Shah Parth, Patel Jinish, Soror Noha N, Kartan Ritha
Internal Medicine, Western Reserve Health Education/Northeast Ohio Medical University (NEOMED), Warren, USA.
Internal Medicine, Trumbull Regional Medical Center/American University of Antigua, Warren, USA.
Cureus. 2021 Jul 25;13(7):e16620. doi: 10.7759/cureus.16620. eCollection 2021 Jul.
The clinical presentation of coronavirus disease 2019 (COVID-19) has a wide spectrum, ranging from asymptomatic patients to severe presentations with acute respiratory distress syndrome (ARDS), kidney injury, stroke, electrolyte imbalance, and multi-organ failure. Encephalopathy and encephalitis are devastating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus-associated central nervous system complications. We reported a case of a 67-year-old male who was admitted to the hospital for the management of COVID-19 pneumonia. Due to worsening hypoxia, the patient was transferred to ICU and was intubated. On examination, he was aphasic and noted to have right-sided hemiplegia with left-sided hemiparesis on day 4. CT scan of the head without contrast and MRI findings were suggestive of acute necrotizing encephalopathy secondary to intracranial cytokine storm caused by viral infection. The patient was treated with intravenous immunoglobulin (IVIG), and high dose corticosteroids, with clinical improvement in the right-sided hemiparesis on day 5. A repeat MRI brain revealed decreased edema. The pathogenesis of encephalopathy associated with COVID-19 may be multifactorial. Postulated mechanisms include hypoxic/metabolic changes produced by the intense inflammatory response due to cytokine storm and neurotropism. Cytokine storm causes hypoxia and metabolic insults that result in global dysfunction of the brain. Altered consciousness, ranging from mild confusion, delirium, to deep coma, are some of the cardinal clinical features. The most common imaging finding on MRI T2-weighted fluid-attenuated inversion recovery (MRI T2/FLAIR) includes symmetric, multifocal lesions with invariable thalamic involvement. Other commonly involved locations include the brainstem, cerebral white matter, cortical and subcortical white matter, and cerebellum. In a few case reports, cerebrospinal fluid (CSF) analysis has shown the presence of the virus. Management of encephalopathy in COVID-19 patients involves supportive care including supplemental oxygen therapy and immune modulators. Immune modulation therapy including high-dose corticosteroids and IVIG have been shown to improve outcomes in these patients.
2019冠状病毒病（COVID-19）的临床表现范围广泛，从无症状患者到出现急性呼吸窘迫综合征（ARDS）、肾损伤、中风、电解质失衡和多器官功能衰竭的严重表现。脑病和脑炎是严重急性呼吸综合征冠状病毒2（SARS-CoV-2）病毒相关的毁灭性中枢神经系统并发症。我们报告了一例67岁男性，因COVID-19肺炎入院治疗。由于缺氧加重，患者被转入重症监护病房并插管。检查发现，患者在第4天出现失语，右侧偏瘫伴左侧轻瘫。头颅无对比剂CT扫描和MRI检查结果提示为病毒感染引起的颅内细胞因子风暴继发的急性坏死性脑病。患者接受了静脉注射免疫球蛋白（IVIG）和大剂量皮质类固醇治疗，第5天右侧轻瘫有临床改善。重复脑部MRI显示水肿减轻。与COVID-19相关的脑病发病机制可能是多因素的。推测的机制包括细胞因子风暴引起的强烈炎症反应导致的缺氧/代谢变化和神经嗜性。细胞因子风暴导致缺氧和代谢损伤，进而导致大脑整体功能障碍。意识改变，从轻度意识模糊、谵妄到深度昏迷，是一些主要的临床特征。MRI T2加权液体衰减反转恢复序列（MRI T2/FLAIR）上最常见的影像学表现包括对称、多灶性病变，丘脑受累常见。其他常见受累部位包括脑干、脑白质、皮质和皮质下白质以及小脑。在一些病例报告中，脑脊液（CSF）分析显示存在病毒。COVID-19患者脑病的治疗包括支持性护理，如补充氧气治疗和免疫调节剂。包括大剂量皮质类固醇和IVIG在内的免疫调节治疗已被证明可改善这些患者的预后。
