Ischemic arterial stroke, epileptic status and choreoathetosis in late vasculitis COVID-19: a case report

Case presentation: A 3-year-old patient started with runny nose and fever onset treatment for pneumonia, without improvement with amoxacillin and Clavulanic Acid for 10 days; later with azithromycin 5 days, without improvement and joined our service due to impaired respiratory function, when performing chest computer tomography (CT): seen opacities in matte glass bilaterally. Screening tests for COVID-19 in the initial care unit were negative. The patient evolved with pleural effusion, convulsive status, and left complete hemiplegia. Due to the worsening breath was intubated, cranial-CT showed multiple infarctions, compromising bilateral left-wing of middle cerebral artery (MCA) territory, associated with diffuse brain edema, cranial CT angiography: occlusion of the proximal segment of cervical and top of intracranial right internal carotid artery (ICA), occlusion of the right MCA and left anterior cerebral artery (ACA) A2 segment. There wasn’t no history of cervical trauma. We performed a study of vascular wall by MRI (“black blood”) that showed parietal thickening in the thrombosed segments, as well as foci of concentric parietal enhancement, representing vascular inflammatory process. After extubation, she developed paroxysmal autonomic instability, dystonia; and, but later, choreothetosis in the right side. Performed viral panel in liquor including research for COVID-19: negative; but serology for this virus IgG and IgM were positive. Rare causes of stroke in children were negative in investigations. During the evolution, anticoagulation was performed, achieved adequate control of seizures, currently in deformity prevention and motor rehabilitation.

Discussion: Virus-induced endotheliopathy leading to thrombosis is observed in SARS-CoV-2 infections in several organs, although research by nasopharyngeal swab testing, and cerebrospinal fluid was negative, serology showed COVID-19 infection, which has already been reported in the literature, probably due to the low viral load in the sample, transient viremia or due to delay in the test after the onset of symptoms. Latency time between the infection and late-onset vasculitis varies from 2–5 weeks, due to delayed immune reactivation triggered by the virus.

Final comments: Due to the technical difficulties for viral research, it is of great importance to pay attention to the signs of focal neurological deficit, as well as an adequate evaluation with neuroimaging given the potential of COVID-19 to affect the central nervous system.

 

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Artikel online veröffentlicht:
18. September 2023