Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2025 Aug 7;25(1):990.
doi: 10.1186/s12879-025-11404-5.

Acute haemorrhagic necrotizing encephalopathy and inflammatory demyelinating encephalopathy associated with COVID-19 in adults in Southern China

Sha Tan #  1 , Chunping Cui #  1 , En-Peng Song #  2 , Yilong Shan  3 , Yanyu Chang  1 , Wei Qiu  4 , Zhengqi Lu  5
Affiliations
Case Reports

Acute haemorrhagic necrotizing encephalopathy and inflammatory demyelinating encephalopathy associated with COVID-19 in adults in Southern China

Sha Tan et al. BMC Infect Dis. .

Abstract

Background: COVID-19 manifests with diverse systemic symptoms, including central nervous system involvement. Acute necrotizing encephalopathy (ANE), acute hemorrhagic leukoencephalitis (AHLE), and acute disseminated encephalomyelitis (ADEM) exhibit overlapping clinical features, creating diagnostic challenges. This study characterizes COVID-19-associated neuroinflammatory syndromes in patients without apparent respiratory symptoms.

Methods: We conducted a retrospective case series analysis of four patients with confirmed COVID-19 and acute neurological decline. Diagnostic evaluation included brain MRI, cerebrospinal fluid analysis, autoimmune/paraneoplastic antibody panels, and exclusion of alternative etiologies through microbiological/metabolic testing.

Results: Four cases were identified: two with ANE, one with ADEM, and one with AHLE. All patients tested SARS-CoV-2-positive by RT-PCR despite absent respiratory symptoms. Magnetic resonance imaging revealed characteristic patterns: Symmetric thalamic lesions in ANE (Cases 1-2), hemorrhagic lesions in basal ganglia and bilateral cerebellar hemispheres in AHLE (Case 3), widespread cortical and subcortical demyelination in ADEM (Case 4).

Conclusions: ANE, AHLE, and ADEM are critical neuroinflammatory complications of COVID-19 requiring urgent differentiation. It is imperative to maintain a high level of clinical suspicion when patients present with acute encephalopathy in the absence of respiratory symptoms, as this enables timely intervention.

Keywords: Acute disseminated encephalomyelitis; Acute hemorrhagic leukoencephalitis; Acute necrotizing encephalopathy; COVID-19; Coronavirus.

PubMed Disclaimer

Conflict of interest statement

Declarations. Ethics approval: Written informed consent was obtained from the patient for the participation as well as the publication of the case report and any accompanying images. And this study was approved by the ethics committee of South China Agricultural University (ethical number: CR2023-011-01).A copy of the written consent is available upon request from the corresponding author. Consent for publication: Written informed consent for publication of identifying images or other personal or clinical details was obtained from the the participants or parents or legal guardians of any participant under the age of 18. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Patient 1 Acute necrotizing encephalopathy in a 25-year-old girl presenting with fever and consciousness disturbance. Axial FLAIR (B and F) and (C and G) T2-weighted images show hyperintensities in the bilateral thalami, PONS, and bilateral cerebellar hemisphere. Axial T1-weighted image (A and E) reveals hyperintensities, suggesting haemorrhages in the thalami and pons. D and H SWI image demonstrating cerebral microbleeds in the bilateral thalami and bilateral cerebellar hemisphere
Fig. 2
Fig. 2
Patient 2 Acute necrotizing encephalopathy in a 23-year-old male presenting with mental disorders. Axial T2-weighted (B and F) and T2 FLAIR (C and G) images show hyperintensities in the bilateral thalami and pons. Axial T1-weighted image (A and E) reveals hyperintensities, suggesting haemorrhages in the right thalami and pons. D and H SWI image demonstrating cerebral microbleeds in the right thalamus
Fig. 3
Fig. 3
Patient 3 Encephalitis in a 35-year-old male presenting with fever, seizure and coma. Axial T1-weighted (A, E, I) and T2-weighted (B, F, J) images show abnormal signals in the basal ganglia region, corona radiata, bilateral frontal and temporal regions and pons. Axial diffusion-weighted image (C, G, K) reveals decreased diffusion (high signal intensity) in the same regions. SWI (D, H, L) images reveal dispersed microhaemorrhages in the above lesions that are predominantly located in the basal ganglia and bilateral cerebellar hemispheres
Fig. 4
Fig. 4
Patient 4 with acute disseminated encephalomyelitis in a 52-year-old female. Axial T2 (A and E) and DWI (B and F) images show multifocal hyperintense lesions, the left cerebellar hemisphere and the right brachium of the pons. Axial postcontrast T1-weighted images (C and G) reveal mild contrast enhancement of the abnormalities. Sagittal T2-weighted image (D and H) shows patchy hyperintensity at the frontoparietal temporal lobe
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, China. JAMA Neurol. 2020;77(6):683–90. - PMC - PubMed
    1. Ellul MA, Benjamin L, Singh B, Lant S, Michael BD, Easton A, et al. Neurological associations of COVID-19. Lancet Neurol. 2020;19(9):767–83. - PMC - PubMed
    1. Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, et al. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med. 2020;382(23):2268–70. - PMC - PubMed
    1. Maury A, Lyoubi A, Peiffer-Smadja N, de Broucker T, Meppiel E. Neurological manifestations associated with SARS-CoV-2 and other coronaviruses: a narrative review for clinicians. Rev Neurol (Paris). 2021;177(1–2):51–64. - PMC - PubMed
    1. Ermilov VV, Dorofeev NA. Clinical and morphological features of SARS-COV-2 associated acute hemorrhagic necrotizing encephalopathy: case report. Egypt J Neurol Psychiatr Neurosurg. 2021;57(1):158. - PMC - PubMed

Publication types

MeSH terms

LinkOut - more resources