COVID‐19 Pneumonia and Exacerbation of Multiple Sclerosis Flares Necessitating Placement of Suprapubic Catheter and PEG Tube: A Case Study

Jaisankar, Prashanth; Kucera, Aurelia; Chin, Justin; Lomiguen, Christine

One of the public health challenges posed by the COVID‐19 pandemic is the management of patients with chronic neurological conditions, including multiple sclerosis. Here, we present the case of a 45‐year‐old male patient with severe multiple sclerosis without disease‐modifying therapy who was admitted for COVID‐19 pneumonia, treated with dexamethasone and Remdesivir, and then discharged. Subsequently, the patient was readmitted twice in the next month for complications arising from worsening dysphagia, musculoskeletal weakness, and neurogenic bladder. On the first of these re‐admissions, the patient presented with altered mental status, secondary to uremic encephalopathy due to acute kidney injury precipitated by lack of adequate PO hydration. This admission was complicated by multiple pulmonary emboli necessitating transfer from the floor to the ICU, in addition to central line placement, candidemia, Pseudomonas urinary tract infection, and hemorrhagic cystitis. Despite this protracted course, the patient's mental function and orientation slowly improved as his renal function improved secondary to intravenous fluid administration. Because the patient's worsening dysphagia and weakness made adequate hydration by mouth untenable, the possibility of PEG tube placement was broached with the patient and his family. After consent was obtained, a PEG tube was placed, and the patient was subsequently discharged home under the care of his family. Two days after discharge, however, the patient presented to the Emergency Department, again with altered mental status due to uremic encephalopathy secondary to dehydration. During this admission, blood cultures also revealed Pseudomonal sepsis, likely secondary to recurrent UTI ultimately caused by neurogenic bladder. Accordingly, a suprapubic catheter was placed, and the care team worked with the patient's family to develop an adequate hydration regime before discharge. This case study suggests that COVID‐19 may exacerbate ongoing neuropathological processes in patients with chronic neurological disease, and illustrates strategies clinicians and patients use to grapple with these changes.