key: cord-0920748-67cen16b
authors: Dharsandiya, Mitkumar; Patel, Ketan; Patel, Atul
title: Response to the comments received on a case report SARS-CoV-2 viral sepsis with meningoencephalitis
date: 2021-04-28
journal: Indian J Med Microbiol
DOI: 10.1016/j.ijmmb.2021.04.004
sha: 7ec697586853e646edb025d5544cca2cdc5f930c
doc_id: 920748
cord_uid: 67cen16b

nan

Response to the comments received on a case report SARS-CoV-2 viral sepsis with meningoencephalitis Dear Editor, We thank J. Finsterer for their comments on our case report "SARS-CoV-2 Viral Sepsis with Meningoencephalitis" and appreciated the opportunity to respond.

Author queried the diagnosis of meningoencephalitis and suggested possibility of inflammatory meningoencephalitis. We diagnosed meningoencephalitis based on his clinical symptoms of fever, altered sensorium, and episode of seizure and was subjected for investigated to confirm a clinical diagnosis by CT scan brain to rule out intracranial haemorrhage, followed by CSF study. MRI study of brain was not possible because of his critical condition. We couldn't get his CSF for SARS-CoV-2 PCR, as laboratory denied it while CSF BioFire FilmArray Meningitis/ Encephalitis panel was negative. In view of clinical features and lymphocytic pleocytosis in the CSF, diagnosis of meningo-encephalitis was entertained. Clinical presentation of inflammatory meningoencephalitis is similar, but CSF analysis is normal or shows mild-to-moderate elevation in the protein level without pleocytosis despite radiological evidence of meningeal inflammation [1] . Our patient has lymphocytic pleocytosis with normal protein levels favouring viral invasion.

Patient on presentation had a severe illness and hyper CKemia was likely to be because of rhabdomyolysis which was improving during hospital course. In agreement with authors comment, we should have added rhabdomyolysis as a presenting complication along with sepsis and meningoencephalitis in his clinical discussion. Rhabdomyolysis received less attention in the discussion as primary aim of reporting this case was to sensitize readers about a possibility of viral sepsis and meningoencephalitis in SARS CoV-2.

Diagnosis of viral sepsis is challenging, and we state the same in the discussion part. There are no specific diagnostic criteria, but viral sepsis is suspected in a patient with a confirmed diagnosis of viral infection as arrived by antigen detection, molecular diagnostics, viral culture or demonstration of viral particles on histopathological examination with organ dysfunction because of dysregulated host response in absence of bacterial or fungal pathogen [2, 3] . Our patient was satisfying this definition; he has RT PCR confirmed SARS CoV-2 infection with features of peripheral circulatory failure (cold extremities with color changes in absence of overt hypotension, in fact patient had hypertension with BP 180/100 mm of Hg) and no evidence of bacterial or fungal blood infection at the time of viral sepsis. SARS CoV-2 is associated with endothelial infection and endothelitis contributing to poor organ perfusion and dysfunction [4] . Again, SARS CoV-2 PCR was not possible to carry out from blood or plasma because of laboratory restrictions.

Author also commented and raised concerns about treatment received by patients. This patient was admitted during the initial period of Covid-19 outbreak, second week of May 2020. Hydroxychloroquine was a standard of care according to local treatment guideline from the ministry of health and family welfare during that period [5]. Remdesivir was not introduced into the Indian market. Aspirin, along with low molecular weight heparin, was prescribed to get potential benefit by antiplatelet action in the treatment of intravascular coagulopathy. After seizure, the patient was treated with levetiracetam and no adverse drug reactions were recorded. This patient was diabetic, as mentioned in the case report. We agree that providing laboratory reference values will help readers to interpret the results. We feel that presented case was diagnosed adequately with clinical features and available supporting laboratory features.

None.

None.

Central nervous system complications associated with SARS-CoV-2 infection: integrative concepts of pathophysiology and case reports

Viral sepsis is a complication in patients with novel corona virus disease (COVID-19)

SARS-CoV-2 and viral sepsis: observations and hypotheses

Endothelial cell infection and endotheliitis in COVID-19

Atul Patel * Department of Infectious Diseases, Sterling Hospital