Acute Necrotizing Encephalitis as an Early Manifestation of COVID-19

In addition to respiratory symptoms, SARS-CoV-2 infection has been linked to numerous neurologic sequelae including acute necrotizing encephalopathy. Here we present the case of a 33-year-old woman infected with SARS-CoV-2 who arrived at the hospital unresponsive. She was comatose with intact brainstem reflexes, and brain imaging was consistent with acute necrotizing encephalopathy affecting the bilateral thalami, medial temporal lobes, and pons. She was treated quickly with intravenous corticosteroids and plasmapheresis and regained neurologic function over weeks. Acute necrotizing encephalopathy is a rare para-infectious syndrome characterized by rapidly progressing encephalopathy, seizures, and/or coma caused by multifocal inflammatory central nervous system (CNS) lesions. The mechanism(s) underlying this condition remain unclear, though cytokine storm and disruption of the blood-brain barrier has been proposed as initiating event. This report presents a case of adult acute necrotizing encephalopathy in the early period after SARS-CoV-2 infection, adding to the literature on this rare condition and its relation to SARS-CoV-2 infection. We also report on the clinical outcome of treatment with prompt immunosuppression.