COVID-19 Parainfectious Demyelinating Lesion in a Pediatric Patient

Background: Although COVID-19 primarily causes respiratory symptoms, the virus may affect other organ systems. SARS-CoV-2 neuropathology continues to be defined, but recent studies have indicated that a considerable percentage of COVID-19 patients experience neurological or psychiatric symptoms.

Case Information: A previously healthy 15-year-old female presented to the emergency department with altered mental status and seizures. The patient was intubated for airway protection and transferred to intensive care. The patient was initially COVID negative but later found to be COVID positive. Extensive laboratory workup including inflammatory, infectious, oncologic, and rheumatologic studies were unrevealing. Lumbar puncture demonstrated benign cerebrospinal fluid with no malignant cells. Initial brain magnetic resonance imaging (MRI) demonstrated a diffusely heterogeneously enhancing white matter lesion in the left parietal and temporal lobes. Electroencephalogram demonstrated periodic lateralized epileptiform discharges in the left central and temporal region. Rheumatology, infectious disease, hematology, nephrology, and neuro-oncology were consulted. To control the seizures, intravenous Keppra and Ativan were administered. High-dose steroids and plasma exchange were initiated as treatment for possible demyelinating lesion as demonstrated on MRI. The first MRI after completion of plasma exchange showed expansion of the lesion although the patient clinically improved significantly. Follow-up MRIs indicate that the lesion has continued to demonstrate regression over time. Her clinical symptoms have also shown improvement.

Conclusion: SARS-CoV-2 is a pathogen capable of causing severe illness affecting a variety of different organ systems. There is potential for a variety of neurological complications in patients who are COVID-19 positive, and patients can present with neurologic complications even in the absence of more typical symptoms. Successful treatment in this patient included high dose intravenous steroids and plasma exchange as well as seizure management. Long-term immunotherapy was not necessary for continued improvement.