COVID-19 Encephalopathy Presenting As New-Onset Seizure: A Case Report

A 52-year-old diabetic female arrived at our emergency department (ED) with a three-day history of headaches, anosmia, dizziness, weakness, lethargy, vomiting, and appetite loss. The patient denied fever, photophobia, neck pain, flu-like symptoms, and shortness of breath. Past medical, surgical, and allergic history was of no significance. She had no history of sick contacts and was not a smoker. On arrival to the ED, she was tachypneic (respiratory rate {RR}: 20 breaths per minute {bpm}), tachycardic (heart rate {HR}: 117 beats per minute {bpm}), was saturating well on room air (SpO2: 99%), and had a Glasgow Coma Scale (GCS) of 14/15. General cardiorespiratory and neurological examination was otherwise unremarkable.

The initial impression was pneumonia with respiratory distress based on elevated inflammatory markers and chest x-ray finding of bilateral pulmonary consolidations (Figure 1). The patient was empirically treated with antibiotics as per local protocols.

Figure
1:
Chest x-ray showing bilateral pulmonary consolidations.

AP: anteroposterior

Twenty minutes later, the patient developed two episodes of generalized tonic-clonic seizures and required intubation. CT thorax showed features typical of COVID-19 pneumonia with a severity score of moderate (Figure 2).

COVID-19 nasopharyngeal swab test (performed by the MDx 2019 n-COV reverse transcription polymerase chain reaction {RT-PCR}) was positive and COVID-19 prognostic markers were all elevated (Table 1). 

Table
1: COVID-19 prognostic markers as per hospital protocol.

LDH: lactate dehydrogenase; CRP: c-reactive protein; COVID-19: coronavirus disease 2019; HI: high

The patient was admitted to the ICU as a case of COVID-19 pneumonia with sepsis and possible secondary meningitis, encephalitis, and/or encephalopathy. Following her positive COVID-19 nasopharyngeal swab result, she was started on COVID-19 therapy as per local protocol which, at the time, included hydroxychloroquine sulfate and favipiravir.

A full workup, including CT head, was done to rule out other correctable causes of seizures, and they were all unremarkable. Given the picture of high inflammatory markers, new seizure activity, and a normal CT brain, lumbar puncture was done and she was empirically treated with acyclovir, ceftriaxone, and vancomycin for meningoencephalitis.

Subsequently, lumbar puncture result revealed a WBC count of 10/mm3 with a lymphocyte predominance (73%), high protein (0.57 g/L), and glucose (124 mmol/L), and a negative CSF culture, pointing to encephalopathy rather than encephalitis (Table 2).

Due to unavailability of CSF PCR analysis, presence of COVID-19 virus in CSF could not be ruled out. During the course of the ICU stay, GCS remained 3/15 without sedation, so status epilepticus was suspected and treatment with levetiracetam and lacosamide was started. EEG could not be done because of risk of exposure as per hospital protocols. The repeat CT brain was unremarkable, and she was scheduled for an MRI of the brain. MRI brain revealed extensive leptomeningeal enhancement and bilateral symmetrical basal ganglia enhancement, suggestive of meningoencephalopathy (Figure 3).

Figure
3:
MRI brain scan showing extensive leptomeningeal enhancement and bilateral symmetrical basal ganglia enhancement.

T1-weighted image pre-contrast (left) and T1-weighted image post-contrast (right).

Eventually, given that her Glasgow Coma Score (GCS) remained 4/15 off paralytics and sedatives, tracheostomy was done and she was shifted to a long-term care facility once she became COVID-negative, where she resides to date.