Case Report: Cerebrovascular Events Associated With Bacterial and SARS-CoV-2 Infections in an Adolescent

Abstract

Neurologic manifestations associated with Covid-19 are increasingly reported, especially stroke and acute cerebrovascular events. Beyond cardiovascular risk factors associated with age, some young adults without medical or cardiovascular history had stroke as a presenting feature of Covid-19. Suggested stroke mechanisms in this setting are inflammatory storm, subsequent hypercoagulability, and vasculitis. To date, a handful of pediatric stroke cases associated with Covid-19 have been reported, either with a cardioembolic mechanism or a focal cerebral arteriopathy. We report the case of an adolescent who presented with febrile meningism and stupor. Clinical, biological, and radiological features favored the diagnosis of Lemierre syndrome (LS), with Fusobacterium necrophorum infection (sphenoid sinusitis and meningitis) and intracranial vasculitis. The patient had concurrent SARS-CoV-2 infection. Despite medical and surgical antimicrobial treatment, stroke prevention, and venous thrombosis prevention, he presented with severe cerebrovascular complications. Venous thrombosis and stroke were observed, with an extension of intracranial vasculitis, and lead to death. As both F. necrophorum and SARS-CoV-2 enhance inflammation, coagulation, and activate endothelial cells, we discuss how this coinfection may have potentiated and aggravated the usual course of LS. The potentiation by SARS-CoV-2 of vascular and thrombotic effects of a bacterial infection may represent an underreported cerebrovascular injury mechanism in Covid-19 patients. These findings emphasize the variety of mechanisms underlying stroke in this disease. Moreover, in the setting of SARS-CoV-2 pandemic, we discuss in what extent sanitary measures, namely, lockdown and fear to attend medical facilities, may have delayed diagnosis and influenced outcomes. This case also emphasizes the role of clinical assessment and the limits of telemedicine for acute neurological condition diagnosis.

The Characteristics of Patients With COVID‐19–Associated Pediatric Vasculitis: An International, Multicenter Study

“…The higher mortality rate in the previous literature cohort could be attributed to the presence of patients with severe central nervous system (CNS) vasculitis. All 4 patients with CNS vasculitis died ( 16 , 17 , 18 , 19 ). There were no patients with CNS vasculitis in our cohort.…”

Pediatric COVID-19 Involving Complicated Sinusitis With Intracranial Extension and Lemierre Syndrome: A Case Report

“…While SARS-CoV-2 has an affinity for the respiratory epithelium and can manifest with many otolaryngologic symptoms, progression to complicated otolaryngologic disease is rare. While unclear if infection with SARS-CoV-2 was the precipitating event for the development of complicated sinusitis and Lemierre syndrome in this patient or a coincidental finding, other published reports offer support for COVID-19 possibly predisposing patients to severe illness in adolescents [6,8,10,12]. Regardless, this is a rare case of complicated sinusitis with intracranial abscess and Lemierre syndrome in a pediatric patient following SARS-CoV-2 infection.…”

“…Lemierre syndrome is most common in adolescents and young adults. A report by de Marcellus et al is the only published case of Lemierre syndrome following SARS-CoV-2 infection [12]. Given documented betalactam resistance of Fusobacterium, treatment with antibiotics with anaerobic activity and beta-lactamase resistance is often sufficient [14].…”

Cerebrovascular Complications in Pediatric Patients with COVID-19 Infection

“…Marked cytokine elevation also leads to endothelial injury. 3,22,23,31,37,38,40,41 Autoimmune-mediated effects have been described in association with COVID-19, although primarily in the adult population, with reports of postinfectious development of new autoimmune diseases, including systemic lupus erythematosus, autoimmune hemolytic anemia, and rheumatoid arthritis. [42][43][44] To a lesser extent, the development of new autoimmune disease following COVID-19 infection has also been seen in children, particularly systemic vasculitides.…”