Clinical, Radiological, and Molecular Findings of Acute Encephalitis in a COVID-19 Patient: A Rare Case Report

Abstract

We report a case of encephalitis in a young male patient with severe coronavirus disease 2019 (COVID-19) who initially presented with typical symptoms of fever, dry cough, and shortness of breath but later on developed acute respiratory distress syndrome and required mechanical ventilation. Two days post-extubation, the patient developed new-onset generalized tonic-clonic seizures and confusion. MRI of the brain was done and it showed an abnormal signal in the bilateral medial cortical frontal region. His cerebral spinal fluid (CSF) analysis revealed a characteristic picture of a viral infection with a high white blood cell count and normal glucose and protein levels. After ruling out all common causes of viral encephalitis such as herpes simplex virus (HSV) and based on the review of available literature regarding the neurological manifestations of COVID-19, this case was labeled as acute viral encephalitis secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Cerebrospinal fluid in COVID-19: A systematic review of the literature

“…CSF WBC count, when provided, ranged from 0 to 90 cells/μL for every patient except the patients reported by Mardani et al and Yousefi et al, who had a CSF WBC count of 1,920 cells/μL (90% neutrophils) and 1,870 cells/μL (90% neutrophils, CSF RBC count of 350 cells/μL), respectively [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 199 , 224 , 225 , 227 , 238 , 241 ]. The CSF RBC count was provided for 7/16 (44%) patients, 1 of whom had 0 cells/μL; the remainder had a CSF RBC count of 50–1,685 cells/μL [ 28 , 29 , 180 , 184 , 227 , 241 ]. The CSF protein was normal or mildly increased (maximally 115 mg/dL) for 14/16 (88%) patients; the other 2 patients had a CSF protein of 685 mg/dL and 9,480 mg/dL, the latter of which was the same patient who had a CSF WBC count of 1,920 cells/μL [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 199 , 224 , 225 , 227 , 236 , 238 , 241 ].…”

“…Although the CSF RBC count was only reported for 61/430 (14%) patients [ 22 , 28 , 29 , 31 , 35 , 39 , 40 , 44 , 73 , 74 , 77 , 78 , 81 , 89 , 92 , 102 , 110 , 118 , [120] , [121] , [122] , [123] , 128 , 133 , 134 , [138] , [139] , [140] , 156 , 165 , 166 , [172] , [173] , [174] , [175] , [176] , 180 , 184 , 188 , 191 , 192 , 198 , 202 , 204 , 208 , 215 , 220 , 225 , 227 , 233 , 241 , 242 , 246 ], the CSF white blood cell (WBC) count was provided for 409/430 (95%) patients, 270 (66%) of whom had >0 cells/μL, >1 WBC:1,000 RBC or were noted to have “pleocytosis” ( Fig. 3 ) [ [5] , [6] , [7] , [8] , 10 , 13 , [15] , [16] , [17] , [18] ...…”

“…The CSF SARS-CoV-2 PCR resulted positive for 16/303 (5%) patients, all of whom had symptoms that localized to the CNS (16/238 (7%) patients with symptoms that localized to the CNS): 8/16 (50%) who had encephalopathy/coma +/- seizures, 4/16 (25%) who had headache +/- encephalopathy, 1/16 (6%) who had cerebellar symptoms, 1/16 (6%) who had paresthesias, 1/16 (6%) who had seizures without encephalopathy and 1/16 (6%) who had vision loss ( Table 2 ) [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 199 , 224 , 225 , 227 , 236 , 238 , 241 ]. The cycle threshold (Ct; the number of amplification cycles required for the target gene to exceed the threshold, which is inversely related to viral load) was only provided for 2/16 (13%) patients with a positive CSF SARS-CoV-2 PCR (37.12, 37.52 and 36.44 for the N1 gene, but negative for N2 for the patient reported by Moriguchi et al and 34.29 for the patient reported by Virhammar et al), though Fadakar et al noted that a Ct of 35 was the cutoff for a positive SARS-CoV-2 PCR [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 184 , 195 , 199 , 224 , 225 , 227 , 236 , 238 , 241 ]. There were 6/16 (38%) patients who did not have a positive nasopharyngeal/oropharyngeal SARS-CoV-2 PCR, 1 of whom had positive SARS-CoV-2 serum antibodies [ 26 , 27 , 153 , 184 , 241 , 250 ].…”

“…The majority (12/16, 75%) of patients with a positive CSF SARS-CoV-2 PCR were admitted to the hospital because of neurological symptoms [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 224 , 236 , 241 ]. There were 10/16 (63%) patients who had acute findings on neuroimaging and 5/16 (31%) patients who had acute findings on chest imaging [ 26 , 27 , 150 , 153 , 164 , 180 , 199 , 225 , 227 , 236 , 238 ]. CSF WBC count, when provided, ranged from 0 to 90 cells/μL for every patient except the patients reported by Mardani et al and Yousefi et al, who had a CSF WBC count of 1,920 cells/μL (90% neutrophils) and 1,870 cells/μL (90% neutrophils, CSF RBC count of 350 cells/μL), respectively [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 199 , 224 , 225 , 227 , 238 , 241 ].…”

“…There were 10/16 (63%) patients who had acute findings on neuroimaging and 5/16 (31%) patients who had acute findings on chest imaging [ 26 , 27 , 150 , 153 , 164 , 180 , 199 , 225 , 227 , 236 , 238 ]. CSF WBC count, when provided, ranged from 0 to 90 cells/μL for every patient except the patients reported by Mardani et al and Yousefi et al, who had a CSF WBC count of 1,920 cells/μL (90% neutrophils) and 1,870 cells/μL (90% neutrophils, CSF RBC count of 350 cells/μL), respectively [ [26] , [27] , [28] , [29] , 150 , 164 , 180 , 195 , 199 , 224 , 225 , 227 , 238 , 241 ]. The CSF RBC count was provided for 7/16 (44%) patients, 1 of whom had 0 cells/μL; the remainder had a CSF RBC count of 50–1,685 cells/μL [ 28 , 29 , 180 , 184 , 227 , 241 ].…”