Bilateral globus pallidus lesions associated with COVID-19: Mimicking acute carbon monoxide poisoning

Bilateral symmetrical globus pallidus (GP) involvement associated with coronavirus disease 2019 (COVID-19) infection is an extremely rare finding among cases of COVID-19-related encephalopathy.

A 76-year-old man was diagnosed with pneumonia and subsequently tested positive for COVID-19. He was transferred to the hospital on day 9 after symptom onset due to worsening respiratory distress and hypotension. Despite improvement in his pneumonia following the transfer, his mental status remained altered throughout his hospital stay.

A neurologic work-up, including brain magnetic resonance imaging (MRI) performed 2 weeks after the onset of altered mental state, revealed symmetrical high signal intensity lesions in the bilateral GP on MRI.

The patient received high-flow nasal oxygen therapy with norepinephrine infusion for hemodynamic support, along with intravenous meropenem and remdesivir.

The patient gradually recovered and was able to engage in simple communication by the 3rd week. Follow-up MRI at 5 weeks showed resolution of GP lesions.

Differentiating COVID-19-related encephalopathy from acute carbon monoxide poisoning is challenging in the presence when bilateral symmetrical GP lesions are present. However, coexisting multiple ischemic lesions - common in COVID-19-related encephalopathy but rare in carbon monoxide poisoning - may serve as a useful radiologic clue.