key: cord-0743328-m1c48gb0
authors: Aoud, Sahar EL; Sorial, Didier; Selmaoui, Amel; Menif, Imen; Lazard, Michel; Hocine, Madjid Si; Thomas, Laurent
title: A first case of Mild Encephalitis with Reversible splenial lesions (MERS) as a presenting feature of SARS-CoV-2
date: 2020-07-04
journal: Rev Neurol (Paris)
DOI: 10.1016/j.neurol.2020.06.001
sha: 429a1feb0a664039de637485df765d511ed3f13d
doc_id: 743328
cord_uid: m1c48gb0

nan

I would like to kindly ask you if it is possible to add a coauthor in the authorship list.

This coauthor is Dr Tarek Chaabouni. He is the biologist who was responsible of the patient laboratory tests. He explained all detailed information about the serologic test used, the results, and the validation of this test to confirm COVID 19 infection.

All authors agree with this addition. I confirm also the acceptance of Dr Tarek Chaabouni to be added in the authorship list. The patient was treated with analgesic drugs and amoxicillin/clavulanic acid for 6 days. We did not start antiepileptic drugs due to the absence of seizure evidence. On day 6, psychomotor impairment and myalgia had gradually improved, vertigo and headaches had completely recovered. Unconsciousness disturbance, seizures and focal signs did not occur during several weeks of follow-up. One month after disease onset, a follow-up imaging showed complete disappearance of SCC abnormal signals on the brain MRI and reduced pulmonary lesions on the chest CT (Figure 2 B) .

MERS is a rare clinico-radiological syndrome that was first described by Tada et al. [4] in 2004.

Its spectrum comprises type 1 with an isolated lesion in the SCC and type 2 with bilateral extension in the subcortical white matter and/or entire corpus callosum [5] . The specific pathogenesis of this syndrome is still unknown. Nevertheless, reversible DWI signals associated with reduced ADC suggest that cerebral cytotoxic edema probably due to cytokine release might be the underlying causative mechanism of this condition [6] . MERS usually develops in children and young adults [6] . The most described neurological features of MERS are agitation, disorientation, delirious behavior, seizures and consciousness disturbance [6, 7] . [6] . It can also be caused by withdrawal of antiepileptic drugs, metabolic disorders and poisoning [7] . Zhu Y et al. [6] reported 15 cases of MERS. The therapeutic regimens included acyclovir for 11 patients, corticosteroids for six patients and antiepileptic drugs for two patients. Intravenous immunoglobulin was prescribed for three critically ill patients presenting consciousness disturbance, headache, meningeal irritation (2 cases) and seizures (2 cases) with severe neurological sequelae in two cases. Thirteen patients had complete recovery within 1 month.

No special medication was given for our patient except for antibiotics to prevent bacterial superinfection with complete recovery and favorable outcome.

Our case report illustrates a MERS type1 complicating COVID-19 infection and demonstrates that this virus must be added to the list of various causes associated with MERS. The pathogenic mechanism of corpus callosum lesions during this infection remains unclear. Recently, immune mediated injury due to cytokine storm and excessive inflammatory response has been suggested as a possible mechanism of COVID-19 neurological damages [2] .

Our patient had simultaneous occurrence of neurological lesions and suggestive pulmonary clinical and CT features for COVID-19 with negative nasal swab. Although RT-PCR remains the molecular test of choice for identifying acute infection, serological assays can be also useful for confirming the diagnosis of COVID-19 if it is performed within the correct timeframe after disease onset [9, 10] .

Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease

Neurological manifestations and complications of COVID-19: A literature review

Neurological manifestations of COVID-19 and other coronavirus infections: A systematic review

Clinically mild encephalitis/encephalopathy with a reversible splenial lesion

Differences in the time course of splenial and white matter lesions in clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS)

Reversible splenial lesion syndrome associated with encephalitis/encephalopathy presenting with great clinical heterogeneity

Clinicoradiological spectrum of reversible splenial lesion syndrome (RESLES) in adults: a retrospective study of a rare entity

Mild encephalopathy with a reversible splenial lesion mimicking transient ischemic attack: A case report

The important role of serology for COVID-19 control

Laboratory Diagnosis of COVID-19: Current Issues and Challenges

Figure 1 : Initial MRI imaging showing an hyperintense signal in the SCC on DWI (A) and T2-FLAIR images (B, C) with reduced ADC value (D)

Figure 2 : Lung CT showing ground-glass opacities with basal consolidations (A)