key: cord-262343-oo55qvpk
authors: Sohal, Sandeep; Mossammat, Mansur
title: COVID-19 Presenting with Seizures
date: 2020-05-01
journal: IDCases
DOI: 10.1016/j.idcr.2020.e00782
sha: 
doc_id: 262343
cord_uid: oo55qvpk

This case report examines a male with no previous history of seizures initially admitting to the medical service later upgraded to ICU after respiratory failure developing multiple episodes of seizures. Laboratory values on admission, neurological investigations, as well as review of current literature on COVID-19 encephalitis is provided.

cerebral edema [3] . Future therapies including the role of direct antiviral agents lopinavir/ritonavir, immunomodulators tocilizumab in combating the cytokine storm and treating/preventing encephalopathy in COVID-19 patients should be investigated further.

A 72 year old man with history of hypertension, coronary artery disease with stent, diabetes type 2, end stage kidney disease on hemodialysis presented with complaints of weakness and lightheadedness after experiencing a hypoglycemic episode. Initially admitted to the medical floor the patient shortly developed worsening respiratory status with increased work of breathing and altered mental status requiring intubation and transfer to the intensive care unit.

Initial ABG showed a pH of 7.13, PaO2 of 68mmHg and PCO2 of 78mmHg. BNP was elevated at 541 pg/mL. Troponin was elevated at 0.11ng/mL and peaked at 0.35ng/mL. Suspicion for COVID 19 was raised after finding abnormal labs typically seen in COVID 19 patients (1) : elevated CRP at 61 mg/L, LDH of 230 U/L, lymphopenia noticed at 0.5 k/cmm with leukopenia at 4000k/cmm. A chest x-ray on admission was negative. Patient was started on oseltamivir however was discontinued when Influenza tested negative Two sets of blood cultures were negative for bacterial growth. Unfortunately, ROSC could not be achieved and the patient passed.

Seizures in COVID 19 patients have been first documented by Moriguchi and colleagues [2] Prior to admission, the patient had no known history of seizures and family denied any additional history of seizures. The first noted seizure was on hospital day 2. Blood glucose levels recorded before and after the seizure episodes did not show hypoglycemia. Additionally, the patient was off his home oral sulfonylureas for multiple days and underwent dialysis sessions making it less likely that the continued effects of oral hypoglycemic agents was the cause of his seizures. The patient was persistently febrile throughout admission possibly related to the cytokine storm so frequently seen in COVID 19. Lumbar puncture would have been a useful diagnostic tool, unfortunately however the patient died before lumbar puncture could be J o u r n a l P r e -p r o o f arranged. Additionally the amount of viral particles in CSF may be insufficient for detection [3] .

Herpes encephalitis appeared less likely as there were no findings on CT head suggestive of such. The findings of lateral ventriculitis in the hippocampus documented by Takseshi and Colleagues (2020) was not seen in this patient [2] . MRI brain was not completed due the patient being too unstable for transport.

Although exact mechanism by which SARS COV-2 causes encephalitis is currently unknown for certain, it is believed that the virus can move via retrograde from the olfactory nerve or other cranial nerves into the CNS [2, 3] . Hematogenous spread of viral particles into the CNS via circulating lymphocytes is another possible mechanism [2] . In addition to viral infection, host immune response causing a cytokine storm leading to damage in the blood brain barrier and increased leukocyte migration may be another mechanism in causing encephalitis [2] .

Many different viral infections can cause neurological symptoms [2] . As our understanding of COVID-19 progresses, the possibility of encephalitis and seizures is becoming more accepted clinically, but currently has limited documentation in the literature [2] [3] [4] . This case report adds to the literature the increasing neurological manifestations presented in COVID-19. Use of mannitol to decrease cerebral edema has been reported in one case report which improved patient's consciousness [3] . Additionally, identifying if there are any reoccurring changes on CT/MRI imaging or CSF fluid analysis that can be pathognomonic in diagnosis would be helpful going forward. 

Epidemiological characteristics and clinical features of 32 critical and 67 noncritical cases of COVID-19 in Chengdu

A First Case of Meningitis/Encephalitis Associated with SARS-Coronavirus-2

Encephalitis as a clinical manifestation of COVID-19

Central Nervous System Manifestations of COVID-19: A Systematic Review