COVID can do weird things to our CNS - still!

I want to present a case I saw, to remind ourselves there is a lot of unknown to COVID still...

5yo female, developmentally normal, with up to date vaccines, presented to our institution with 2 days of lock back pain and urinary incontinence, bilateral leg weakness and acute encephalopathy.

Initial workup revealed she was +ve for COVID.

On exam, her GCS was 7 (E1V2M4), she was moaning, but withdrew all limbs to noxious stimulus.

MRI revealed confluent, multifocal areas of T2 ^intensities, all in supratentorial area, nothing in brainstem nor cerebellum. Spine MRI showed ^intensities at the conus (which explains her incontinence). EEG showed diffuse delta slowing, without epileptogenic activity.

CSF was bland, other than those 10 leukocytes, but normal protein, glucose etc. Viral studies neg, inflammatory markers all normal. NMO and MOG are still pending.

No seizures, but put on Keppra 20mg/kd for prophylaxis. She's now in PICU, but protecting her airway.

We decided to empirically pulse her with MP, slight recovery however still not doing well. Bacterial cultures are still pending, as well AE (autoimmune encephalitis) panels PND. Abx (empirical coverage) are still going on until we have neg cultures.

It's unknown why this dramatic presentation developed in a "normal host" as ID likes to call them, however when I see this atypical presentation, I like to think outside the box and leaving no stone unturned. We are waiting for more CSF tests to come back, but our next step might be IVIG/PLEX if no improvement is achieved after 5 days of high dose steroids. Our working Dx is ADEM related to COVID, lower in Ddx autoimmune vs infectious encephalitis.

Nowadays we see COVID as "another cold" and people are not using masks in hospitals etc.... Unfortunately this is still causing damage and we don't know why these things happen.

Something to reflect on.

Stay tuned.

Diagnosis added by author

ADEM post Covid infection (post viral encephalitis)

Update 1

There is something colloquially called "The Lazarus effect" on IV MP. In this case, patient responded quite well, after 5 days of Methylprednisolone pulsing, she was back to baseline. Slow prednisone, oral taper was provided, DC home from ICU today. Amazing.

Similar cases

1. 2. 3. 4.

Questions

1. Since dx was not confirmed, has anti NMDAR encephalitis ever responded to acyclovir? Can HSVE and the former coexist?
2. How do you differentiate between autoimmune and viral encephalitides clinically?
3. Could there have been any other encephalitic condition that we missed?