A Rare Case of Acute Hemorrhagic Leukoencephalitis in a COVID-19 Patient

Yong, Ming Hui; Chan, Yvonne; Liu, Jiaxuan; Sanamandra, Sarat Kumar; Kheok, Si Wei; Lim, Kheng Choon; Sewa, Duu Wen

doi:10.1016/j.jns.2020.117035

Cited by 30 publications

(30 citation statements)

References 9 publications

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“…Follow-up MRI depicted rapid progression with florid parenchymal hemorrhages, which against this clinical background and CSF picture led us to make a final diagnosis of AHLE. The imaging features in our case parallel the findings demonstrated by Yong et al and Chalil et al, albeit with severe edema, mass effect, and hemorrhagic component which could explain the fatal outcome [5,6]. Intraventricular hemorrhage described by Chalil et al was not seen in our case [6].…”

Section: Discussionsupporting

confidence: 87%

“…Infective cause was not demonstrable in a few cases, and there may not be a linear relationship between the severity of neurological illness and antecedent chest symptoms [ 1 , 4 ]. Though neurological symptoms are common in COVID-19 patients, only a handful of COVID-19 associated AHLE have been reported to date [ 5 – 11 ].…”

Section: Discussionmentioning

confidence: 99%

“…Subcortical and deep white matter predominance with characteristic asymmetric distribution is seen. Although less frequent, there can be brainstem, cerebellar peduncle, and deep grey matter involvement [ 5 , 7 ]. The lesions are hyperintense on T2W and FLAIR images and hypointense on T1W images and show microhemorrhage-related blooming in susceptibility-weighted images (SWI).…”

Section: Discussionmentioning

confidence: 99%

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Acute hemorrhagic leukoencephalitis in a COVID-19 patient—a case report with literature review

Varadan¹,

Shankar²,

Rajakumar³

et al. 2021

Neuroradiology

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Purpose Acute hemorrhagic leukoencephalitis (AHLE) is a rare and severe form of acute disseminated encephalomyelitis (ADEM). Only a few reports of AHLE in coronavirus disease 2019 (COVID-19) patients have been described to date. We report a case of COVID-19-related AHLE along with a literature review describing salient clinical and imaging characteristics. Methods A literature search was performed on Medline (2020-present), PubMed, Cochrane Library, CINAHL, and Google scholar on 28 January 2021 for all articles published using MeSH terms “COVID-19” or “SARS-CoV-2” with “Acute hemorrhagic leukoencephalitis” or “Acute hemorrhagic encephalitis.” Relevant case reports and case series describing clinical and imaging features of AHLE associated with SARS-CoV-2 infection were included, data compiled, and critically reviewed. Results Acute onset encephalopathy and rapidly deteriorating neurological status is the common clinical presentation in AHLE. CSF analysis reveals elevated proteins and lymphocytic pleocytosis. Typical neuroimaging features include multifocal, variable-sized, poorly defined cerebral white matter lesions with cortical sparing. Involvement of the brainstem, cerebellar peduncles, and deep grey matter can also occur, although rarely. Lesions are hyperintense on T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) images, hypointense on T1W images, and show microhemorrhages, variable diffusion restriction, and post-contrast enhancement. Extensive microhemorrhages, brainstem involvement, and gross hemorrhage often portend a poor prognosis. Conclusion Heightened awareness about the clinical and imaging presentation of COVID-19-related AHLE can positively alter the outcome in a select few by enabling early diagnosis and aggressive management.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Acute hemorrhagic leukoencephalitis in a COVID-19 patient—a case report with literature review

Varadan¹,

Shankar²,

Rajakumar³

et al. 2021

Neuroradiology

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“…On the other hand, the emerging reports of ADEM [ 17 , 18 ] and acute necrotizing encephalopathy (ANE) [ 13 ], the presence of LAC, and good response to immunomodulatory treatment [ 13 , 14 ] support a dysimmune-inflammatory pathophysiology. Cases 1 and 4 [ 24 ] were suggestive of ADEM and AHLE (a severe variant in ADEM spectrum) respectively. However, we could not completely discount the possibility of a direct viral effect, especially in Cases 2 and 3 .…”

Section: Discussionmentioning

confidence: 99%

Neurology of COVID-19 in Singapore

Koh

Silva

Quek

et al. 2020

Journal of the Neurological Sciences

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Purpose To describe the spectrum of COVID-19 neurology in Singapore. Method We prospectively studied all microbiologically-confirmed COVID-19 patients in Singapore, who were referred for any neurological complaint within three months of COVID-19 onset. Neurological diagnoses and relationship to COVID-19 was made by consensus guided by contemporaneous literature, refined using recent case definitions. Results 47,572 patients (median age 34 years, 98% males) were diagnosed with COVID-19 in Singapore between 19 March to 19 July 2020. We identified 90 patients (median age 38, 98.9% males) with neurological disorders; 39 with varying certainty of relationship to COVID-19 categorised as: i) Central nervous system syndromes-4 acute disseminated encephalomyelitis (ADEM) and encephalitis, ii) Cerebrovascular disorders-19 acute ischaemic stroke and transient ischaemic attack (AIS/TIA), 4 cerebral venous thrombosis (CVT), 2 intracerebral haemorrhage, iii) Peripheral nervous system-7 mono/polyneuropathies, and a novel group, iv) Autonomic nervous system-4 limited dysautonomic syndromes. Fifty-one other patients had pre/co-existent neurological conditions unrelated to COVID-19. Encephalitis/ADEM is delayed, occurring in critical COVID-19, while CVT and dysautonomia occurred relatively early, and largely in mild infections. AIS/TIA was variable in onset, occurring in patients with differing COVID-19 severity; remarkably 63.2% were asymptomatic. CVT was more frequent than expected and occurred in mild/asymptomatic patients. There were no neurological complications in all 81 paediatric COVID-19 cases. Conclusion COVID-19 neurology has a wide spectrum of dysimmune-thrombotic disorders. We encountered relatively few neurological complications, probably because our outbreak involved largely young men with mild/asymptomatic COVID-19. It is also widely perceived that the pandemic did not unduly affect the Singapore healthcare system.

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“…Moreover, Paterson et al [38] reported a total of nine cases of acute disseminated encephalomyelitis in 29 SARS-CoV-2 PCR-positive cases, suggesting its incidence is not rare. In addition, some cases of COVID-19 associated post-infectious immune-mediated encephalitis and rare acute hemorrhagic leukoencephalitis were also reported [39][40][41].…”

Section: Covid-19-associated Acute Disseminated Encephalomyelitis Andmentioning

confidence: 99%

COVID-19-Associated Acute Brain Dysfunction Related to Sepsis

2021

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In global term, as of November 30, 2020, over 30 million people has been infected by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and more than 10,000,000 of them died of acute organ failure. Our reviews have shown that coronavirus disease 2019 (COVID-19) patients with pneumonia and acute respiratory distress syndrome (ARDS) have life-threatening acute brain dysfunction (ABD), ranging from altered mental status/delirium to stupor/coma. Altered mental status/delirium was the most common manifestation of ABD caused by severe COVID-19. The prevalence of altered mental status and/or delirium was up to 66-79.5%, and prevalence of coma was 10%. The most common clinical type of COVID-19-associated ABD was COVID-19-associated acute stroke including ischemic and hemorrhagic stroke (n > 350 cases), followed by COVID-19-associated encephalopathy (n > 200 cases), and COVID-19-associated central nervous system (CNS) infection (n > 70 cases). According to the Sepsis-3 criteria, we confess that severe COVID-19-associated ABD with ARDS and altered mental status is related to sepsis. Moreover, we also review the diagnosis and treatment of COVID-19-associated ABD with sepsis. In view of the fact that COVID-19 is at the peak of epidemic worldwide, we hope that this review will provide evidence of COVID-19 sepsis threating to the brain dysunction. Thus, recognizing the COVID-19-associated ABD related to sepsis is very important for early empirical combination therapy to survive severe COVID-19.

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A Rare Case of Acute Hemorrhagic Leukoencephalitis in a COVID-19 Patient

Cited by 30 publications

References 9 publications

Acute hemorrhagic leukoencephalitis in a COVID-19 patient—a case report with literature review

Acute hemorrhagic leukoencephalitis in a COVID-19 patient—a case report with literature review

Neurology of COVID-19 in Singapore

COVID-19-Associated Acute Brain Dysfunction Related to Sepsis

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