COVID-19-ASSOCIATED MENINGOENCEPHALITIS TREATED WITH STEROIDS AND REMDESIVIR

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The novel coronavirus, named SARS-CoV-2, is known to have emerged in Wuhan, China in late 2019. A wide variety of organs have been found to be involved with SARS-CoV-2 infection. Recent reports indicate that the CNS is not spared. Headache, dysguesia and hyposmia, some more serious neurologic manifestations including encephalopathy Guillain Barre syndrome and stroke are now being reported as the number of patients with COVID-19 across the globe. We report a case of meningoencephalitis associated with SARS-CoV-2 who presented with altered mental status. CASE PRESENTATION: 43-year-old male with a PMH significant for insulin-dependent diabetes presented with altered mental status. In Emergency department was noted to have rhythmic jerking movements and his gaze was deviated to the right, concerning for seizure activity. Upon admission it was confirmed to have COVID-19 via detection of SARS-CoV-2 viral nucleic acid in a nasopharyngeal swab specimen using the Simplexa SARS-CoV-2 assay. Neurological examination revealed confusion with orientation only to self, inability to follow commands, and no apparent focal neurological deficits. Otherwise, general examination was unremarkable and vital signs were within normal. CT head was negative for any acute pathology. His cerebrospinal fluid (CSF) was clear and color less with an elevated CSF cell count and lymphocytic predominance suspicious for viral encephalitis.The CSF glucose (70 mg/dL) was increased and CSF protein levels (19 mg/dL) were decreased. A CSF PCR panel including Cryptococcus neoformans, HSV, varicella zoster virus, Streptococcus pneumoniae, Neisseria meningitidis and enterovirus was negative. The SARS-CoV-2 CSF PCR was negative. Labs were significant for elevated ferritin, LDH, C reactive protein and Di dimer. EEG shows diffuse slowing in the theta range indicative of encephalopathy and lacked any epileptogenic activity. Patient started on steroids, Remedesivir with concern of COVID 19 meningoencephalitis. Within the next 3 days, his mentation progressively improved;he was able to communicate, and was following commands. DISCUSSION: The neuroinvasive nature of human coronavirus has been previously reported during the 2002–2003 SARS-CoV pandemic when viral nucleic acids were found in the human brain upon autopsies. It was postulated by scientists in China that SARS-CoV-2, a novel coronavirus from the SARS-CoV family, could also infect the brain when they observed neurologic signs among patients with COVID-19 related respiratory illness. CONCLUSIONS: Although rare, meningoencephalitis should be considered as a possible manifestation of COVID-19 disease. A suspicion for SARS-CoV-2 meningitis or encephalitis should be high among patients presenting with neurological symptoms during this era of pandemic. SARS-CoV-2 testing should be included as part of the workup in addition to other infectious causes. REFERENCE #1: Gu J., Gong E., Zhang B. Multiple organ infection and the pathogenesis of SARS. J Exp Med. 2005;202(3):415–424. doi: 10.1084/jem.20050828 REFERENCE #2: Moriguchi T., Harii N., Goto J. A first case of meningitis/encephalitis associated with SARS-coronavirus-2. Int J Infect Dis. 2020;94:55–58. doi: 10.1016/j.ijid.2020.03.062 DISCLOSURES: No relevant relationships by Ajay Adial, source=Web Response No relevant relationships by Muhammad Azaz Cheema, source=Web Response No relevant relationships by Asma Iftikhar, source=Web Response No relevant relationships by Hamza Quadri, source=Web Response