Acute Necrotizing Encephalitis as an Early Manifestation of COVID-19

Abstract

In addition to respiratory symptoms, SARS-CoV-2 infection has been linked to numerous neurologic sequelae including acute necrotizing encephalopathy. Here we present the case of a 33-year-old woman infected with SARS-CoV-2 who arrived at the hospital unresponsive. She was comatose with intact brainstem reflexes, and brain imaging was consistent with acute necrotizing encephalopathy affecting the bilateral thalami, medial temporal lobes, and pons. She was treated quickly with intravenous corticosteroids and plasmapheresis and regained neurologic function over weeks. Acute necrotizing encephalopathy is a rare para-infectious syndrome characterized by rapidly progressing encephalopathy, seizures, and/or coma caused by multifocal inflammatory central nervous system (CNS) lesions. The mechanism(s) underlying this condition remain unclear, though cytokine storm and disruption of the blood-brain barrier has been proposed as initiating event. This report presents a case of adult acute necrotizing encephalopathy in the early period after SARS-CoV-2 infection, adding to the literature on this rare condition and its relation to SARS-CoV-2 infection. We also report on the clinical outcome of treatment with prompt immunosuppression.

Acute necrotizing encephalopathy in children with COVID-19: a retrospective study of 12 cases

“…The global COVID-19 pandemic has resulted in millions of SARS-CoV-2 infections and unprecedented morbidity and mortality ( 6 ). Although the respiratory system complications of COVID-19 have been the most frequent and life-threatening, increasing reports indicative of neurological complications ( 7 ), including encephalopathy ( 8 ), ANE ( 3 ), brain microhemorrhages ( 9 ), and Guillain–Barré syndrome ( 10 ), have emerged.…”

COVID-19 related acute necrotizing encephalopathy presenting in the early postoperative period

“…Therapy with methylprednisolone, 1g intravenously daily followed by prednisone taper, and antiseizure drugs has been recommended [ 1 , 6 ]. Immunotherapy and plasmapheresis have also been reported [ 7 - 9 ]. Because of the rare manifestation of this clinical entity, specific guidelines have not been established yet.…”

COVID-19-Associated Encephalopathy (COVEP): Basic Aspects of Neuropathology

“…In the case of confirmed limbic and autoimmune encephalitis, SARS-CoV-2 can be both a triggering and a concomitant factor, as has been reported with other viruses [103,104]. For necrotizing and hemorrhagic-necrotic encephalitis cases, the relationship has since become more dubious in the absence of histology, as most of these reports are based on neuroradiology and can be mimicked by the systemic and vascular effects of the virus [82,[97][98][99]. The relationships and capabilities of SARS-CoV-2 to lead to the development of true encephalitis are further disputed by most morphological studies, as despite histology the morphological changes may be highly similar to those of encephalitis, and while there are data on micro-and astroglyopathy, as well as cytotoxic T lymphocyte infiltration, immunologically only a few studies have isolated viral presence in the central nervous system [9,62,67,78,105,106].…”

“…As already mentioned, a focal point of research is the direct neurotropic effect of SARS-CoV-2 and its potential to lead to encephalitis, as in some of its close relatives [29,35,36,[91][92][93]. In the initial phases of the pandemic, multiple studies reported encephalitis in COVID-19 patients ranging from panencephalitis to acute hemorrhagic, acute necrotizing, limbic, and autoimmune encephalitis [82,[91][92][93][94][95][96][97][98][99][100][101][102]. In the case of confirmed limbic and autoimmune encephalitis, SARS-CoV-2 can be both a triggering and a concomitant factor, as has been reported with other viruses [103,104].…”