COVID-19 meningitis without pulmonary involvement with positive cerebrospinal fluid PCR

Coronavirus disease 2019 (COVID-19) typically presents with respiratory illness ranging in severity. Neurological complications of the disease remain largely unknown. Herein, we discuss the case of a woman diagnosed with COVID-19 meningitis following two positive cerebrospinal fluid (CSF) RT-PCR assays, and highlight the importance of recognizing the neurological manifestations of the disease.

The patient was a 49-year-old woman with a history of hypertension who presented with non-specific symptoms (fever, headache, malaise, nausea/vomiting). Chest computed tomography (CT) revealed a lack of pulmonary involvement and oropharyngeal/nasopharyngeal RT-PCR was negative for COVID-19. A lumbar puncture was performed on the third day of admission and the CSF analysis elucidated a viral pattern, but the CSF bacterial culture and RT-PCR assay for herpes simplex virus were both negative. Surprisingly, the CSF RT-PCR for COVID-19 was positive. The diagnosis of COVID-19 meningitis was made and the patient was treated solely with Kaletra^® , with a second CSF analysis confirming our unique finding 1 week later. The patient's clinical characteristics improved progressively, and she was discharged in excellent general condition after 21 days.

In contrast to what was originally believed, the SARS-CoV-2 can cause meningitis in isolation, perhaps by crossing the blood-brain barrier. Hence, it seems essential that physicians maintain a high index of suspicion for neurological involvement among COVID-19 patients, with early CSF analysis and brain imaging sometimes being indicated.