no headache, vision loss, nausea, vertigo, or history of seizure or other neurologic complaints.
Brain MRI with and without contrast was performed that was completely normal and showed no abnormal meningeal or cranial nerve enhancement at that stage.
Electrodiagnostic studies (EDX) including needle electromyography (needle EMG) and nerve conduction studies (NCS), were performed to search for polyneuropathies, including GBS and its variant Miller Fisher syndrome, but there was no conduction block, decreased conduction velocity, increased distal latency, ongoing denervation potentials including brillations or positive sharp waves or sensory loss in all examined nerve CMAPs and SNAPs and muscle MUAPs to suggest such a diagnosis. The only positive ndings in the EDX study were chronic neurogenic ndings, such as polyphasic long duration MUAPS in L5 and S1 innervated muscles bilaterally, which was in favor of old radiculopathy. The EDX study report is attached.
Regarding normal brain MRI and no obvious peripheral polyneuropathy, cranial mononeuropathy was considered, and treatment with IV corticosteroid (2 doses of intramuscular dexamethasone 5 days apart) was started which resulted in complete improvement of the patient's neurologic symptoms.
After 20 days , there were no neurologic or dermatologic symptoms remained.

Discussion
In conclusion, some cases of neurological or dermatological complications of COVID-19 have been reported so far, but we presented a rare case of a patient who had both neurological and dermatological symptoms at the same time in addition to his respiratory symptoms.
There is a need to diagnose these non respiratory manifestations at the earliest stage to prevent longterm sequelae as much as possible . Much research is needed to explore the role of SARS-CoV-2 in causing these neurological and dermatological manifestations and also the risk factors of their development(5)

Declarations
The study was approved by the local ethic committee. The patients gave informed consent and approved the publication of the manuscript.
The authors declare no con ict of interest.  Figure 1 dermatologic presentation