Bipallidal Lesions in a COVID-19 Patient: A Case Report and Brief Review of Literature

Abstract

BackgroundAltered mentation in COVID-19 patients can be a function of any number of metabolic abnormalities associated with the infection. Here we present the case of an encephalopathic COVID-19 patient with bilateral globus pallidus lesions. While imaging abnormalities involving basal ganglia have been reported in encephalitis caused by neuroinvasive flaviviruses, the bipallidal lesions noted here likely resulted from hypoxic-ischemic brain injury.Case PresentationA 51-year-old African American woman was found unresponsive at home by her fiancé. She had been complaining of shortness of breath and cough for three days. She is a former smoker with past medical history of hypertension, nephropathy, and bipolar disorder. Upon examination, she was alert but nonverbal, following commands inconsistently, and unable to move extremities against gravity. After several minutes, she was able to state her name but kept repeating it in response to all questions. Chest radiograph revealed bilateral lung infiltrates. CT of the head showed hypodensities in bilateral globus pallidi. A non-contrast MRI of the brain showed symmetric restricted diffusion and FLAIR hyperintense signal changes in bilateral globus pallidi. Abnormal SWI signal seen in bilateral globus pallidi likely represents mineralization or hemosiderin. There were no striatal or thalamic lesions. Major intracranial arteries were widely patent.The patient later tested positive for 2019-nCoV using real-time PCR assay, and was transferred to our COVID-19 designated hospital campus. Thereafter, she had waxing and waning mentation. Repeat CT imaging 11 days after the first scan demonstrated resolution of the bipallidal hypodensities. The patient was recently discharged to a subacute rehab facility but is still experiencing confusion.ConclusionsAs we come across neurological manifestations of COVID-19, we believe neuroimaging is likely to play an important role in establishing if central nervous system involvement is invariably due to indirect mechanisms such as metabolic or hypoxic-ischemic brain injury or if direct neuroinvasive disease is a possibility, as with certain viruses.

COVID-19 and Parkinsonism: A Critical Appraisal

“…The description of patient one ( Table 1 ) suggests extrapyramidal features due to encephalitis with basal ganglia damage. In particular, bipallidal T2 hyperintense lesions have been described in a wide range of conditions, from cocaine use [ 41 ] to COVID-19 [ 42 , 43 ], and parkinsonism is a key clinical manifestation of this neuroimaging pattern [ 44 ]. The neuroradiological picture of patients two and five ( Table 1 ), with a similar clinical scenario, shows a different type of encephalitic involvement in COVID-19, namely acute necrotizing encephalopathy with acute bilateral thalamic lesions, a severe disease prevalent among children in East Asia, outside COVID-19 [ 45 ].…”