Lessons of the month 1: A case of rhombencephalitis as a rare complication of acute COVID-19 infection

Abstract

A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient's abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.A 40-year-old never-smoker with minimum alcohol intake, originally from Nigeria and now settled in the UK with his family after moving here 7 years ago, attended the emergency department reporting a 10-day history of persistent fever and progressive dyspnoea on exertion while self-isolating at home during the COVID-19 crisis. He was on long-term treatment with ramipril and amlodipine for hypertension and on dorzolamide (a carbonic anhydrase inhibitor) with timolol maleate eye drops for closed angle glaucoma. He reported malaise, a new cough with yellow sputum and diarrhoea (non-bloody) over 3 days. There was no recent foreign travel or family history of medical conditions but he shared the concern that his wife was currently pregnant.On presentation, temperature was 38.4°C, heart rate regular at 86 beats/minute, blood pressure 129/83 mmHg; oxygen saturation 93% on room air as he was tachypnoeic at 32 breaths/minute. On auscultation, heart sounds were normal but there were bi-basal ABSTRACT Authors: A ST4 Respiratory Medicine, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; B clinical fellow, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; C consultant neurologist, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; D consultant respiratory physician, The Shrewsbury and Telford Hospital NHS Trust, Telford, UKcrackles. There was no gross focal neurological deficit. Initial 12-lead electrocardiography showed sinus tachycardia and chest X-ray showed a right lower zone consolidation. Arterial blood gas on room air revealed hypoxia (PaO 2 8.77 kPa) with pH 7.432, PaCO 2 4.21 kPa, HCO 3-20.6 mmol/L, base excess 2.6 mmol/L, lactate 0.98 mmol/L. Haemoglobin was 139 g/L, white cell count 7.0 × 10 9 /L (lymphocytes 1.2 × 10 9 /L) and C-reactive protein (CRP) marginally raised at 50 mg/L, and similar slight increases were seen in serum gamma glutamyl transferase (GGT) 107 U/L (range 0-75) and alanine aminotransferase (ALT) 88 U/L (range 0-45), with other liver tests and urinary electrolytes within the normal ranges.

Central and peripheral nervous system involvement by COVID-19: A systematic review of the pathophysiology, clinical manifestations, neuropathology, neuroimaging, electrophysiology, and cerebrospinal fluid findings

“…Similarly, in some patients with GBS and cranial nerve impairment, III, VI, VII, and VIII contrast enhancement in MRI was evident [44]. Finally, some authors reported compromise of low cranial nerves among patients with COVID-19, including dysphagia as part of GBS [47], isolated dysphagia [48], and hypoglossal de cit due to rhombencephalitis [49].…”

SARS-CoV-2 and nervous system: From pathogenesis to clinical manifestation

“…Another report from UK described a patient with fever and respiratory symptoms who developed progressive unsteady gait, diplopia, limb ataxia, altered sensation in the right arm, hiccups, and dribbling when eating, found to have a rhomboencephalitis in the MRI with involvement of the right inferior cerebellar peduncle ( Table 3 ). CSF showed normal protein, normal white blood cell (WBC) counts and negative bacterial culture ( Wong et al, 2020a ). Unfortunately, the SARS-CoV-2 PCR test was not administered, and there were no results for the myelin oligodendrocyte glycoprotein and aquaporin 4 antibodies sent as part of the workup.…”

Neurological Complications of COVID-19 and Possible Neuroinvasion Pathways: A Systematic Review

“…Wong and colleagues [59] reported the case of a 40-year-old man who developed diplopia, limb ataxia, unsteady gait and nystagmus after contracting SARS-CoV-2 infection. MRI revealed brainstem inflammation, coherent with a diagnosis of rhombencephalitis.…”