Steroid-responsive severe encephalopathy in SARS-CoV-2 infection

Andrea Pilotto; SIlvia Odolini; Stefano Masciocchi; Agnese Comelli; Irene Volonghi; Stefano Gazzina; Sara Nocivelli; Alessandro Pezzini; Emanuele Foca'; Arnaldo Caruso; Matilde Leonardi; Maria Pia Pasolini; Roberto Gasparotti; Francesco Castelli; Alessandro Padovani

Based on the history, the radiological findings and COVID-19 outbreak in the region, a real-time reverse transcriptase-polymerase chain reaction assays (RT-PCR) on nasopharyngeal swab was performed and confirmed a SARS-CoV-2 infection. Antiviral therapy with Lopinavir/Ritonavir 400/100 mg BID and hydroxychloroquine 200 mg BID was started. A brain CT scan was unremarkable, and the patient was hospitalized. At admission, a lumbar puncture was performed, and CSF showed inflammatory findings with mild lymphocytic pleocytosis (18/uL) and moderate increase of CSF protein (696 mg/dL). The analysis of neurotropic viruses (HSV-1, HSV-2, HSV-6, HSV-8, EBV, VZV and Adenovirus) was negative. CSF RT-PCR for SARS-CoV-2 was also negative. An electroencephalography (EEG) exhibited a generalized slowing, more prominent on the anterior regions with decreased reactivity to acoustic stimuli ( Figure 1 ). The same day an empirical treatment of ampicillin and acyclovir was introduced. The day after, a Brain Magnetic Resonance imaging (MRI) with Gadolinium did not reveal significant alterations or contrast-enhanced areas within brain and/or meninges ( Figure 1 ). Three days after admission, given the persistence of clinical symptoms, a high intravenous steroid treatment was started (methylprednisolone 1 g/day for five days). CSF analyses, carried out one day after steroids administration, showed lymphocytic pleocytosis (18/uL), hyperproteinorrachia (1272 mg/dL) and normal Link index without oligoclonal bands. CSF RT-PCR for SARS-CoV-2 was still negative.