The association of SARS-CoV-2 infection and acute disseminated encephalomyelitis without prominent clinical pulmonary symptoms

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spreading around the world, and the outbreak continues to increase in different parts of the world. Patients with SARS-CoV-2 infection syndrome (COVID-19) characteristically present with fever and respiratory symptoms; however, evidence of multi-organ dysfunction is reported [1].Central nervous system (CNS) involvement, especially in the form of encephalopathy, is reported in some patients [2], and it has been reported that the virus can be detected in the brain or cerebrospinal fluid. Acute Disseminated Encephalomyelitis (ADEM), is usually a para or post-infectious syndrome characteristically multifocal and monophasic immune-mediated central nervous system disorder [3]. It usually occurs in early childhood after infection with the influenza virus [3]. Recently, the first case of acute hemorrhagic leukoencephalitis associated with COVID-19 has been reported [4]. Herein, we describe clinical manifestations and response to treatment of a patient with concurrent infection of SARS-CoV-2, and ADEM with favorable response to treatment. The patient has given consent to publish his data.A 58-year-old man presented to the emergency department because of a decreased level of consciousness and the inability to walk. Initial symptoms began with slowly progressive gait disturbance around one month before admission; however, consciousness profoundly deteriorated two days before the admission. There were no complaints of pulmonary symptoms such as cough or dyspnea. On admission, his body temperature was 37.1 0 C; he was drowsy but could obey simple tasks, and speaking consisted of short, simple words. He could move all limbs; nevertheless, the left upper limb moved less. Deep tendon reflexes were brisk and plantar reflexes were upgoing. Initial investigations revealed Hb: 15.5 g/dL, WBC: 17,000 [lymphocyte count: 1020/ mm 3 , normal range: 800-5000/mm 3 ], CRP: 82 mg/L (normal < 10 mg/L), ESR: 40 mm/h (normal < 20 mm/h), and Ferritin 876 ng/mL (normal range: 12 to 300 ng/mL). CSF examination revealed WBCs: 0 /mm 3 (normal range: 0-5/mm 3 ), Glucose: 105 mg/dL (normal < 80 mg/dL), and protein: 15 mg/dL (normal < 45 mg/dL). The CSF was negative for viruses such as herpes simplex, varicella-zoster, cytomegalovirus, and Epstein-Barr virus. Moreover, we did not found oligoclonal bands in CSF. Blood Interferon-Gamma Release Assays (IGRAs) for Tuberculosis, and ELISA for the Brucella antibody and Human

Cerebrospinal fluid findings in neurological diseases associated with COVID-19 and insights into mechanisms of disease development

“…Although ADEM is more common among pediatric patients, especially under ten years of age, it can occur at any age( Tenembaum et al 2007 ). However, cases of ADEM associated with SARS-CoV-2 infection to date, including two in this study, have been described in adults ( Abdi et al, 2020 , Demirci Otluoglu et al, 2020 , Parsons et al, 2020 , Zanin et al, 2020 ). This discrepancy may reflect the fact that children with COVID-19 are more likely to be asymptomatic or have mild-to-moderate illness ( Mehta et al, 2020a , Rajapakse and Dixit, 2020 ).…”

“…ADEM is usually associated with pleocytosis but OCB are infrequent ( Scolding 2001 ). A case of ADEM with normal CSF cell counts and protein levels, mild glucose elevation, with neurological presentation preceding mild respiratory symptoms was recently described ( Abdi et al 2020 ). Here, one case of ADEM was also associated with normal CSF findings but with detectable SARS-CoV-2 RNA, although close to the limit of detection of the RT-qPCR.…”

COVID-19-Associated Encephalitis: Systematic Review of Case ReportsFindings on Cytokine-Immune-Mediated Inflammation as an Underlying Mechanism

“…The most used pharmacological agents (Table 3) were hyroxychloroquine (48.48%), azithromycin (27.27%), and favipiravir (24.24%). Intravenous steroids were given in 8 cases (5 methylprednisolone 18,26,29,31,32 , 2 dexamethasone 28,33 , 1 unspeci ed 21 ), while immunotherapy such as, plasmapheresis and intravenous immunoglobulin (IVIG) were given to 10 patients (6 plasmapheresis 34 , 4…”

Covid-19 systemic infection exacerbates pre-existing acute disseminated encephalomyelitis (ADEM)

“…However, more specific etiologies exist. Seizures, diffuse +/− focal cerebral hypoxia, reversible cerebral vasoconstriction syndrome, acute (para-infectious) disseminated encephalomyelitis (ADEM), and direct viral encephalomyelitis are all reported conditions that should be considered in a COVID-19 patient who becomes acutely encephalopathic with or without focal manifestations (Koralnik and Tyler, 2020;Hepburn et al, 2020;Anand et al, 2020;Reichard et al, 2020;Parsons et al, 2020;Abdi et al, 2020). Clinical management and prognosis differ according to the underlying pathology.…”