key: cord-0807023-trh3fwga authors: Lima, Behnam Safarpour; Khorasani, Negar Mohammadi; Aghamiri, Seyed Hossein; Omidi, Fatemeh; Nilipour, Yalda title: Neurological Complications of COVID-19: A Rare Case of Bilateral Blindness date: 2021-07-19 journal: J Emerg Med DOI: 10.1016/j.jemermed.2021.07.035 sha: 92ee100da900433a39d8710d55b0438674e63f46 doc_id: 807023 cord_uid: trh3fwga BACKGROUND: There are growing reports of the neurologic involvement among the patients with COVID-19. Headache, confusion, and anosmia following olfactory nerve disruption are the most prevalent presentation of the neurologic involvement related to COVID-19. However, small numbers of the central nervous system (CNS) involvement have been reported. CASE REPORT: A 49-year-old male was referred to our hospital with an abrupt vision loss. Three weeks earlier he was admitted to hospital based on his respiratory symptoms and was diagnosed with COVID-19 infection. Initial Brain MRI indicated diffuse restricted bilateral foci in both parietal and occipital lobes in favor of acute infarction. Diffuse Weighted Imaging (DWI) demonstrated restricted bilateral hyperintense signals in parietal and occipital region. Occipital cortex biopsy showed brain tissue with focal infiltration of foamy macrophages mixed with reactive astrocytes and no plasma cell infiltration. Considering all the evidence, post-COVID-19 encephalitis diagnosis was considered for the patient, and methyl prednisolone pulse-therapy and intravenous immunoglobulin (IVIg) was initiated. Why should an emergency physician be aware of this? Although there are growing reports of the neurologic involvement among the patients, blindness can rarely be observed as a complication of post-COVID-19 encephalitis. To our knowledge this is the first case of post-COVID-19 encephalitis which presented with bilateral vision loss primarily. This case may raise physicians’ awareness of neurological complications of COVID-19. Background: There are growing reports of the neurologic involvement among the patients with COVID-19. Headache, confusion, and anosmia following olfactory nerve disruption are the most prevalent presentation of the neurologic involvement related to COVID-19. However, small numbers of the central nervous system (CNS) involvement have been reported. Case report: A 49-year-old male was referred to our hospital with an abrupt vision loss. Three weeks earlier he was admitted to hospital based on his respiratory symptoms and was diagnosed with COVID-19 infection. Initial Brain MRI indicated diffuse restricted bilateral foci in both parietal and occipital lobes in favor of acute infarction. Diffuse Weighted Imaging (DWI) demonstrated restricted bilateral hyperintense signals in parietal and occipital region. Occipital cortex biopsy showed brain tissue with focal infiltration of foamy macrophages mixed with reactive astrocytes and no plasma cell infiltration. Considering all the evidence, post-COVID-19 encephalitis diagnosis was considered for the patient, and methyl prednisolone pulse-therapy and intravenous immunoglobulin (IVIg) was initiated. Although there are growing reports of the neurologic involvement among the patients, blindness can rarely be observed as a complication of post-COVID-19 encephalitis. To our knowledge this is the first case of post-COVID-19 encephalitis which presented with bilateral vision loss primarily. This case may raise physicians' awareness of neurological complications of COVID-19. Keywords: COVID-19; SARS-CoV-2; Encephalitis; blindness; Neurology During the current pandemic, the novel SARS-CoV-2 infection has leaded to a surge in respiratory tract infection in the world. However, there are growing reports of the neurologic involvement among the patients [1] . Headache, confusion, and anosmia following olfactory nerve disruption are the most prevalent presentation of the neurologic involvement related to COVID-19. However, infinitesimal numbers of the central nervous system (CNS) involvement have been detected recently [2] . Despite the importance of neurologic manifestations, data about the neurologic involvement of SARS-CoV-2 infection is scarce [3] . Hence, we report a rare case of post COVID-19 encephalitis presenting with bilateral blindness in a male patient. A 49-year-old male was referred to our hospital with an abrupt complete vision loss in his right eye and visual impairment in the left one. Three weeks earlier he was admitted to hospital based on his respiratory symptoms and was diagnosed with COVID-19 infection (confirmed with PCR test). Four days after he was discharged, he noticed a sudden vision loss in his right eye and a mild visual impairment in his left eye. In addition, he complained of moderate headache. His past medical history was significant for diabetes controlled by pioglitazone (30 mg BD) and gliclazide (80 mg daily). In the physical and neurological examination, he was afebrile, awake, oriented, and the speech was normal. Both pupils were symmetric and mid-sized on the first day of admission. The right pupil was non-reactive, while the left one was reactive. Visual acuity on the first day was Considering all the evidence, post-COVID-19 encephalitis diagnosis was considered for the patient. In accordance with infectious disease consult, our patient underwent methyl prednisolone pulse-therapy (1gr/daily) for 3 days, and then, prednisolone (1mg/kg/ day) as a maintenance therapy was initiated. Later, the patient presented confusional state and right hemiparesis. Therefore, intravenous immunoglobulin (IVIg) (25 g/d for 5 days) was initiated for the patient, which resulted in the improvement of both mental state and clinical symptoms. Patients was then discharged with acceptable general condition; however, both eyes remained blind (no light perception). Right lower-extremity muscle force was recorded as 1/5, while others were observed as 4/5. Patient was advised to use prednisolone (60 mg/kg), and warfarin (5 mg/d). After 3 months of clinical follow-up, patient is still blind (no light perception) without pupillary light reflex. Muscle forces returned to normal; nevertheless, a wide-based gait is still observed (which is not reliable due to blindness). MRI also shows no new lesions. Prednisolone is being tapered (10 mg/d), and patient is receiving warfarin (INR 2.2). Herein, we describe a rare case of post-COVID-19 encephalitis, which led to bilateral blindness, 3 weeks after the COVID-19 infection. To our knowledge this is the first case of post-COVID-19 encephalitis which presented with bilateral vision loss primarily. It should also be maintained that retrobulbar optic neuritis may be another differential diagnosis justifying patient's blindness. However, MRI evaluation did not reveal any abnormalities in optic nerve; nevertheless, it cannot be ruled out. Atypical optic neuritis has also been reported after COVID-19 as a rare complication [4] . The possible mechanisms of neurologic sequels attributed to the COVID-19 infection could be either the direct invasion of the virus from nasopharyngeal rout [5] or increasing inflammatory factors due to the severe infection, which can decrease the function of blood-brain-barrier [6] . These theories can be classified into two groups, para-infection encephalitis and post-infection encephalitis [7] . In our patient, PCR of SARS-CoV-2 in the CSF was negative and COVID-19 symptoms had improved three weeks earlier. However, according to the previous studies, negative SARS-CoV-2 PCR of the CSF cannot rule out the direct invasion of the virus to the brain [8] . Curiously, the manifestation of the encephalitis three weeks after the COVID-19 infection may highlight the pivotal role of inflammatory factors following the infection rather than direct invasion of the virus. Discovering the exact mechanism of encephalitis could help to recognize the best management for these patients. In previous reports, corticosteroid has been suggested as an appropriate treatment for post-infection immune mediated encephalitis, through reducing the level of inflammatory factors, and there are some reports of COVID-19 patients with encephalitis whose clinical course improved after the administration of corticosteroid [9, 3] . Furthermore, IVIg has been reported as a safe and effective choice for COVID-19-associated encephalopathy [10] . In our case, however, it is unclear whether receiving steroid pulse-therapy led to improvement or IVIg was the effective treatment. Thus, more studies are required in order to define best treatment options for the patients with post-COVID-19 encephalitis. Although there are growing reports of the neurologic involvement among the patients, blindness can rarely be observed as a complication of post-COVID-19 encephalitis. To our knowledge this is the first case of post-COVID-19 encephalitis which presented with bilateral vision loss primarily. This case may raise physicians' awareness of neurological complications of COVID-19. Funding: None to declare. Consent to participate: Obtained. Ethical approval: All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. 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