Acute encephalitis in pediatric multisystem inflammatory syndrome associated with COVID-19

Abstract

Objective: To characterize neurological involvement in multisystem inflammatory syndrome in children (MIS-C) related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Methods: Retrospective analysis of the clinical, electroencephalographic, CSF and neuroradiological parameters recorded in seven children (3 males, aged 3-10 years) affected by MIS-C with acute neurological involvement.

Results: All cases presented acute encephalopathy with drowsiness, irritability, mood deflection and diffuse EEG slowing with periodic posterior complexes. Focal neurological signs, normal brain MRI and CSF, were present in four patients; these patients received intravenous methylprednisolone at 30 mg/kg/day for 3 days. In all cases, the clinical picture rapidly improved in the first three days, and all neurological symptoms and EEG abnormalities disappeared within 10 and 30 days respectively. The severity and duration of the EEG abnormalities was proportional to the extent of the neurological involvement.

Conclusions: Patients with MIS-C may present acute encephalitis characterized by rapid-onset encephalopathy and EEG abnormalities (slow wave activity and/or epileptic abnormalities), in some cases associated with focal neurological signs that disappear with immunomodulatory therapy. The detection through neurological evaluation of sentinel neurological signs and distinctive EEG patterns documentable at disease onset will allow timely diagnosis and treatment of these cases.

Keywords: COVID-19; EEG abnormalities; Encephalitis; Multisystem inflammatory syndrome in children (MIS-C); Neurological symptoms; SARS-CoV-2.

Fig. 1

Timeline of patient 1's course. EEG day 4: wake: diffuse delta (0,5–1,5 Hz) activity; sleep: biphasic delta slow complexes. EEG day 7: wake: focal posterior delta (1,5-2 Hz) waves; sleep: lack of physiological organization, theta rhythmic discharges. EEG day 10: wake: reactive theta (6 Hz) posterior dominant rhythm; sleep: focal bilateral anterior discharges. IVIg: intra-venous immunoglobulins; IVMP: intra-venous methylprednisolone.