Spectrum of Hemorrhagic Encephalitis in COVID-19 Patients: A Case Series and Review

Sharma, Rohan; Nalleballe, Krishna; Shah, Vishank; Haldal, Shilpa; Spradley, Thomas; Hasan, Lana; Mylavarapu, Krishna; Vyas, Keyur; Kumar, Manoj; Onteddu, Sanjeeva; Gökden, Murat; Kapoor, Nidhi

doi:10.3390/diagnostics12040924

Cited by 6 publications

(5 citation statements)

References 59 publications

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“…Our results are consistent with Kandemirli et al study, which suggested that one of the most common imaging finding was cortical signal abnormalities on FLAIR images [ 14 ]. Presence of FLAIR abnormalities and microhemorrhages has been reported in other studies as well [ 5 , 15 , 16 , 17 ]. Some studies have proposed leptomeningeal enhancement; however, majority of our patients did not undergo contrast-enhanced images.…”

Section: Discussionsupporting

confidence: 76%

Magnetic Resonance Imaging (MRI) Findings in COVID-19 Associated Encephalitis

Tanwar

Singhal

Alizadeh

et al. 2023

Neurology International

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We conducted this study to investigate the scope of the MRI neuroimaging manifestations in COVID-19-associated encephalitis. From January 2020 to September 2021, patients with clinical diagnosis of COVID-19-associated encephalitis, as well as concomitant abnormal imaging findings on brain MRI, were included. Two board-certified neuro-radiologists reviewed these selected brain MR images, and further discerned the abnormal imaging findings. 39 patients with the clinical diagnosis of encephalitis as well as abnormal MRI findings were included. Most (87%) of these patients were managed in ICU, and 79% had to be intubated-ventilated. 15 (38%) patients died from the disease, while the rest were discharged from the hospital. On MRI, FLAIR hyperintensities in the insular cortex were the most common finding, seen in 38% of the patients. Micro-hemorrhages on the SWI images were equally common, also seen in 38% patients. FLAIR hyperintensities in the medial temporal lobes were seen in 30%, while FLAIR hyperintensities in the posterior fossa were evident in 20%. FLAIR hyperintensities in basal ganglia and thalami were seen in 15%. Confluent FLAIR hyperintensities in deep and periventricular white matter, not explained by microvascular angiopathy, were detected in 7% of cases. Cortical-based FLAIR hyperintensities in 7%, and FLAIR hyperintensity in the splenium of the corpus callosum in 7% of patients. Finally, isolated FLAIR hyperintensity around the third ventricle was noted in 2% of patients.

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Section: Discussionsupporting

confidence: 76%

Magnetic Resonance Imaging (MRI) Findings in COVID-19 Associated Encephalitis

Tanwar

Singhal

Alizadeh

et al. 2023

Neurology International

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“…Several cases developed neurological impairment following respiratory symptoms. The latency between the onset of the infection with respiratory manifestations and the onset of neurological complications varied between 3 days and 41 days [ 12 , 24 , 27 , 28 , 30 , 32 , 34 , 36 , 37 , 43 , 45 , 51 , 56 , 58 , 64 , 65 , 70 , 76 , 80 , 81 , 82 , 83 , 85 , 86 , 89 , 90 , 91 , 93 , 94 ]. Overall, 13 patients were intubated and mechanically ventilated due to respiratory distress; in these cases, the detection of neurological impairment happened when sedation was interrupted, with latency ranging between 4 and 38 days depending on the case [ 27 , 32 , 34 , 76 , 80 , 82 , 85 , 93 ].…”

Section: Resultsmentioning

confidence: 99%

“…Until 2021, therapeutical plasmapheresis and immunosuppressive drugs were rarely prescribed. After the first period of the COVID-19 pandemic, immunomodulating agents, in particular IVIG and tocilizumab, plasmapheresis, and convalescent’s serum, have been used more often, with good response [ 21 , 51 , 59 , 60 , 70 , 81 , 83 , 88 ], except for the most severe cases, like in ANHE.…”

Section: Resultsmentioning

confidence: 99%

Encephalitis in Patients with COVID-19: A Systematic Evidence-Based Analysis

Islam

Cavestro

Alam

et al. 2022

Cells

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Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) predominantly infects the respiratory system, several investigations have shown the involvement of the central nervous system (CNS) along the course of the illness, with encephalitis being one of the symptoms. The objective of this systematic review was to evaluate the characteristics (clinical, neuro-radiological aspects, and laboratory features) and outcomes of encephalitis in COVID-19 patients. PubMed, Scopus, and Google Scholar databases were searched from 1 December 2019 until 21 July 2022 to identify case reports and case series published on COVID-19 associated with encephalitis. The quality of the included studies was assessed by the Joanna Briggs Institute critical appraisal checklists. This systematic review included 79 studies, including 91 COVID-19 patients (52.7% male) experiencing encephalitis, where 85.6% were adults (49.3 ± 20.2 years), and 14.4% were children (11.2 ± 7.6 years). RT-PCR was used to confirm 92.2% of the COVID-19 patients. Encephalitis-related symptoms were present in 78.0% of COVID-19 patients at the time of diagnosis. In these encephalitis patients, seizure (29.5%), confusion (23.2%), headache (20.5%), disorientation (15.2%), and altered mental status (11.6%) were the most frequently reported neurologic manifestations. Looking at the MRI, EEG, and CSF findings, 77.6%, 75.5%, and 64.1% of the patients represented abnormal results. SARS-CoV-2-associated or -mediated encephalitis were the most common type observed (59.3%), followed by autoimmune encephalitis (18.7%). Among the included patients, 66.7% were discharged (37.8% improved and 28.9% fully recovered), whereas 20.0% of the reported COVID-19-positive encephalitis patients died. Based on the quality assessment, 87.4% of the studies were of high quality. Although in COVID-19, encephalitis is not a typical phenomenon, SARS-CoV-2 seems like a neuropathogen affecting the brain even when there are no signs of respiratory illness, causing a high rate of disability and fatality.

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“…A substantial number of patients having a COVID-19 infection had acute cerebrovascular events, including ischemic stroke [ 4 ]. The general incidence of encephalitis in COVID-19 patients is less than 1 percent, but may reach as high as 6 to 7 percent in patients with severe illness [ 10 ]. The clinical symptoms, such as a low state of consciousness, seizures, headache, and motor impairments, are comparable to those of other types of encephalitis; however, the mortality rate was determined to be around 13 percent, which is considerably higher compared with other types of encephalitis [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

Tolosa–Hunt Syndrome and Hemorrhagic Encephalitis Presenting in a Patient after COVID-19 Vaccination Followed by COVID-19 Infection

et al. 2022

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The presence of neurological symptoms within the clinical range of COVID-19 disease infection has increased. This paper presents the situation of a 45-year-old man having the medical antecedent diabetes mellitus, who presented to the emergency department with fever, headache, and respiratory symptoms, nine days following vaccination with the Ad26.COV2-S COVID-19 vaccine. The patient tested positive for SARS-CoV-2 based on nasal polymerase chain reaction (RT-PCR). Two weeks after the presentation, he developed Tolosa–Hunt Syndrome, an autoimmune phenomenon, with painful left ophthalmoplegia. Significant improvement was seen in terms of his discomfort; however, ptosis and ocular mobility improved only moderately after treatment with intravenous methylprednisolone, and the patient was discharged on a new insulin regimen. The patient returned after four weeks and the neurological exam results showed significant signs of right hemiparesis, mixed aphasia, incomplete left ophthalmoplegia, severe headache, and agitation; after a few days, the patient experienced a depressed level of consciousness and coma. The patient’s clinical condition worsened and, unfortunately, he died. MRI brain images revealed multiple ischemic strokes, meningitis, infectious vasculitis, and hemorrhagic encephalitis, which are all serious complications of COVID-19.

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Spectrum of Hemorrhagic Encephalitis in COVID-19 Patients: A Case Series and Review

Cited by 6 publications

References 59 publications

Magnetic Resonance Imaging (MRI) Findings in COVID-19 Associated Encephalitis

Magnetic Resonance Imaging (MRI) Findings in COVID-19 Associated Encephalitis

Encephalitis in Patients with COVID-19: A Systematic Evidence-Based Analysis

Tolosa–Hunt Syndrome and Hemorrhagic Encephalitis Presenting in a Patient after COVID-19 Vaccination Followed by COVID-19 Infection

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