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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 4  |  Page : 198-200

SARS-CoV-2 infection associated-meningoencephalitis treated with acyclovir


1 Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
2 Department of Infectious Disease, Hamad Medical Corporation, Doha, Qatar
3 Department of Hematology, Hamad Medical Corporation, Doha, Qatar

Date of Submission19-Nov-2020
Date of Acceptance30-Nov-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Mohammad N Kloub
Department of Internal Medicine, Hamad Medical Corporation, PO Box 3050, Doha
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_97_20

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  Abstract 


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus infection is now a pandemic distributed worldwide. All age groups are susceptible to infection, the elderly population, and those with a background of chronic medical comorbidities being particularly vulnerable for severe symptoms and complicated outcome. SARS-CoV-2 infection mainly targets the respiratory system and can establish infection in the upper part of the respiratory tract as well as the lower part of the respiratory tract, presenting in a spectrum ranging from asymptomatic infection reaching up to severe acute respiratory distress syndrome; however, the viral infection is not solely confined to the respiratory system as many cases have been reported where the patients present with different bodily system symptoms without having respiratory symptoms as usual. We report a 51-year old male who presented with symptoms of fever and dry cough and was diagnosed as a case of COVID-19 pneumonia that was later complicated by meningoencephalitis. The patient underwent diagnostic neuroimaging and lumbar puncture; patient received therapy with intravenous acyclovir and intravenous ceftraixone and improved with a favorable outcome. Meningioencephalitis is a serious neurological complication of SARS-CoV-2 infection and should be suspected in patients who develop signs and symptoms suggesting this condition, and we aim from publishing this case to draw attention to this serious complication.

Keywords: COVID-19, meningioencephalitis, severe acute respiratory syndrome coronavirus 2


How to cite this article:
Kloub MN, AlHiyari MA, Parengal J, Errayes E, Yassin MA. SARS-CoV-2 infection associated-meningoencephalitis treated with acyclovir. Libyan J Med Sci 2020;4:198-200

How to cite this URL:
Kloub MN, AlHiyari MA, Parengal J, Errayes E, Yassin MA. SARS-CoV-2 infection associated-meningoencephalitis treated with acyclovir. Libyan J Med Sci [serial online] 2020 [cited 2021 Jan 19];4:198-200. Available from: https://www.ljmsonline.com/text.asp?2020/4/4/198/305249




  Introduction Top


In December 2019, the outbreak of the novel coronavirus disease (Severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) in China spread worldwide, becoming an emergency of major international concern.[1] The etiological agent of SARS-CoV-2 has been confirmed as a novel coronavirus, now known as SARS-CoV-2, which is most likely originated from zoonotic coronaviruses such as SARS-CoV, which emerged in 2002. Within a few months of the first report, SARS-CoV-2 had spread across China and worldwide, reaching a pandemic level.[2]

As the new virus strain had already caused an enormous number of people being infected worldwide, with a large number of morbidity and mortality. Not to forget the serious impact on lifestyle routines and the impact on economy throughout the whole world, it definitely was crucial to put all differences aside and unite altogether to fight off this new pandemic.

More information about this virus and its infection is reported each day, which allows modifying the recommendations for its prevention and treatment without forgetting that the ultimate goal is to control this pandemic.[3]

SARS-CoV-2 infection has been shown to cause a wide variety of extrarespiratory complications, as SARS-CoV-2 is not confined strictly to the respiratory system. In addition to the usual presentation that targets the respiratory system, complications involving various systems of the human body were reported including neurological system involvement (stroke, epileptic seizures and others),[4] autoimmune system (cytokine release syndrome and others),[5] and cardiovascular system (arrhythmias, myocarditis, and others).[6]

Neurological symptoms have been reported in patients affected by SARS-CoV-2 such as headache, dizziness, myalgia, and anosmia,[4] but SARS-CoV-2-induced meningoencephalitis is a rare entity and we would like to shed the light on this complication.


  Case Report Top


A 51-year old Asian male, not known to have any chronic medical illnesses and not on any regular medications, and not known to have a history of alcoholism, smoking, or any type of substance abuse who presented with a history of fever and dry cough, associated with generalized body aches for 8-day duration, otherwise no symptoms present and review of systems negative. The patient turned to have SARS-CoV-2 PCR positive and was admitted and treated according to protocol initiated, as a case of SARS-CoV-2 pneumonia. He had no sick contacts and started on hydroxychloroquine 200 mg once daily PO for 10-day duration.

The patient was vitally stable, and his oral temperature recorded at admission was 36.9C. Initial general laboratory workup is shown in [Table 1]. Chest X-ray at the time of admission showed left lower patchy consolidation and bilateral lower atelectatic bands. Over the next 2 days of the patient's hospital stay, he started complaining of weakness in his upper limbs; neuorlogy assessment showed bilateral symmetrical proximal upper and lower limbs weakness (power 4/5). Sensory examination and remainder of neurological examination yielded negative findings. Overnight and on follow-up next day, the patient was found to be confused and disoriented, he was only following one step commands; his Glasgow Coma Scale was E4M6V4,14/15. Head computed tomography-angiogram showed no focal brain lesion, intracranial hemorrhage, infarction, or hydrocephalus, with normal opacification of the cerebral deep venous sinuses and cerebral veins, normal opacification of the four vessels in the neck, no occlusion or thrombosis, and nonvisualization of the A1 portion of the right anterior cerebral artery. The rest of cerebral arterial vessels are intact anterior and posterior. Cerebrospinal fluid (CSF) analyses are shown in [Table 2]. CSF study results are suggesting the diagnosis of viral meningoencephalitis. Bacterial culture and Gram stain of CSF turned to be negative. Viral PCR (including herpes virus and enterovirus) and tuberculosis (TB) workup from CSF were negative. Viral serology tests for HIV and hepatitis B and C were negative. Autoimmune screen was negative as well as TB QuantiFERON test.
Table 1: Laboratory results at presentation

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Table 2: Results of cerebrospinal fluid analysis

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The Patient started promptly on empiric treatment with intravenous ceftriaxone 2 g BID + intravenous acyclovir 700 mg once daily for a total of 10 days, the rationale for starting this treatment is as empirical treatment for meningoencephalitis, although we strongly believe that this was induced by SARS-CoV-2 infection, which was not tested for in the CSF, and therefore empiric treatment had to be started after lumbar puncture done and CSF samples obtained.

With monitoring and management, the patient showed clinical improvement over the next few days, regaining his muscle power and regaining full consciousness; therefore, lumber puncture was not repeated. The patient went on to recover completely from SARS-CoV-2 infection and also recover from his symptoms of meningoencephalitis and was discharged in a stable condition.


  Discussion Top


SARS-CoV-2 is enveloped positive-sense RNA viruses. The spike proteins project form the envelop surface of the virus giving the virus a solar corona-like appearance, and hence the name corona.[7] Similar to SARS-CoV, SARS-CoV-2 establishes itself within host cells through a physiologic mechanism uses the angiotensin-converting enzyme 2 receptor that includes but are not limited to airway epithelium and parenchyma cells, vascular endothelial cells, and kidney, and small intestinal cells.[7] It is well established that SARS-CoV-2 virus mainly infects the respiratory tract mucosa, with a small percentage of infected patients presenting with respiratory symptoms as cough and shortness of breath. However, the remaining large percentage of patients would be asymptomatic and would not have any complaints.[8]

SARS-CoV-2-induced neurological system complications are attributable to multiple pathophysiologic mechanisms such as direct infection such as across the cribriform plate, blood circulation through the blood–brain barrier (complications through this mechanism are more likely due to SARS-CoV-2-induced cytokine release, which in turn increases the permeability of the blood–brain barrier), neuronal pathway in which the virus can migrate through infecting sensory or motor nerve endings.[9],[10]

As mentioned above, SARS-CoV-2 can infect the nervous system through multiple pathways, it can present with any infected patient, but those experiencing severe disease are most vulnerable, therefore accurate detection and documentation of neurological symptoms coupled with thorough neurological investigations including CSF studies to isolate the virus is necessary, it is vital to keep a low threshold of suspected CNS infection when a patient develops any type of neurological symptoms.[9],[11]

The mode of treatment of COVID-associated meningoencephalitis is not yet clear. In the present case, acyclovir was used, to which the patient has responded. In other case reports, intravenous immunoglobulin has been used as treatment with potential benefit.[12] Our successful use of acyclovir in this case may suggest a possible benefit in SARS-CoV-2. As there is no formal treatment or specific guidelines for SARS-CoV-2-assciated meningoencephalitis, it warrants using acyclovir in such circumstances.


  Conclusion Top


Meningoencephalitis could be one of serious complications induced by SARS-CoV-2 infection and should be considered in any clinical encounter suggesting this condition. As formal specific treatment or guidelines for remain unclear, acyclovir may be of the potential benefit of SARS-CoV-2-assciated meningoencephalitis.

Acknowledgment

Authors would like to acknowledge the internal medicine and infectious disease departments at Hamad Medical Corporation for supporting this publication.

Informed consent

Written informed consent was obtained from the patient to allow the publication of information including images. The case approved by HMC Medical Research Center.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhai P, Ding Y, Wu X, Long J, Zhong Y, Li Y. The epidemiology, diagnosis and treatment of COVID-19. Int J Antimicrob Agents 2020;55:105955.  Back to cited text no. 1
    
2.
Ahn DG, Shin HJ, Kim MH, Lee S, Kim HS, Myoung J, et al. Current status of epidemiology, diagnosis, therapeutics, and vaccines for novel coronavirus disease 2019 (COVID-19). J Microbiol Biotechnol 2020;30:313-24.  Back to cited text no. 2
    
3.
Sifuentes-Rodríguez E, Palacios-Reyes D. COVID-19: The outbreak caused by a new coronavirus. COVID-19: La epidemia causada por un nuevo coronavirus. Bol Med Hosp Infant Mex 2020;77:47-53.  Back to cited text no. 3
    
4.
Carod-Artal FJ. Neurological complications of coronavirus and COVID-19. Rev Neurol 2020;70:311-22.  Back to cited text no. 4
    
5.
Zhang C, Wu Z, Li JW, Zhao H, Wang GQ. Cytokine release syndrome in severe COVID-19: Interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality. Int J Antimicrob Agents 2020;55:105954.  Back to cited text no. 5
    
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Cheng P, Zhu H, Witteles RM, Wu JC, Quertermous T, Wu SM, et al. Cardiovascular risks in patients with COVID-19: Potential mechanisms and areas of uncertainty. Curr Cardiol Rep 2020;22:34.  Back to cited text no. 6
    
7.
Acharya A, Kevadiya BD, Gendelman HE, Byrareddy SN. SARS-CoV-2 infection leads to neurological dysfunction. J Neuroimmune Pharmacol 2020;15:167-73.  Back to cited text no. 7
    
8.
Baggett TP, Keyes H, Sporn N, Gaeta JM. Prevalence of SARS-CoV-2 infection in residents of a large homeless shelter in boston. JAMA 2020;323:2191-2.  Back to cited text no. 8
    
9.
Wu Y, Xu X, Chen Z, Duan J, Hashimoto K, Yang L, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun 2020;87:18-22.  Back to cited text no. 9
    
10.
Baig AM. Neurological manifestations in COVID-19 caused by SARS-CoV-2. CNS Neurosci Therapeut 2020;26:499.  Back to cited text no. 10
    
11.
Asadi-Pooya AA, Simani L. Central nervous system manifestations of COVID-19: A systematic review. J Neurol Sci 2020;413:116832.  Back to cited text no. 11
    
12.
El-Zein RS, Cardinali S, Murphy C, Keeling T. COVID-19-associated meningoencephalitis treated with intravenous immunoglobulin. BMJ Case Rep 2020;13:2020;13:e237364.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2]



 

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