Clinical and morphological features of SARS-COV-2 associated acute hemorrhagic necrotizing encephalopathy: case report

Abstract

Background The current case report presents acute hemorrhagic necrotizing encephalopathy (AHNE) as an example of a fatal complication, the etiology of which could be coronavirus disease 2019 (COVID-19) with multiple organ damage along with the existing respiratory tuberculosis. Case presentation A male in his 20s had severe symptoms of central nervous system lesion, which developed against the background of COVID-19 and respiratory tuberculosis, for which he was treated in the intensive care unit. Autopsy confirmed that he died from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated AHNE in adults with severe fatal endothelial dysfunction and respiratory tuberculosis. The main morphological signs of brain damage were desquamative endotheliitis, thrombosis, parenchymal hemorrhagic necrosis, encephalitis, severe necrobiotic neuronal damage. Conclusion The defeat of endothelial cells with the development of generalized endotheliitis in COVID-19, especially in conjunction with comorbid pathology, in particular tuberculosis, can lead to a fatal complication that affects the nervous system—AHNE. Therefore, it is worth paying close attention to the appearance of neurological symptoms in patients with a similar combination of diseases.

Exclude differentials before diagnosing SARS-CoV-2-associated acute haemorrhagic necrotising encephalitis

“…Particularly, we should know if the CSF was investigated for Mycobacterium tuberculosis . Exclusion of tuberculosis is crucial as AHNE has been previously reported in association with cerebral tuberculosis ( Ermilov et al, 2021 ). Arguments for tuberculous meningitis in the index patient are the mild pleocytosis, low CSF glucose, and lactic acidosis.…”

Consider cerebral tuberculosis as differential of SARS-CoV-2-associated acute, haemorrhagic, necrotising encephalitis

“…With interest we read the article by Ermilov et al about a young male in his twenties, born to a consanguineous marriage, who developed a spontaneous pneumothorax after having been hospitalised in a primary infectious hospital for moderate COVID-19 [1]. Work-up for the cause of pneumothorax revealed "infiltrative pulmonary tuberculosis in the phase of disintegration and seeding" [1]. Consecutively the patient developed impaired consciousness and epilepsy which was attributed to fatal acute, haemorrhagic, necrotising encephalitis (AHNE) [1].…”

“…Work-up for the cause of pneumothorax revealed "infiltrative pulmonary tuberculosis in the phase of disintegration and seeding" [1]. Consecutively the patient developed impaired consciousness and epilepsy which was attributed to fatal acute, haemorrhagic, necrotising encephalitis (AHNE) [1]. It was concluded that "the death of the patient, as well as the severity of the disease, was largely due to COVID-19".…”

“…Regarding cerebral tuberculosis, neither the cerebrospinal fluid (CSF) intra vitam nor the brain at autopsy had been investigated for Mycobacterium tuberculosis by culture, histology, immune histology, or PCR [1]. Excluding cerebral tuberculosis is crucial given the findings of generalised cerebral vasculitis, which occurs in up to one-quarter of the patients with intra-cranial tuberculosis [4].…”

“…Missing is the visualisation of the cerebral vessels by conventional angiography, computed tomography angiography (CTA), or by magnetic resonance angiography (MRA) [1]. Since the patient presented with generalised cerebral vasculitis on autopsy [1], it would have been useful to document cerebral vasculitis on imaging of the cerebral vasculature. It would have been also necessary to exclude aneurysm formation, which can be a complication of tuberculous cerebral vasculitis [5].…”