Autoimmune encephalitis and hepatitis after SARS-CoV-2: a case of multiple autoantibodies

Autoimmune encephalitis can occur in isolation or as a postinfectious complication, such as following infection with SARS-CoV-2.

A patient presented with neuropsychiatric symptoms 3 weeks after SARS‑CoV‑2 infection, including dysphagia, psychosis, and partial-onset seizures. The patient tested positive for anti-N-methyl-d-aspartate receptor antibodies in cerebrospinal fluid as well as anti-γ-aminobutyric acid type A receptor and anti-glutamic acid decarboxylase antibodies in the serum. Findings from brain magnetic resonance imaging and electroencephalography were unremarkable. Cerebrospinal fluid analysis revealed 3 white blood cells/μL, slightly elevated total protein levels (3.16 mmol/L [reference range, 0.83-2.50 mmol/L]), normal blood glucose levels (3.44 mmol/L [reference range, 2.22-3.88 mmol/L]), and negative results on Gram stain and cytologic examination. Nevertheless, a diagnosis of autoimmune encephalitis was established. After 3 months, elevated liver enzyme levels and positive anti-liver-kidney microsomal type 1, anti-smooth muscle, and anti-α-actinin antibodies led to liver biopsy and diagnosis of autoimmune hepatitis.

The patient was treated with repeated pulses of intravenous methylprednisolone, followed by rituximab administered every 6 months for 2 years, resulting in complete recovery.

This unprecedented case raises a high index of suspicion for autoimmune states in patients presenting with compatible clinical features, even when typical laboratory findings are unremarkable.