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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Coronavirus disease 2019 &#40;COVID-19&#41; can cause severe acute respiratory distress &#40;ARDS&#41; and long-term complications&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> We report a case of delayed bilateral vocal cord paralysis &#40;BVCP&#41; as an exceptional complication of severe COVID-19 pneumonia&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 41-year-old patient was admitted for severe ARDS caused by bilateral SARS-CoV-2 pneumonia that required orotracheal intubation for 6 days&#46; The patient was extubated&#44; but reintubation was required for laryngeal edema that was treated with corticosteroids&#44; following which he was successfully extubated&#46; Fiberoptic laryngoscopy showed mild laryngeal edema and vocal cord pathology was ruled out&#46; Seventy-six days after discharge&#44; the patient consulted for progressive dysphonia and inspiratory stridor&#44; so corticosteroid treatment was started&#46; Respiratory function tests showed amputated flow&#47;volume curves&#46; Fiberoptic laryngoscopy was repeated&#44; confirming complete paralysis of both vocal cords&#46; A subsequent neck and chest CT scan ruled out other lesions&#44; so we opted for speech therapy and respiratory physiotherapy that resulted in clinical improvement&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">BVCP has a broad etiology&#58; surgery&#44; cancer&#44; and neurological disorders are the most common causes&#44; while intubation and viral infection are much more infrequent&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Up to 50&#37; of cases are classified as idiopathic but may conceal a viral etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Vocal cord involvement has been reported in several viral diseases&#46; Influenza A&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> for example&#44; has been associated with delayed postviral vagal neuropathy at 22 weeks and a good prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The absence of other possible causes and the timeframe of the case suggested a viral etiology&#46; Severe SARS-CoV-2 infection can cause delayed cranial nerve changes<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> and there is evidence of the neuroinvasive potential of the virus&#44; possibly as a result of direct neurotoxicity mediated by ACE-2 receptors that allow access to the central nervous system &#40;CNS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Once the virus has accessed the CNS it is difficult to eliminate due to the absence of major histocompatibility complex antigens and the homeostatic characteristics of the CNS cells&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> This situation&#44; along with a progressive inflammatory cascade and persistent immune hyperreactivity&#44; could affect various cranial and peripheral nerves that&#44; due to their more caudal location&#44; would account for delayed involvement in a very limited number of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a> Furthermore&#44; retrograde transport of SARS-CoV-2 along the vagus nerve to the brainstem causing delayed BVCP has been mooted&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The real incidence of BVCP caused by SARS-CoV-2 is unknown&#44; but it is clearly very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The few reported cases involved a serious event that appeared 3&#8211;40 days after discharge&#44; although in our case&#44; BVCP developed even later&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The possibility of BVCP in the late stages of a serious SARS-CoV-2 infection must be recognized to facilitate prompt diagnosis and treatment of this potentially life-threatening condition&#46; It can be diagnosed by assessing patient background&#44; clinical history&#44; respiratory function tests&#44; and direct endoscopic images&#44; and appropriate treatment must be administered in line with severity and clinical impact&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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