Acute Necrotizing Encephalopathy Associated With SARS-CoV-2 Exposure in a Pediatric Patient

Abstract

We present the case of a nine-month-old male child with three days of fever, irritability, left focal seizure, and febrile focal status epilepticus. He had no history of previous comorbidities. A lumbar puncture was performed, which showed cerebrospinal fluid (CSF) leukocytosis; protein and glucose were normal, and the polymerase chain reaction (PCR) panel for 14 pathogens in CSF was negative. Immunoglobulin G (IgG) qualitative and quantitative tests were positive for coronavirus disease 2019 (COVID-19) upon arrival. An MRI performed one week after the initial onset showed findings suggestive of acute necrotizing encephalopathy (ANE). The patient required mechanical ventilation. However, his symptoms did not improve and follow-up imaging two weeks later showed progression of the disease with hemorrhagic changes. To our knowledge, this is the first reported case of ANE associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-​2) infection in a pediatric patient.

Keywords: acute necrotizing encephalitis; child; covid-19; sars cov-2.

Figure 1. First and second brain MRI

Axial T2-weighted images (A and B) and the axial T1-inversion recovery image (C) show necrosis of both the thalamus and at the cortico-subcortical junction of both parietal and occipital lobes with a lack of contrast enhancement (D). Images E-H show the evolution of the previous findings two weeks later with the loss of parenchyma MRI: magnetic resonance imaging

Figure 2. MRI – diffusion and SWI

Diffusion (A, B) and ADC map (C, D) at the initial exam show restriction in the posterior limb of the internal capsule, cortico-subcortical junction of the occipital lobes (A and C), the posterior body of the corpus callosum, and corona radiate (B and D). A little dot of hemorrhage was visualized in the frontal lobe at the initial exam as a blooming artifact in the susceptibility-weighted image (E). In the follow-up exam, more hemorrhagic changes were visualized in the parietal lobes (F) MRI: magnetic resonance imaging; SWI: susceptibility-weighted imaging; ADC: apparent diffusion coefficient