Introduction: 
The outbreak of COVID-19 was caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first identified in Wuhan, a city in Hubei province in China in December 2019. As of September 21, 2020, nearly 31.1 million cases and 962,000 deaths were reported in 213 countries and territories. Severe acute respiratory syndrome CoV (SARS-CoV) and novel CoV were believed to share the same receptor, angiotensin-converting enzyme (ACE), hence the virus is termed as SARS-CoV-2, and World Health Organization named the disease as coronavirus disease 2019 (COVID-19) in February 2020 and declared as pandemic on March 11, 2020.
Initially, fever, cough, shortness of breath, and myalgia were reported as common symptoms and pneumonia-like features in chest computerized tomography (CT) scan in patients affected by COVID-19.1 But, later, various neurological manifestations were noticed. Olfactory and gustatory involvement resulting in anosmia and dysgeusia are common neurological symptoms in mild cases. Guillain-Barre syndrome and inflammation of the brain, spinal cord, meninges, cranial nerve, and peripheral nerve involvement are reported.2 Various cutaneous manifestations like a morbilliform rash, urticaria, vesicular eruptions, acral lesions, petechiae, chilblains, Livedo racemosa, and distal necrosis are also seen.3
We report a 63-year-old Caucasian female journey who had a diagnosis of COVID-19 with other associated manifestations during her visit to a small country in Europe.
Case:
A 63-year-old Caucasian female with a past medical history of aplastic anemia, mitral valve prolapse with regurgitation, celiac disease, and motion sickness presented with a runny nose and breathlessness. She did not report fever, chills, cough, or chest pain. Given the past history of aplastic anemia, she took over the counter iron pills for shortness of breath with no improvement. She is a resident of the United States but an avid traveler and was in Europe when the symptoms developed. The symptoms developed in March 2020 when there were no reported COVID-19 cases.
When there were no signs of improvement after a few days of symptomatic management, the PCR for the SARS-CoV-2 test was performed, which came back positive, confirming the diagnosis of COVID-19, and she was advised home quarantine.
About four weeks after the initial episode, the patient developed twitching of the left eye and left cheek, diarrhea, generalized weakness, palpitations, sleep disturbances, decreased appetite, skin rash, anosmia, and dysgeusia. Twitching was involuntary, initially started near the left eye, and progressed to the left side of the face. The patient described it as a strong one that disturbed her daily activities. It was not associated with pain, loss of sensations, or numbness. There were 8-10 painful, red skin lesions around 3mm in size in the lower face, especially around the mouth. These lesions are herpes labialis caused by herpes simplex type-1 (HSV-1). There was no associated itching, bleeding, blistering, or discharge. She also noticed the purple discoloration at the base and whitish discoloration at the fingers’ tips with temperature changes, as shown in the picture (Figure 1). As she is a visitor with a traveler’s health insurance, she could not receive investigations or treatment. She took plenty of fluids, symptomatic treatment, and over-the-counter baby aspirin, multivitamins, and calcium supplements. Over the next four weeks, she began to improve. The patient was tested for COVID-19 every week until she was negative on the 58th day.
One week after she tested negative for COVID-19, she suddenly had chills, vomiting and woke up in the middle of the night with dizziness, the room spinning with an unsteady gait. She denied tinnitus or hearing loss. Physical examination showed a strong phase of nystagmus to the right, indicating left ear involvement. Dix-Hallpike maneuver was performed, and she was confirmed with vertigo and diagnosed post-viral vestibular neuritis. Initially, she was managed with meclizine, antiemetics, and Cawthorne vestibular rehabilitation exercises. When symptoms got worse, the patient was given 60mg of methylprednisolone tapered gradually for ten days. On the 10th day of steroids, the patient noticed a sudden onset of flashes and floaters, vertically and temporally located in the left eye. A slit-lamp examination diagnosed posterior vitreous detachment (PVD) of the left eye. PVD was attributed to an increase in intraocular pressure with steroid use. There is a slight improvement in vision after cessation of steroids.
Several weeks later, the patient developed high-grade fever, arthralgias, arthritis, and a non-itchy urticarial rash all over her chest and abdomen eight hours following the intake of 2g Augmentin for a dental procedure. Fever was as high as 102F, not associated with chills and rigors. The patient did not develop lymphadenopathy or pedal edema. Symptoms subsided in a couple of days without any treatment. Five months after positive COVID-19 test, she is negative for IgG antibodies.