Posterior Reversible Encephalopathy Syndrome in a Patient With SARS-CoV-2 Infection Treated With Tocilizumab

Abstract

As the world has struggled to adapt to the coronavirus disease (COVID-19) pandemic, new evidence has emerged suggesting that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may manifest with a wide variety of neurologic symptoms. We present the case of a 70-year-old patient hospitalized for COVID-19 related pneumonia who was treated with off-label interleukin (IL)-6 inhibitor tocilizumab and eventually developed prolonged delirium. MRI findings were consistent with posterior reversible encephalopathy syndrome (PRES). PRES was felt to be from SARS-CoV-2 infection, tocilizumab, or a combination. The patient received symptomatic treatment without success. These findings are consistent with few other recent reports, which have chronicled PRES findings in patients with SARS-CoV-2 infections. However, this is only the second example of PRES in a COVID-19 patient treated with tocilizumab. While cases of PRES have been noted to occur with other infectious diseases, clinicians should be aware of the association with SARS-CoV-2 infection and tocilizumab therapy, particularly when considering tocilizumab treatment outside its approved indication. Future research efforts are needed to establish evidence-based guidelines for the management of these patients.

Brain MRI findings in COVID-19 patients with PRES: A systematic review

“…Small foci of restricted diffusion in deep white matter. Present Present Discharged P30/M/70 Talluri K et al 43 Hypertensive Absent Present Absent Mechanical ventilation Tocilizumab Cortical and subcortical FLAIR signal in bilateral occipital lobes and paramedian frontal and parietal lobes. Restricted diffusion bilateral occipital lobes, posterior thalami and left temporal lobe.…”

Persistent visual dysfunction following posterior reversible encephalopathy syndrome due to COVID‐19: Case series and literature review

“…Database search recovered 37 unique articles describing PRES and COVID‐19, of which five were excluded after abstract review. The remaining 32 articles underwent full text review; 22 articles met all inclusion criteria and contained detailed clinical information on 32 individuals with PRES and COVID‐19 [6–27]. All cases reported MRI findings consistent with a diagnosis of PRES (Table 1).…”

“…Many cases had complete resolution of neurological issues by the time of publication, but approximately one third of individuals had residual problems including cognitive deficits, vision loss, and weakness (Figure 4b and Table 1). Death occurred in four (11%) cases (Figure 4b and Table 1) [6,18,23,25].…”

Neuropsychiatric manifestations of COVID-19, potential neurotropic mechanisms, and therapeutic interventions

“…Increasing evidence supports the safety and efficiency of the IL-6 receptor blocker tocilizumab for treating patients with severe or critical COVID-19, especially those with cytokine release syndrome [ 189 – 191 ]. Case reports described that tocilizumab exerted potential beneficial effects on COVID-19-related neuropsychiatric symptoms, including encephalopathy presenting with aphasia and posterior reversible encephalopathy syndrome [ 192 , 193 ]. Case reports and case series showed that immunotherapy with intravenous immunoglobulin was safe and effective for the treatment of COVID-19-associated neurological disorders, including encephalopathy, GBS, and new-onset refractory status epilepticus [ 194 – 196 ].…”