Ziemele Dace, Ķauķe Gundega, Skrējāne Krista, Jaunozoliņa Līga, Karelis Guntis
Department of Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia.
Rīga Stradiņš University, Riga, Latvia.
Eur J Neurol. 2021 Nov;28(11):3870-3872. doi: 10.1111/ene.14966.
An increasing number of published reports on SARS-CoV-2 neurological manifestations have revealed a wide spectrum of symptoms, diagnostic features, and outcomes. We report a fatal case of a COVID-19-associated acute necrotizing encephalopathy (ANE).
We report a 70-year-old man brought to the hospital after a generalized tonic-clonic seizure. He was confused and disoriented. Nasopharyngeal swab testing for SARS-CoV-2 was positive. A head computed tomography (CT) scan and cerebrospinal fluid (CSF) analysis showed no signs of acute pathology. After recurrent seizures, he was sedated and intubated. Throughout the days that followed he remained in a therapeutic coma. After discontinuation of sedatives, he remained unconscious. A repeated head CT scan showed signs of pontine edema, and brain magnetic resonance imaging (MRI) revealed inhomogeneous hyperintensities with microhemorrhages and small autonecrotic cavities in both thalami, brain stem, and cerebellar peduncles. With a high suspicion of a COVID-19-associated ANE, the patient was started on high-dose glucocorticoids; however, he died the next day. The CSF tested negative for SARS-CoV-2.
A variety of COVID-19 neurological manifestations have been reported to date, including various forms of encephalitis and encephalopathy. In our patient, encephalopathy with seizures was the presenting symptom of SARS-CoV-2 infection. The radiological findings on days 8 and 9 were consistent with an ANE. The precise pathogenesis of ANE remains unclear; however, an immune-mediated mechanism is suspected. Early diagnostics with prompt administration of immunomodulators may be lifesaving. Suspicion of a COVID-19-related encephalopathy/encephalitis should be raised in all patients with altered mental status, seizures, and/or coma.
越来越多关于严重急性呼吸综合征冠状病毒2（SARS-CoV-2）神经表现的报道揭示了一系列广泛的症状、诊断特征和预后情况。我们报告一例与冠状病毒病2019（COVID-19）相关的急性坏死性脑病（ANE）致死病例。
我们报告一名70岁男性，在发生全身强直阵挛性癫痫发作后被送往医院。他神志不清且定向障碍。SARS-CoV-2的鼻咽拭子检测呈阳性。头颅计算机断层扫描（CT）和脑脊液（CSF）分析未显示急性病变迹象。在反复癫痫发作后，他接受了镇静和插管治疗。在随后的几天里，他一直处于治疗性昏迷状态。停用镇静剂后，他仍未苏醒。再次进行头颅CT扫描显示脑桥水肿迹象，脑部磁共振成像（MRI）显示双侧丘脑、脑干和小脑脚有不均匀的高信号，伴有微出血和小的自身坏死腔。由于高度怀疑为与COVID-19相关的ANE，该患者开始接受大剂量糖皮质激素治疗；然而，他于次日死亡。CSF的SARS-CoV-2检测呈阴性。
迄今为止，已报道了多种COVID-19神经表现，包括各种形式的脑炎和脑病。在我们的患者中，伴有癫痫发作的脑病是SARS-CoV-2感染的首发症状。第8天和第9天的影像学检查结果与ANE一致。ANE的确切发病机制尚不清楚；然而，怀疑是免疫介导机制。早期诊断并及时给予免疫调节剂可能挽救生命。对于所有出现精神状态改变、癫痫发作和/或昏迷的患者，都应怀疑与COVID-19相关的脑病/脑炎。
