Focal Status Epilepticus as a Presenting Symptom of SARS CoV2 Infection
COVID 19, caused by SARS CoV2 virus is a global pandemic and has affected more than 3 million people worldwide. Most patients with COVID 19 present with respiratory symptoms, however, neurological involvement is not uncommon. Previously, stroke, Guillain Barre Syndrome, meningitis and encephalitis have been reported as the presenting manifestation of COVID 19, in the absence of respiratory symptoms. The current case report is of the first patient, who presented with focal status epilepticus as the initial symptom of COVID 19.
78-year old Italian lady presented with recurrent focal myoclonic jerks affecting right eyelid and upper lip of two hours duration. She had a history of herpes simplex encephalitis two years ago. She was left with aphasia and mild right hemiparesis due to post-encephalitic damage of left fronto-temporal lobe. She also had a post-encephalitic epilepsy, well controlled on valproate (VPT) and levetiracetam.
She was alert and afebrile. EEG showed features left focal status epilepticus, with epileptiform discharges arising from left fronto-centro-temporal regions. MRI showed old gliotic changes in left fronto-temporal regions without any new acute lesions. Seizures were controlled with IV VPT and IV midazolam.
12 hours after admission to ER, she developed fever. Chest X-ray was normal. Blood and urine culture were sterile. Blood counts showed decrease in lymphocyte count. Blood gases were normal. Fever did not respond to empirical antibiotics. In view of history of contact with her son, whose friends had tested positive for Covid 19 infection, her nasopharyngeal swab was tested by RT-PCR, which turned out positive for SARS-CoV2. Lumbar puncture was not done. She was treated with lopinavir-ritonavir plus hydroxychloroquine. She responded to the treatment and became afebrile. She was discharged 16 days after admission, after COVID tests turned negative on two occasions.
Glial cells and neurons exhibit angiotensin-converting enzyme 2 (ACE 2). SARS CoV2 viruses are known to enter cells that express ACE 2. This can explain the neuroinvasive propensity of corona viruses.
(Reference: Seizure, April 21, 2020)