key: cord-0832578-rh4jkqc6
authors: Vollono, Catello; Rollo, Eleonora; Romozzi, Marina; Frisullo, Giovanni; Servidei, Serenella; Borghetti, Alberto; Calabresi, Paolo
title: Focal status epilepticus as unique clinical feature of COVID-19: a case report
date: 2020-04-21
journal: Seizure
DOI: 10.1016/j.seizure.2020.04.009
sha: 78829af9e68bc92b7fc24d6fc2c3caa87cb82c2e
doc_id: 832578
cord_uid: rh4jkqc6

Abstract SARS-CoV-2, a novel zoonotic coronavirus, is currently spreading all over the world, causing a pandemic disease defined coronavirus disease 2019 (COVID-19). The spectrum of COVID-19 ranges from asymptomatic or mild infection to rapidly progressive, acute respiratory distress syndrome and death 1 .To the best of our knowledge, status epilepticus has never been described as initial presentation of COVID-19. We report a patient affected by COVID-19 whose primary presentation was a focal status epilepticus.

On 12 th March 2020 a 78-year-old woman was admitted to our Emergency Department for ongoing myoclonic jerks of the right face and right limbs. She suffered from hypertension and postencephalitic epilepsy. When she was 76, the patient developed a Herpes Simplex Virus-1 (HSV-1) encephalitis. The initial presentation of the herpetic encephalitis were repetitive oral buccal automatisms and aphasia lasting 6 hours associated with the electroencephalographic findings of subcontinuous epileptiform discharges over the left temporal fields, configuring a nonconvulsive status epilepticus (NCSE). The status epilepticus was successfully treated with a sequence of antiepileptic drugs. Because of the encephalitis, fluent aphasia and mild right limbs weakness persisted, with only a partial recovery after neuro-rehabilitation. Since then, the patient was steadily under treatment with valproic acid and levetiracetam and remained seizure-free for more than two years. She was under regular neurologic follow-up and the last electroencephalogram performed ten days prior to admission was normal ( Figure 1 ultrasound were negative for interstitial pneumonia. Since then, no other seizures occurred. During the hospitalization, she did not require oxygen therapy. On 28 th March she was discharged in stable condition, afebrile after two negative swabs for SARS-CoV-2.

COVID-19 is of critical concern in the medical community not only for its fast spread, potentially causing the collapse of the Health System, but also for its variability of presentation. Since some patients with COVID-19 do not show fever or radiologic abnormalities on initial clinical picture, the diagnosis of SARS-CoV-2 infection is a challenging one 1 . The neuroinvasive propensity has been reported to be a common feature of coronaviruses such as SARS-CoV-2, which is able to enter J o u r n a l P r e -p r o o f into the cells that express the angiotensin-converting enzyme 2 (ACE2) 2 

have been found to express ACE2 as well 3 . A role of neurotropism of SARS-CoV-2 has been hypothesized in unexpected acute respiratory failure of some patients without a consistent radiological worsening 4 . Our patient developed a focal status epilepticus as the initial presentation of SARS-CoV-2 infection in the context of a predisposing but well-controlled post-encephalitic epilepsy. Noteworthy, in our patient the disease did not express an important pulmonary involvement (she did not develop pneumonia nor did she require oxygen therapy). The limitation of this case is the absence of a proven central nervous system invasion by the virus (i.e. lumbar puncture and a PCR of the cerebrospinal fluid were not performed). Nevertheless, standing the atypical disease presentation and chronological correlation of symptoms, it is possible to hypothesize that SARS-CoV-2 could trigger seizures through a neurotropic pathogenic mechanism.

Overall, we suggest the importance of considering possible neurological manifestations of SARS-CoV-2 infection, even as initial presentation.

We describe the first patient to develop a focal status epilepticus as a presenting symptom of SARS-CoV-2 infection. Even in the absence of fever or respiratory symptoms, the recurrence or worsening of paroxysmal neurological events should raise the diagnostic hypothesis of SARS-CoV-2 infection. Further data is necessary to understand and assess the real burden of neurological symptoms in COVID-19 and how those contribute to morbidity and mortality, especially in timedependent pathologies.

J o u r n a l P r e -p r o o f

Clinical characteristics of coronavirus disease 2019 in China

Evidence of the COVID-19 Virus Targeting the CNS: Tissue Distribution, Host-Virus Interaction, and Proposed Neurotropic Mechanisms

The neuroinvasive potential of SARS-CoV2 may be at least partially responsible for the respiratory failure of COVID-19 patients