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

Abstract

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.

Acute Disseminated Encephalomyelitis and Acute Encephalitis Following Vaccination Against SARS-CoV-2: Two Case Reports and Review of Literature

“…Interestingly, the large lesions showed slight transient hemorrhage on susceptibility weighted Hemorrhage is a rare finding in ADEM [37,38], however, it appears to be more common in ADEM after COVID-19 infection [14]. Especially with regard to less pronounced hemorrhagic findings in our case, differential diagnosis of an acute hemorrhagic leukoencephalitis, i. e., Weston -Hurst syndrome as a rare fulminant form of ADEM was not considered [10,20,39]. While CSF in ADEM may exhibit pleocytosis of up to 200 cells/µl and above with granulocytic predominance, cell count and protein level during the second presentation seemed unusually high [28,33].…”

“…Hemorrhage is a rare finding in ADEM 37 38 , however, it appears to be more common in ADEM after COVID-19 infection 14 . Especially with regard to less pronounced hemorrhagic findings in our case, differential diagnosis of an acute hemorrhagic leukoencephalitis, i. e., Weston -Hurst syndrome as a rare fulminant form of ADEM was not considered 10 20 39 .…”

“…Neurological key symptoms are headache, neuropsychological deficits, disorientation and dizziness 33 . ADEM associated with COVID-19 vaccination is rare and review of the literature currently yielded 22 cases with documented additional MR imaging abnormalities 2 3 4 5 6 7 8 9 10 11 13 14 16 18 19 20 21 22 . We report on another two cases of acute encephalitis and ADEM following COVID-19 vaccination.…”

“…However, in 9442 AEFI reported in the Vaccine Adverse Event Reporting System (VAERS) of the Centers for Disease Control (CDC) 2.69% of cases presented with severe neurological manifestations 1 . A recent systematic review 2 analyzing the spectrum of such severe neurological complications differentiated between cerebral involvement, especially cerebrovascular events and inflammatory diseases 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 , spinal cord damage such as transverse myelitis 1 2 4 23 24 cranial and peripheral nerve involvement 2 4 25 and muscle affections, e. g. myositis 2 4 .…”

Neurological Adverse Reactions to SARS-CoV-2 Vaccines

“…SC2V-related cerebrovascular diseases include VST, ischemic stroke, ICH, SAB, pituitary apoplexy, RCVS, cerebral vasculitis, and Susac syndrome ( Table 2 ) [ 4 , 6 …”