Acute encephalopathy with elevated CSF inflammatory markers as the initial presentation of COVID-19

Abstract

Background: COVID-19 is caused by the severe acute respiratory syndrome virus SARS-CoV-2. It is widely recognized as a respiratory pathogen, but neurologic complications can be the presenting manifestation in a subset of infected patients.

Case presentation: We describe a 78-year old immunocompromised woman who presented with altered mental status after witnessed seizure-like activity at home. She was found to have SARS-CoV-2 infection and associated neuroinflammation. In this case, we undertake the first detailed analysis of cerebrospinal fluid (CSF) cytokines during COVID-19 infection and find a unique pattern of inflammation in CSF, but no evidence of viral neuroinvasion.

Conclusion: Our findings suggest that neurologic symptoms such as encephalopathy and seizures may be the initial presentation of COVID-19. Central nervous system inflammation may associate with neurologic manifestations of disease.

Keywords: COVID-19; SARS-CoV-2; neuroinflammation.

Figure 1

Chest radiographs. Chest X-ray on admission (left) and on hospital day 13 (right), showing worsening bilateral infiltrates.

Figure 2

MRI brain. MRI without contrast demonstrates generalized atrophy and patchy periventricular and subcortical white matter hyperintensities.

Figure 3

Cytokine analysis of CSF and plasma. The COVID-19 patient showed a marked increase of a variety of inflammatory cytokine and chemokines in CSF and plasma compare to three control subjects including IL-17A, IL-6, IL-8, IP-10, with a unique MCP-1 signature identified in COVID-19 CSF. All samples were run in duplicate. Mean +/− SD.