key: cord-1004293-fet8a1bq authors: de Freitas, Gabriel R.; Figueiredo, Marcos Ravi; Vianna, Arthur; Brandão, Carlos Otávio; Torres‐Filho, Helio M.; Martins, Andrea F. A.; Tovar‐Moll, Fernanda; Barroso, Paulo F. title: Clinical and radiological features of severe acute respiratory syndrome coronavirus 2 meningo‐encephalitis date: 2021-09-15 journal: Eur J Neurol DOI: 10.1111/ene.14687 sha: db638b417d7c8596c2c0deedf3e927115532671b doc_id: 1004293 cord_uid: fet8a1bq BACKGROUND AND PURPOSE: This case illustrates for the first time the clinical and radiological evolution of SARS‐CoV‐2 meningo‐encephalitis. METHODS: A case of a SARS‐CoV‐2 meningo‐encephalitis is reported. RESULTS: A 65‐year‐old man with COVID‐19 presenting with meningo‐encephalitis without respiratory involvement is described. He had fever, diarrhea and vomiting, followed by diplopia, urinary retention and sleepiness. Examination disclosed a convergence strabismus and ataxia. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis, oligoclonal bands and increased interleukin 6 level. SARS‐CoV‐2 was detected in the CSF through reverse transcriptase polymerase chain reaction, but not in nasopharyngeal, tracheal secretion and rectal samples. Brain magnetic resonance imaging showed lesions on white matter hemispheres, the body and splenium of the corpus callosum and resembling the projection of corticospinal tract, remarkably on cerebellar peduncles. CONCLUSIONS: This demonstrates the challenges in diagnosing COVID‐19 in patients with neurological presentations. Meningo-encephalitis in the context of COVID-19 may occur through direct invasion of the brain by the virus [2] [3] [4] , intracranial cytokine storm with blood-brain barrier breakdown [5] or autoimmune disorders secondary to viral illness [6, 7] . There are few other reports of patients with confirmed RT-PCR for SARS-CoV-2 in CSF [3, 8] . In one report, the authors discussed that the observed temporal lobe and hippocampal lesions could be secondary to multiple epileptic seizures rather than by direct viral invasion [3] . In the other report, brain MRI was not performed. Our patient did not have seizures and electroencephalography showed no epileptic discharges. In addition, the lesions described here are analogous to those of zika virus encephalomyelitis described by our group [9] . In this carefully studied case, the clinical and radiological evolution of the SARS-CoV-2 meningo-encephalitis is shown through serial examinations of brain MRI and inflammatory markers in the CSF. Most previous reports of SARS-CoV-2-associated meningitis-encephalitis had pulmonary involvement and/or a detectable RT-PCR of the nasopharynx [3, [5] [6] [7] . In this case, no clinical, radiological or laboratory evidence of respiratory involvement was present. Diagnosis was challenging since only one out of the two RT-PCRs for SARS-CoV-2 in CSF was positive and four other RT-PCRs collected in other samples (nasopharynx, rectal and tracheal secretion) were negative. Indeed, even in cases of suspected viral invasion of the central nervous system, the SARS-CoV-2 RNA is rarely detected in vivo. This can be explained by the very early viral central nervous system invasion and its clearance before neurological symptoms occur [10] . Other possible explanations include low levels of viral RNA, a sequence mismatch between viral template and primers or probes [11] or absence of virus in the subarachnoid space despite its presence in selected parenchymal areas [12] . Similarly, in the context of enterovirus D68 (EV-D68) associated acute flaccid myelitis (AFM), the presence of enterovirus RNA by RT-PCR was demonstrated in the CSF only in one of 55 children. Detection of intrathecal antibody synthesis was significantly more sensitive than RT-PCR for the diagnosis EV-D68-associated AFM [11] . In our patient, evaluation for SARS-CoV-2 antibodies in the CSF was negative at three different time points. This case illustrates the clinical and radiological evolution of SARS-CoV-2 meningo-encephalitis. It also demonstrates the challenges in diagnosing COVID-19 in patients with predominantly neurological presentations. None. Consent was obtained from the patient. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Gabriel R. de Freitas https://orcid.org/0000-0003-3178-0460 Marcos Ravi Figueiredo https://orcid.org/0000-0003-3517-3238 Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the central nervous system A first case of meningitis/encephalitis associated with SARS-Coronavirus-2 Meningoencephalitis without respiratory failure in a young female patient with COVID-19 infection in Downtown Los Angeles COVID-19-associated acute hemorrhagic necrotizing encephalopathy: CT and MRI features Plasmapheresis treatment in COVID-19-related autoimmune meningoencephalitis: case series Steroid-responsive encephalitis in COVID-19 disease SARS-CoV-2 detected in cerebrospinal fluid by PCR in a case of COVID-19 encephalitis Zika virus causing encephalomyelitis associated with immunoactivation Threesteps" infection model and CSF diagnostic implication Antibodies to enteroviruses in cerebrospinal fluid of patients with acute flaccid myelitis Understanding enterovirus D68-induced neurologic disease: a basic science review