Case report: central nervous system vasculitis due to COVID-19

Case presentation: A two year-old previously-healthy male was admitted at the emergency room due to severe acute respiratory syndrome. Initial evaluation detected right pneumonia and ipsilateral pleural effusion. A nasopharyngeal SARS-COV-2 RT-PCR test was positive. He was admitted for intravenous treatment and, after 7 days, presented a decreased level of consciousness and left hemiparesis. CT scan was normal and spinal fluid showed pleocytosis, elevated protein and low glucose, suggesting meningitis. Antimicrobial therapy was scalonated. After 3 days, the patient deteriorated (GCS 7) and presented focal seizures, requiring intubation and transference to the PICU. A new CT was performed, showing a hypodense lesion in the right thalamus. Then, an AngioMRI was performed and demonstrated multiple acute infarcts in the brainstem, right thalamus and temporal lobes probably caused by an arteritis due to the infection in process. The child improved clinically in the following weeks. During his stay, a control MRI was performed 11 days later and indicated a new acute infarct at the brainstem. Due to the event recurrence, despite his clinical improvement, he received a methylprednisolone pulse for 3 days. It was repeated monthly for the next 3 months. He also received enoxaparin and acetylsalicylic acid.

Discussion: Neurologic involvement associated to COVID-19 is not uncommon, either as in the acute disease or associated with MIS-C. However, life-threatening neurologic complications occur in a minority of patients and are rare in previously healthy children. They can manifest as severe encephalitis, ischemic or hemorrhagic stroke, acute infection of the central nervous system, acute fulminant cerebral edema and Guillain Barré Syndrome. At this moment, the pathogenic mechanisms are uncertain. It is suggested to involve neuroinvasive mechanisms directly linked to the virus, neuroinflammatory by the elevated production of cytokines, dysregulation of the post-infectious immune system or even secondary to complications of systemic inflammation.

Final comments: As a recent outbreak, COVID-19 is yet being comprehended. Our case reinforces the possibility of CNS vascular involvement complicating this disease in previously healthy children. Therefore, further studies are necessary for better understanding of its pathogenesis. Also, children affected will require follow-up for evaluation of the morbidity.

 

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Artikel online veröffentlicht:
18. September 2023