Covid-19 associated Acute Haemorrhagic Leukoencephalomyelitis

Abstract

Since the first appearance of Covid-19 in December 2019 in Wuhan, China, the disease has spread world-wide infecting more than 13 million people and causing approximately five hundred eighty-five thousand deaths. The disease which was initially thought to primarily involve respiratory and cardiovascular system only, over time has been reported to involve central and peripheral nervous system with varying frequency. The importance of identifying neurological symptoms cannot be over emphasised by the fact that loss of sense of smell is now considered as one of the earliest features of Covid-19. Although, impaired consciousness has been reported in approximately 17% patients with Covid-19, acute haemorrhagic leukoencephalomyelitis (AHL) as its cause has been reported in a very few cases. It is imperative for the emergency and respiratory physicians to be aware of this condition as mostly they are the ones who initially come in contact with the Covid-19 patients, as early diagnosis and aggressive treatment would greatly help in improving the prognosis and reducing the morbidity in this otherwise fatal disease. We herein report a case of acute haemorrhagic leukoencephalomyelitis secondary to Covid-19 from a tertiary care centre in India. To the best of our knowledge, this is the first case of Covid-19 associated AHL to be reported from India.

COVID-19-Associated Neurological Manifestations: An Emerging Electroencephalographic Literature

“…Diffuse or focal slowing was also associated in many case reports with various neurological presentations, mainly of vascular or inflammatory origin. Main vascular complications included ischemic and hemorrhagic strokes (Chaumont et al, 2020;Díaz-Pérez et al, 2020;Morassi et al, 2020;Soldatelli et al, 2020;Zahid et al, 2020), intracranial hemorrhage with cerebral venous thrombosis (Roy-Gash et al, 2020), posterior reversible encephalopathy syndrome (PRES) (Llansó and Urra, 2020;Princiotta Cariddi et al, 2020), intracranial vasculitis (Dixon et al, 2020), subarachnoid hemorrhage (Harrogate et al, 2020), acute hemorrhagic leukoencephalitis or leukoencephalomyelitis (Handa et al, 2020;Kihira et al, 2020;Svedung Wettervik et al, 2020), and acute necrotizing encephalopathy (Delamarre et al, 2020;Virhammar et al, 2020). Main inflammatory syndromes included acute disseminated encephalomyelitis (ADEM) (Parsons et al, 2020;Umapathi et al, 2020), acute leukoencephalopathy (Abenza-Abildúa et al, 2020;Anand et al, 2020;Brun et al, 2020;Huang H. et al, 2020;Kihira et al, 2020;Klironomos et al, 2020), acute leukoencephalitis (Perrin et al, 2020), meningoencephalitis without any acute lesions on brain imaging (Duong et al, 2020;El-Zein et al, 2020;Pilotto et al, 2020b), Bickerstaff encephalitis (Llorente Ayuso et al, 2020), and concomitant autoimmune encephalitis (Grimaldi et al, 2020;Panariello et al, 2020).…”

Spinomedullary Weston Hurst Syndrome After COVID-19 and Influenza Co-Infection: A Case Report

“…Para-infectious acute necrotizing encephalopathy and post-infectious acute disseminated encephalomyelitis (ADEM) in association with microhemorrhages have been reported, usually followed only by partial recovery. [1][2][3] As with other neuroimmunologic disorders, prompt recognition of a post-infectious inflammatory attack holds the greatest potential for treatment to minimize deficit nadir and maximize recovery. To this end, we use this case of hyper-acute hemorrhagic rhombencephalomyelitis (in keeping with Weston Hurst syndrome) to illustrate the atypical features of neuroinflammation following COVID-19 infection and the aggressive immunotherapies that may be necessary to treat it in fulminant cases.…”

Acute Hemorrhagic Leukoencephalitis (AHLE): A Comprehensive Review on Causes, Symptoms, Link with COVID-19, Diagnosis, and Treatment

“…Despite the fact that patients with COVID-19 often have neurological symptoms, only a few cases of AHLE related to COVID-19 have been recorded so far [61][62][63][64][65][66]. The neurological symptoms of COVID-19 are thought to be secondary to direct viral cytotoxic effects on neurons, immune inflammation, and the development of intracranial cytokine storms [64,67].…”

“…There is a predominance of subcortical and deep white matter, with a distinctive asymmetric distribution. Although less common, brainstem, deep grey matter, and cerebellar peduncle involvement can occur [62,71]. FLAIR and T2W images show hyperintense lesions, T1W images show hypointense lesions, and susceptibilityweighted images (SWI) show microhemorrhage-related blooming.…”