The case of fatal acute hemorrhagic necrotizing encephalitis in a two-month-old boy with Covid-19.

Abstract

SARS-CoV-2 infection in healthy children is usually benign. However severe, life-threatening cases have previously been reported, noticeably in infants. We must be aware that data on natural history of COVID-19 are still full of gaps, especially as far as pediatric population is concerned. Therefore, it is important to describe rare manifestations of SARS-CoV-2 acute infection in children. Here we present the case of acute hemorrhagic necrotizing encephalitis (AHNE) in a previously healthy, 2-month-old infant with SARS-CoV-2 infection. After 2 days of fever with signs of respiratory tract infection, neurological manifestations appeared: irritability, nystagmus, agitation then apathy. As a consequence of apnea, he required emergent intubation and was transferred to our PICU. Brain MRI revealed diffuse areas of oedema associated with numerous symmetrical changes with punctate hemorrhages in basal ganglia, thalami, brainstem, and cerebral gray matter. CSF was clear with pleocytosis 484 cells/µl, elevated lactic acid and protein. Despite broad microbiological testing only SARS-CoV2 was detected in PCR nasal swab. Therefore, acute hemorrhagic necrotizing encephalitis (AHNE) as a result of COVID- 19 was the most probable diagnosis. The outcome was unfavorable - brain death was confirmed, life support was withdrawn.

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

“…We do not agree with the notion that SARS-CoV-2-associated AHNE has not been reported previously in the paediatric population ( Mierzewska-Schmidt et al, 2021 ). In a 9-month-old boy, acute necrotising encephalopathy (ANE) has been described that later progressed to AHNE ( Lazarte-Rantes et al, 2021 ).…”

“…We do not agree with the notion that "paediatric COVID-19 is commonly benign" ( Mierzewska-Schmidt et al, 2021 ). Paediatric patients with COVID-19 may develop multisystem inflammatory syndrome in children (MIS-C), severe dengue with multiinflammatory syndrome, fatal ventricular arrhythmias, autoimmune encephalitis, fatal cerebral vasculitis, chorea, and several other severe complications.…”

“…We eagerly read the article by Mierzewska-Schmidt et al, about a 2-month-old boy who developed progressive neurological compromise (initially irritability, apathia, nystagmus) 2 days after the clinical onset of COVID-19 ( Mierzewska-Schmidt et al, 2021 ). On cerebrospinal fluid (CSF) investigation pleocytosis, lactic acidosis, and low glucose was noted, and cerebral magnetic resonance imaging (MRI) helped diagnose acute, hemorrhaghic, necrotising encephalitis (AHNE) ( Mierzewska-Schmidt et al, 2021 ). Despite maximal treatment, the patient died shortly after admission to the paediatric intensive care unit ( Mierzewska-Schmidt et al, 2021 ).…”

“…On cerebrospinal fluid (CSF) investigation pleocytosis, lactic acidosis, and low glucose was noted, and cerebral magnetic resonance imaging (MRI) helped diagnose acute, hemorrhaghic, necrotising encephalitis (AHNE) ( Mierzewska-Schmidt et al, 2021 ). Despite maximal treatment, the patient died shortly after admission to the paediatric intensive care unit ( Mierzewska-Schmidt et al, 2021 ). The study is interesting but raises concerns that need to be addressed.…”

Encephalitis in Patients with COVID-19: A Systematic Evidence-Based Analysis

“…Only IG therapy showed some benefit. A fatal case of acute hemorrhagic necrotizing encephalitis (AHNE) affected a 2-month-old boy, who presented with fever and general symptoms, but had cardiac arrest followed by brain death within a few days [ 66 ]. Another young patient was a 9-month-old infant [ 84 ].…”