Grade IV Glioma Potentially Disguised As COVID-19 Encephalitis

Abstract

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2), which became a pandemic in March 2020. Since that time, research has shed light on this disease's pulmonary, cardiac, and hematologic complications. However, we are still unraveling the complex neurologic sequelae of COVID-19. Here we present the case of a 58-year-old female who presented with weakness, gaze preference, and aphasia. She was diagnosed with a stroke which was managed medically. The patient returned two weeks later with memory loss and aphasia. An MRI was consistent with temporal lobe encephalitis, although a lumbar puncture was unremarkable. A polymerase chain reaction (PCR) test for COVID-19 was positive. Treatment was initiated for viral encephalitis with patient improvement. She was discharged a second time, and approximately three months later, she presented again with unrelenting headaches. Further imaging revealed a mass that was determined to be a grade IV glioma. Cases of glioma after viral encephalitis have been studied, but a clear link with COVID-19 has not been established.

Keywords: acute cva; case report; covid-19; glioblastoma multiforme; viral encephalitis.

Figure 1. Axial plane T2 weighted MRI without contrast from the patient’s initial presentation: No radiographic abnormality was identified in this presentation.

Figure 2. Axial plane T2 weighted MRI without contrast from the patient’s second presentation: The temporal lobe of this imaging shows an abnormal T2/FLAIR signal that was determined not to have imaging characteristics compatible with an infarct and was more consistent with encephalitis.

FLAIR: fluid-attenuated inversion recovery

Figure 3. Axial plane T2 weighted MRI with and without contrast from the patient’s third presentation: Seen now in the temporal lobe is an irregular peripherally enhancing mass, measuring approximately 3.4 x 4.4 x 4.1cm, seemingly nodular and ill-defined in some areas with extensive surrounding edema. Also seen is a second peripherally enhancing mass centered in the left basal ganglia/caudate head, measuring approximately 2.9 x 2.7 x 2.6 cm. There is approximately 11 mm of left-to-right midline shift.