Hyperacute reversible encephalopathy related to cytokine storm following COVID-19 vaccine

Abstract

We describe the first case of hyperacute reversible encephalopathy following COVID-19 vaccination. A patient presented with acute onset encephalopathy, mainly characterized by agitation and confusion, rapidly responsive to high dosage steroid therapy and complete remission within 3 days from onset. The clinical manifestation was related with systemic and CSF cytokine hyperproduction, responsive to steroid therapy. Although the occurrence of encephalopathy after vaccination may be just a casual temporal association, we speculate that the cytokine-storm could be the result of an excessive innate immune response against the vaccine, in a predisposed patient susceptible to autoimmunity.

Keywords: COVID-19; Cytokines; Encephalopathy; Neuroinflammation; Vaccination.

Graphical abstract

Fig. 1

Time trend of clinical events and diagnostic investigations. Legend. CSF: cerebrospinal fluid; Glc: glucose (in mg/dL); Prt: proteins (in mg/dL); WBC: white blood cells count (in #/mm³); Link: Link's index; AR: CSF/serum albumin ratio; IL: interleukin (in pg/mL); TNF: tumor necrosis factor (in pg/mL); CRP: c-reactive protein (in mg/dL); EEG: electroencephalogram; CT: computed tomography; MRI: magnetic resonance imaging; Iv: intravenous.

Fig. 2

EEG at onset (a, upper panel) with diffuse slowing partially due to pharmacological effect and at day 7 (a, lower panel) with normal activity. Brain MRI (b) performed at onset did not demonstrate any acute lesion on T2- flair and diffusion weighted images, rare T2 hyperintensities compatible with chronic vessel disease were evident.