COVID-19-related encephalopathy presenting with aphasia resolving following tocilizumab treatment

Abstract

Encephalopathy is emerging as a recurrent complication of COVID-19 yet remains poorly characterized. We report the case of a middle-aged woman with COVID-19-related encephalopathy presenting as expressive aphasia and inattentiveness, subsequently progressing to agitation and marked confusion. Brain MRI and CSF analysis were unremarkable, while EEG showed slowing with frontal sharp waves. Neuropsychiatric symptoms resolved following treatment with tocilizumab. CNS involvement in COVID-19 may present as a subacute encephalopathy characterized by prominent frontal lobe dysfunction, with language disturbances as first neurological manifestation. Future studies should further investigate the role of tocilizumab in treating COVID-19-related encephalopathy.

Association of Clinical, Biological, and Brain Magnetic Resonance Imaging Findings With Electroencephalographic Findings for Patients With COVID-19

“…All EEG abnormalities from the frontal lobe, coupled with the frontal syndrome noted in patients with CORE, suggest frontal lobe dysfunction, which is reminiscent of the hypothesis of a neuroinvasive entry of SARS-CoV-2 into the brain via the olfactory nerves or via the nasopharyngeal mucosa. 18 , 26 A change in neuronal excitability, perhaps mediated by specific cytokines, may occur in brain areas close to the nasopharynx, such as the orbitofrontal lobe and the brainstem. Because inflammatory mechanisms, such as cytokine-mediated response or postviral autoimmune process, are suspected, immunomodulator treatments, such as plasma exchanges or intravenous immunoglobulins, may be proposed as early treatment for patients with CORE ( Table 2 ).…”

“…Because inflammatory mechanisms, such as cytokine-mediated response or postviral autoimmune process, are suspected, immunomodulator treatments, such as plasma exchanges or intravenous immunoglobulins, may be proposed as early treatment for patients with CORE ( Table 2 ). 26 , 27 , 28 …”

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

“…31 patients had matched CSF and serum oligoclonal bands consistent with blood-brain barrier breakdown [ 35 , 79 , 112 , 127 , 147 , 170 , 171 , 177 , 182 , 185 , 187 , 205 , 207 , 213 , 215 ]…”

“…CSF oligoclonal bands were tested in 114 patients who did not have a positive CSF SARS-CoV-2 PCR or positive CSF antibodies to SARS-CoV-2 (103 (90%) who had symptoms that localized to the CNS and 11 (10%) who had symptoms that localized to the PNS) [ 9 , 10 , 19 , 20 , 35 , 36 , 42 , 44 , 45 , 58 , 69 , 74 , 79 , 81 , 101 , 112 , 113 , 116 , 117 , 126 , 127 , 130 , 135 , 136 , 147 , 149 , 152 , 154 , 160 , [168] , [169] , [170] , [171] , 177 , 181 , 182 , [185] , [186] , [187] , [188] , 191 , 194 , 203 , 205 , 207 , 209 , 212 , 213 , 215 , 216 , 218 , 233 , 242 , 245 ]. Of these, 35 (31%) had matched CSF and serum bands [ 9 , 35 , 79 , 112 , 113 , 127 , 147 , 170 , 171 , …”

“…Autoimmune antibodies were tested in the CSF of 72/430 (17%) patients (60 (83%) of whom were encephalopathic or comatose, 4 (6%) of whom were paraparetic, 3 (4%) of whom had seizures, 3 (4%) of whom had cerebellar symptoms, 1 (1%) of whom had parkinsonism and 1 (1%) of whom was locked-in) [ 10 , 25 , 30 , 34 , 44 , 45 , 74 , 122 , 135 , 136 , 141 , 148 , 154 , 164 , 169 , 171 , 177 , 182 , 185 , 186 , 191 , 193 , 194 , [205] , [206] , [207] , 209 , 213 , 215 , 216 , 220 , 233 , 234 , 242 , 245 , 246 ]. Of the 72 patients who had autoimmune antibodies tested in the CSF, 4 (6%) had positive autoimmune antibodies [ 30 , 169 , 171 , 205 ].…”