Post-COVID-19 inflammatory syndrome manifesting as refractory status epilepticus

Abstract

There have been multiple descriptions of seizures during the acute infectious period in patients with COVID-19. However, there have been no reports of status epilepticus after recovery from COVID-19 infection. Herein, we discuss a patient with refractory status epilepticus 6 weeks after initial infection with COVID-19. Extensive workup demonstrated elevated inflammatory markers, recurrence of a positive nasopharyngeal SARS-CoV-2 polymerase chain reaction, and hippocampal atrophy. Postinfectious inflammation may have triggered refractory status epilepticus in a manner similar to the multisystemic inflammatory syndrome observed in children after COVID-19.

Keywords: COVID-19; SARS-CoV-2; inflammatory response; postinfectious; refractory status epilepticus; seizures.

FIGURE 1

A, Magnetic resonance imaging brain axial fluid‐attenuated inversion recovery sequences, from left to right, obtained 3 months prior to diagnosis of COVID‐19, on hospital day (HD) #8, HD #15, and HD #29 of hospital course #2, demonstrating global cerebral atrophy and progressive right > left hippocampal atrophy. B, Electroencephalogram (EEG) from HD #8 of hospital course #2, demonstrating bilateral synchronous periodic discharges maximal over the right posterior quadrant and the left occipital pole. C, EEG from HD #9 of hospital course #2, demonstrating a burst suppression pattern with 20% of the page showing bursts, following initiation of propofol, midazolam, and ketamine drips. Bursts consist of synchronous polyspike and wave discharges. D, EEG from HD #29 of hospital course #2, demonstrating increased burden of brief runs of rhythmic discharges that are again maximal biposteriorly. E, EEG from HD #11 of hospital course #3 demonstrating right posterior quadrant discharges with moderate to severe generalized background slowing. All EEG studies in Figure 2 are shown in time base of 30 mm/s, read at 7 µV/mm, with notch filter of 60 Hz applied, in double banana montage with subtemporal leads

FIGURE 2

Timeline of the 114 days from admission for COVID‐19 to discharge from her third hospitalization. BIRD, brief potentially ictal rhythmic discharge; CRP, C‐reactive protein; CSF, cerebrospinal fluid; EEG, electroencephalography; ESR, erythrocyte sedimentation rate; HD, hospital day; ICU, intensive care unit; IVIG, intravenous immunoglobulin; L, left; LPD, lateralized periodic discharge; MICU, medical ICU; MRI, magnetic resonance imaging; NCHCT, noncontrast head computed tomography; NYU, New York University Hospital; PCR, polymerase chain reaction; R, right; RBC, red blood cells; SAR, subacute rehabilitation; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2; WBC, white blood cells.