Focal Cerebral Arteriopathy in a Pediatric Patient with COVID-19

Abstract

T he neuroinvasive mechanism of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not fully understood. SARS-CoV-2 may enter the central nervous system hematogenously, with other proposed routes, including the olfactory and trigeminal nerves, cerebral spinal fluid (CSF), and lymphatic system (1). Neurologic manifestations in pediatric patients with coronavirus disease 2019 (COV-ID-19) have uncommonly been reported. Herein, we report a presumptive case of ischemic stroke due to focal cerebral arteriopathy (FCA) associated with COVID-19. Case Presentation A previously healthy 12-year-old-boy with a new onset of generalized seizures was initially treated with diazepam. Shortly thereafter, he developed right-sided hemiparesis and dysarthria. There was no previous history of fever, cough, shortness of breath, skin rash, hemoglobinopathy, or recent trauma. No one in his family had a known history of COVID-19 infection. The diagnosis of COVID-19 was made according to the presence of SARS-CoV-2 viral nucleic acid in the nasopharyngeal swab using 2019 novel coronavirus real-time reverse-transcriptase polymerase chain reaction assay. Test results for the presence of SARS-CoV-2 viral nucleic acid in the CSF were also positive. Viral genome was extracted using a viral RNA kit (High Pure; Roche, Basel, Switzerland), with a multiplex one-step reverse-transcriptase realtime polymerase chain reaction test (Pishtaz Teb Zaman Diagnostics, Tehran, Iran) to amplify COVID-19 E, N, and ORF1ab and/or RdRp genes. A CSF bacterial culture showed no growth after 3 days, and tests for herpes simplex viruses 1 and 2 and varicella-zoster virus (QIAGEN, Hilden, Germany) were negative. The serum ferritin level was 86.7 ng/L, the C-reactive protein level was 3 mg/L, and the erythrocyte sedimentation rate was 45 mm/h. CSF analysis demonstrated 21 mg/dL of protein, 62 mg/dL of glucose, 100 red blood cells per cubic millimeter (using traumatic lumbar puncture), and no white blood cells. The CSF opening pressure was 25 mm of H 2 O. d-dimer level was not obtained. The platelet count was 285310 3 /µL, the prothrombin time was 12.1 seconds, the international normalized ratio was 0.9, and the partial thromboplastin time was 27 seconds. The antinuclear antibody level was normal.

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

“…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] ...…”

Neuroimaging manifestations in children with SARS-CoV-2 infection: a multinational, multicentre collaborative study

“…Case reports of COVID-19-associated cerebral vasculopathy can be found in the paediatric literature. 33 …”

Vessel Wall Enhancement and Focal Cerebral Arteriopathy in a Pediatric Patient with Acute Infarct and COVID-19 Infection

“…12,13 It is currently unknown whether the pathophysiology of COVID-19-associated acute infarcts in the pediatric population is similar to that described in adults. A recent report by Mirzaee et al 5 described a case of presumed focal cerebral arteriopathy in a pediatric patient with COVID-19, but VWI was not performed. We similarly observed evidence of focal cerebral arteriopathy on MRA but were able to corroborate the diagnosis of FCA-inflammatory type with VWI.…”