Acute necrotizing encephalopathy with SARS-CoV-2 RNA confirmed in cerebrospinal fluid

Area of Science:

• Neurology
• Infectious Diseases
• Virology

Background:

• COVID-19 can cause severe neurological complications, including acute necrotizing encephalopathy.
• The neurotropism of SARS-CoV-2, the virus causing COVID-19, remains an area of active investigation.
• Diagnosing central nervous system involvement in COVID-19 can be challenging due to variable clinical presentations.

Observation:

• A patient with COVID-19 developed acute necrotizing encephalopathy with coma, despite only mild CSF abnormalities and no hyperinflammatory state.
• Brain MRI revealed characteristic symmetric lesions in the thalami, insular regions, temporal lobes, and brainstem.
• SARS-CoV-2 RNA was detected in cerebrospinal fluid (CSF) 19 days post-symptom onset, even after initial negative tests.

Findings:

• CSF analysis revealed extremely high concentrations of neuronal injury markers: neurofilament light (NFL) and tau protein, along with elevated glial fibrillary acidic protein (GFAP), indicating significant neuronal and astrocytic damage.
• Proteomics analysis of CSF showed elevated levels of neuronal rescue proteins and other relevant pathways.
• Despite severe neurological impairment, the patient showed improvement following treatment with intravenous immunoglobulins and plasma exchange.

Implications:

• This case underscores the potential neurotropic capabilities of SARS-CoV-2 and its ability to cause severe neurological damage.
• Repeated lumbar punctures and comprehensive CSF analysis, including advanced biomarker testing, are crucial for diagnosing neurological complications in COVID-19 patients.
• Early detection and intervention may improve outcomes in patients with COVID-19-related neurological conditions.