208 - Post-COVID Small Fiber Neuropathy of the Perineum

Case Diagnosis: Post-Covid Perineal Neuralgia Syndrome

Case Description: 64-year-old female with no relevant past medical history presented to a Pelvic Health Rehabilitation Clinic via telehealth with unresolved neuropathic pelvic pain three months after COVID-19. The patient developed upper respiratory symptoms and allodynia in her thoracic region, feet, and perineum/vulva. On presentation, her symptoms were perineal pain and mild sensitivity in her feet. The thoracic symptoms had resolved. She had vulvar pain that worsened throughout the day and from sitting or wearing pants due to external pressure on the pelvic region. Her gynecologist had prescribed estradiol cream and topical antifungal. She was also prescribed a steroid taper and gabapentin with no relief.

Discussions:

Physical exam two months after initial visit while on pregabalin was significant for tenderness to palpation over internal and external bilateral transverse perineal muscles, mildly increased internal pelvic floor muscle resting tone, and no allodynia or hyperesthesia.

Lumbar spine MRI showed spondylosis without nerve compression, and pelvis MRI demonstrated right-sided ovarian varicosities and cysts but no other acute findings. Patient was uptitrated on pregabalin which provided improvement in vaginal pain but minimal improvement in extremity pain. 

Conclusions: Post-COVID neuropathic pain due to small fiber neuropathy (SFN) presents several weeks after infection and causes significant disability due to painful paresthesias, allodynia, and numbness in extremities, abdomen, or face. It is hypothesized that the inflammatory immune response during a viral illness leads to immune dysregulation and small fiber nerve damage. This case presents a unique case of painful perineal symptoms, which has not been commonly seen with post-COVID SFN. Studies have looked at IVIG treatment, however this patient showed a positive response to pregabalin.

Post-COVID perineal neuralgia syndrome can affect quality of life; therefore, accurate diagnosis and treatment are necessary for functional recovery. Patients should be closely evaluated for symptoms to ensure adequate treatment is initiated.