In March 2020, a 68-year-old man with a history of pulmonary thromboembolism sought care at the emergency department for fever, cough, headache, and confusion. Because of severe respiratory failure, orotracheal intubation was required, and the patient was admitted to the intensive care unit, where bilateral deep vein thrombosis and hematemesis occurred. After 2 weeks, owing to respiratory improvement, the patient was weaned from ventilator support and sedation. However, persistent fluctuations in confusion, anxiety, agitation, and cognitive-motor slowing were noted. One week later, he was referred to the infectious diseases unit, where altered mental status persisted in the absence of fever, seizures, or episodes of impaired consciousness.
Chest radiography showed small, bilateral, ground-glass opacities. Brain magnetic resonance imaging showed bilateral involvement of mesial temporal lobes and hippocampus on fluid-attenuated inversion recovery sequences, in the absence of contrast enhancement or restricted diffusion. Nasopharyngeal samples were positive for SARS-CoV-2 on reverse transcriptase–polymerase chain reaction testing. Cerebrospinal fluid examination showed a slight increase in protein concentration, 1 white blood cell/µL, and no evidence of central nervous system infection. In particular, SARS-CoV-2 RNA was not detected.
The patient was diagnosed with postinfectious inflammatory (limbic) encephalitis in the course of SARS-CoV-2 infection.
The patient was treated with lopinavir/ritonavir and hydroxychloroquine. His recent thromboembolism prevented the administration of intravenous immunoglobulins, and high-dose corticosteroids were not administered because of the recent episode of hematemesis. Improvement in cognitive symptoms was noted 6 weeks after onset.
At the time of this writing, May 2020, a few cases of encephalitis after COVID-19 had already been described. These have generally been characterized by fever, cognitive dysfunction, epileptic seizures, coma, and cerebrospinal fluid inflammatory findings. It appears that a common magnetic resonance imaging appearance in these patients is that of diffuse inflammatory encephalitis.
Idiopathic subclavian vein thrombosis: anatomical findings by magnetic resonance imaging and correlation with clinical provocation tests
