Encephalitis in Patients with COVID-19: A Systematic Evidence-Based Analysis

Role of toll-like receptors in post-COVID-19 associated neurodegenerative disorders?

In the intricate realm of interactions between hosts and pathogens, Toll-like receptors (TLRs), which play a crucial role in the innate immune response, possess the ability to identify specific molecular signatures. This includes components originating from pathogens such as SARS-CoV-2, as well as the resulting damage-associated molecular patterns (DAMPs), the endogenous molecules released after cellular damage. A developing perspective suggests that TLRs play a central role in neuroinflammation, a fundamental factor in neurodegenerative conditions like Alzheimer's and Parkinson's disease (PD). This comprehensive review consolidates current research investigating the potential interplay between TLRs, their signaling mechanisms, and the processes of neurodegeneration following SARS-CoV-2 infection with an aim to elucidate the involvement of TLRs in the long-term neurological complications of COVID-19 and explore the potential of targeting TLRs as a means of implementing intervention strategies for the prevention or treatment of COVID-19-associated long-term brain outcomes.

Ofatumumab for the treatment of COVID-19-associated autoimmune encephalitis: A case report

Autoimmune encephalitis is a rare but severe complication of Coronavirus disease 2019 (COVID-19) infection. Typically, treatment involves immunomodulatory approaches such as steroids, intravenous immunoglobulin (IVIG), or plasma exchange. While for some patients, the above treatment is not effective. Here, we report a case of COVID-19-associated encephalitis, who exhibited cognitive impairment, epileptic seizures, tachycardia, and diaphoresis, with cranial MRI findings resembling those seen in limbic encephalitis. Initially, the patient exhibited a suboptimal response to antiviral therapy, high-dose steroids, and IVIG treatment. Nevertheless, his clinical symptoms and cranial MRI abnormalities markedly improved following the administration of Ofatumumab. Administering Ofatumumab early in COVID-19-related autoimmune encephalitis may benefit patients more.

Clinical and radiological characteristics and 1-year self-reported outcomes from patients with encephalitis and coronavirus disease 2019

INTRODUCTION

Severe acute respiratory syndrome coronavirus infection is responsible for multisystemic disease and has high transmissibility. It culminated in a pandemic, challenging scientific knowledge and care capacity. Neurological symptoms are highly prevalent, and cases of encephalitis have been described, in both peri- and postinfectious periods. However, pathogenesis and prognosis are unclear. Thus, we aim to describe the clinical findings in cases of encephalitis in patients infected with severe acute respiratory syndrome coronavirus, together with a 1-year follow-up of self-perception of recovery and remaining neuropsychiatric symptoms.

METHODS

This is a retrospective observational study in which patients with cerebrospinal fluid collection and a recent diagnosis of severe acute respiratory syndrome coronavirus infection were screened for encephalitis through analysis of medical records. We describe their clinical and paraclinical findings using descriptive statistics, together with their long-term outcome, through a self-assessment questionnaire.

RESULTS

Among the 135 patients screened, 11 patients were included. Most of them were admitted for neurological symptoms (73%), and in 63% of cases, those symptoms occurred within the first 7 days of systemic symptoms. Most patients had minor pulmonary involvement assessed on chest computed tomography. On cerebrospinal fluid analysis, the most relevant finding was hyperproteinorrachia. Three patients (27%) had positive changes on magnetic resonance studies. In the outcome analysis, most patients (77%) reported gait difficulties and 66% reported memory and concentration problems.

CONCLUSION

Encephalitis associated with severe acute respiratory syndrome coronavirus 2 infection is rare but responsible for chronic sequelae in cognitive and motor aspects. The pathophysiology seems to be associated with both the immune-mediated and inflammatory processes, and the low frequency of paraclinical findings demands a high clinical suspicion.

A step towards quantifying, modelling and exploring uncertainty in biomedical knowledge graphs

OBJECTIVE

This study aims at automatically quantifying and modelling the uncertainty of facts in biomedical knowledge graphs (BKGs) based on their textual supporting evidence using deep learning techniques.

MATERIALS AND METHODS

A sentence transformer is employed to extract deep features of sentences used to classify sentence factuality using a naive Bayes classifier. For each fact and its supporting evidence in a source KG, the deep feature extractor and the classifier are used to quantify the factuality of each sentence which are then transformed to numerical values in [0,1] before being averaged to get the confidence score of the fact.

RESULTS

The fact classification feature extractor enhances the separability of classes in the embedding space. This helped the fact classification model to achieve a better performance than existing factuality classification with hand-crafted features. Uncertainty quantification and modelling were demonstrated on SemMedDB by creating USemMedDB, showing KGB2U's ability to process large BKGs. A subset of USemMedDB facts is modelled to demonstrate the correlation between the structure of the uncertain BKG and the confidence scores. The best-trained model is used to predict confidence scores of existing and unseen facts. The top-ranked unseen facts were grounded using scientific evidence showing KGB2U's ability to discover new knowledge.

CONCLUSION

Supporting literature of BKG facts can be used to automatically quantify their uncertainty. Additionally, the resulting uncertain biomedical KGs can be used for knowledge discovery. BKG2U interface and source code are available at http://biofunk.datanets.org/ and https://github.com/BahajAdil/KBG2U respectively.

The Role of Corticosteroids in Non-Bacterial and Secondary Encephalitis

Encephalitis affects 1.9 to 14.3 people per 100,000 each year, and the mortality rate varies but can be up to 40%. After the identification of a particular microorganism in a patient with encephalitis, appropriate antimicrobial therapy should be initiated. Corticosteroid therapy represents a therapeutic option in the treatment of primary central nervous system diseases due to its ability to reduce the inflammatory commitment of CNS and consequently reduce mortality rates regardless of the causative agent of injury. Corticosteroid therapy represents a therapeutic option in the treatment of primary central nervous system diseases. Their use is also recommended in meningitis with autoimmune etiology. While corticosteroids have repeatedly been used as adjunctive treatment in encephalitis of viral etiology, the scientific evidence supporting their effectiveness remains scarce. The use of standard doses recommended by the guidelines seems reasonable as an initial setting, especially when a definitive diagnosis of the causal agent is still awaited. The subsequent adjustment should be personalized based on the individual clinical response.

Recovery From Long COVID: The Role of Bioelectric Meridian Therapy in Restoring Health and Well-Being

This case report explores the journey to a healthier life of a 57-year-old man who stayed athletic after contracting COVID-19 during a trip to a foreign country. He had minimal symptoms in the beginning. He started with a dull cough, but the symptoms then progressed to loss of taste and smell, mental fatigue, and nerve problems. In this case study, traditional cures helped only to some extent. Out of frustration with these symptoms, the patient started bioelectric meridian therapy (BMT) in August 2021 and benefited from it. The patient described progressive sensation, cognition, and muscle power enhancement during six months of BMT sessions. The therapy relieved the muscles' stiffness and regulated the bio-energy circulation to improve the general quality of life and ease physical exertion operations. The case affirms how supportive modalities such as BMT help handle the after-effects of COVID-19. The patients' recovery involved precise mental concentration, return of appetite, and regained vigor, which improved the patient's life. This case report shows how integrative approaches may be helpful when it comes to the reactivation of health processes after virus infection.

SARS-CoV-2-associated encephalitis: a case report

COVID-19 presents with respiratory symptoms and signs in the majority of cases. The central nervous system can be affected directly or indirectly, which is demonstrated by a number of neurological abnormalities and complications. The aim of this study is to present a clinical case of SARS-CoV-2-associated encephalitis and highlight the severity of this neurological illness over the course of COVID-19. Etiological diagnosis methods include examination of the nasopharyngeal swab and cerebrospinal fluid by PCR.

COVID-19 autism spectrum disorder-like transient neurocognitive clinical presentation

The COVID-19 pandemic has impacted the general population in different ways, including the vulnerable population of children with special needs.In this case report, we will discuss the emergence of a transient, full-blown picture of autism spectrum disorder (ASD) in a child who contracted a COVID-19 infection, and his gradual improvement over the course of a few months. This broadens our perspective on the possible neurocognitive clinical presentations of COVID-19 infection.

Evaluation of the effect of Modafinil in the improvement of the level of consciousness in patients with COVID-19 encephalopathy: A randomized controlled trial

AIM

COVID-19 can lead to encephalopathy and loss of consciousness. This double-blinded randomized clinical trial conducted in Tehran, Iran, aimed to assess the potential effectiveness of modafinil in patients with COVID-19-related encephalopathy.

METHODS

Nineteen non-intubated COVID-19 patients with encephalopathy were randomized into two groups: a treatment group receiving crushed modafinil tablets and a placebo group receiving starch powder. Modafinil was administered at a dose of 100 mg every 2 h, reaching a peak dosage of 400 mg. The level of consciousness was assessed using the Glasgow Coma Score (GCS) at multiple time points on the day of medication administration. The trial was registered under IRCT20170903036041N3 on 23/5/2021.

RESULTS

The average age in the modafinil and placebo groups was 75.33 and 70 years, respectively. No significant differences were observed between the two groups in terms of chronic conditions, clinical symptoms, or laboratory data. GCS scores were similar between the groups at baseline (p-value = 0.699). After four doses of modafinil, GCS scores were slightly higher in the treatment group, but this difference was not statistically significant (p-value = 0.581). GCS scores after each round of drug administration didn't significantly differ between the treatment and placebo groups (p-value = 0.908).

CONCLUSION

Modafinil exhibited a slight improvement in the level of consciousness among COVID-19 patients with encephalopathy, although this improvement did not reach statistical significance when compared to the control group. Further research with larger sample sizes and longer treatment durations is recommended to explore modafinil's potential benefits in managing altered consciousness in COVID-19 patients.

Invasive Listeriosis After Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) Infection

Acute deteriorated consciousness is commonly reported in elderly COVID-19 patients. Secondary bacterial infection is common in critically ill COVID-19 patients. Listeria monocytogenes is a gram-positive, facultatively intracellular rod-shaped bacterium ubiquitously distributed in the environment and is an opportunistic and foodborne pathogen. Pregnant women and their newborns, adults aged 65 years or older, and immunocompromised people are more vulnerable to Listeria -related invasive disease. A 74-year-old man with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with initial presentations of headache and acute disorientation, which was finally diagnosed with L . monocytogenes bacteremia and meningitis. Multiplex polymerase chain reaction (Multiplex PCR) assay was used to rapidly diagnose it in the emergency department.

COVID-19 Neuroimaging Update: Pathophysiology, Acute Findings, and Post-Acute Developments

COVID-19 has prominent effects on the nervous system with important manifestations on neuroimaging. In this review, we discuss the neuroimaging appearance of acute COVID-19 that became evident during the early stages of the pandemic. We highlight the underlying pathophysiology mediating nervous system effects and neuroimaging appearances including systemic inflammatory response such as cytokine storm, coagulopathy, and para/post-infections immune mediated phenomena. We also discuss the nervous system manifestations of COVID-19 and the role of imaging as the pandemic has evolved over time, including related to the development of vaccines and the emergence of post-acute sequalae such as long COVID.

The Neurological Implications of COVID-19: A Comprehensive Narrative Review

The COVID-19 pandemic caused by the coronavirus SARS-CoV-2 revealed a huge number of problems as well as discoveries in medicine, notably, regarding the effects of the virus on the central nervous system (CNS) and peripheral nervous system (PNS). This paper is a narrative review that takes a deep dive into the complex interactions between COVID-19 and the NS. Therefore, this paper explains the broad range of neurological manifestations and neurodegenerative diseases caused by the virus. It carefully considers the routes through which SARS-CoV-2 reaches the NS, including the olfactory system and of course, the hematogenous route, which are also covered when discussing the virus's direct and indirect mechanisms of neuropathogenesis. Besides neurological pathologies such as stroke, encephalitis, Guillain-Barré syndrome, Parkinson's disease, and multiple sclerosis, the focus area is also given to the challenges of making diagnosis, treatment, and management of these conditions during the pandemic. The review also examines the strategic and interventional approaches utilized to prevent these disorders, as well as the ACE2 receptors implicated in the mediation of neurological effects caused by COVID-19. This detailed overview, which combines research outputs with case data, is directed at tackling this pandemic challenge, with a view toward better patient care and outcomes in the future.

SARS-CoV-2 induces blood-brain barrier and choroid plexus barrier impairments and vascular inflammation in mice

The coronavirus disease of 2019 (COVID-19) pandemic has led to more than 700 million confirmed cases and nearly 7 million deaths. Although severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus mainly infects the respiratory system, neurological complications are widely reported in both acute infection and long-COVID cases. Despite the success of vaccines and antiviral treatments, neuroinvasiveness of SARS-CoV-2 remains an important question, which is also centered on the mystery of whether the virus is capable of breaching the barriers into the central nervous system. By studying the K18-hACE2 infection model, we observed clear evidence of microvascular damage and breakdown of the blood-brain barrier (BBB). Mechanistically, SARS-CoV-2 infection caused pericyte damage, tight junction loss, endothelial activation and vascular inflammation, which together drive microvascular injury and BBB impairment. In addition, the blood-cerebrospinal fluid barrier at the choroid plexus was also impaired after infection. Therefore, cerebrovascular and choroid plexus dysfunctions are important aspects of COVID-19 and may contribute to neurological complications both acutely and in long COVID.

Role of the SARS-CoV-2 Virus in Brain Cells

COVID-19, caused by the SARS-CoV-2 virus, can have neurological effects, including cognitive symptoms like brain fog and memory problems. Research on the neurological effects of COVID-19 is ongoing, and factors such as inflammation, disrupted blood flow, and damage to blood vessels may contribute to cognitive symptoms. Notably, some authors and existing evidence suggest that the SARS-CoV-2 virus can enter the central nervous system through different routes, including the olfactory nerve and the bloodstream. COVID-19 infection has been associated with neurological symptoms such as altered consciousness, headaches, dizziness, and mental disorders. The exact mechanisms and impact on memory formation and brain shrinkage are still being studied. This review will focus on pathways such as the olfactory nerve and blood-brain barrier disruption, and it will then highlight the interactions of the virus with different cell types in the brain, namely neurons, astrocytes, oligodendrocytes, and microglia.

Early-onset herpes simplex encephalitis type 1 triggered by COVID-19 disease: A case report

Coronavirus disease 2019 (COVID-19) causes a systemic inflammatory response and a temporary immunosuppression of hosts. Several reports have showed that reactivation of herpes simplex virus type 1 (HSV-1) is strongly associated with COVID-19. We present a case of a 66-year-old female, who developed HSV-1 encephalitis, showing impaired consciousness and typical MRI findings such as hyperintense lesions in the temporal lobe, insular cortices, bilateral medial frontal lobe on diffusion-weighted imaging, 7 days after the onset of COVID-19 symptoms. The number of cases of encephalitis in patients with COVID-19 is increasing. However, there has been limited reports of HSV-1 encephalitis following COVID-19, especially for cases with an interval of 7 days or less from the onset of COVID-19 symptoms to the onset of HSV-1 encephalitis. Our case highlights the importance of considering HSV-1 encephalitis in the differential when managing a patient with COVID-19-associated neurologic complications, even if it is in the early stages of COVID-19.

A case of meningoencephalitis caused by multisystem inflammatory syndrome in adult SARS-CoV-2 infection

A 37-year-old woman was hospitalized with fever and consciousness disturbance. She showed systemic inflammation with stress cardiomyopathy. Brain computed tomography showed diffuse brain edema. Cerebrospinal fluid (CSF) findings revealed markedly elevated cerebrospinal fluid pressure with pleocytosis, elevated protein, and elevated interleukin 6. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nicking enzyme amplification reaction test using a nasopharyngeal swab was positive, and the patient was diagnosed with SARS-CoV-2 infection. From the negative result of the CSF SARS-CoV-2 polymerase chain reaction test and no findings of bacterial or viral infection, we diagnosed meningoencephalitis by multisystem inflammation syndrome in adults (MIS-A). Intravenous methylprednisolone pulse therapy improved her symptoms and brain edema. There have been no cases of MIS-A with meningoencephalitis, and no initial treatment strategy has been established, especially in emergency cases of suspected MIS-A. The present case suggested Early intravenous methylprednisolone pulse with anti-coronaviral therapies after the exclusion of bacterial infection would be useful in suspected MIS-A with emergent meningoencephalitis cases.

Clinical features and virologic lineages of COVID-19-associated encephalitis in Taiwanese children during early epidemic wave of omicron in 2022: Report from a medical center

BACKGROUND

A surge of encephalitis was reported in children during the early wave of the omicron epidemic in Taiwan. Information on the COVID-19-associated encephalitis, including epidemiologic features and factors of unfavorable outcomes, remained unclear.

METHODS

A total of 128 hospitalized Taiwanese children with laboratory-confirmed COVID-19 were enrolled between April 01, 2022, and May 31, 2022. The information on demographics and clinical features was abstracted from the medical records. Virologic lineages were determined by sequences of the spike protein. Factors associated with encephalitis and unfavorable outcomes were identified by comparisons to children without encephalitis and with favorable outcomes, respectively.

RESULTS

The leading syndromes associated with COVID-19 in hospitalized children were febrile seizure (20, 15.7%), fever as the solitary symptom (18, 14.1%), and croup syndrome (14, 10.9%). Encephalitis was diagnosed in nine (7.03%) children. When compared to the three leading syndromes, children with encephalitis were at older ages, had greater rates of hypotension, PICU admissions, use of inotropic agents (P < .001 for all above comparisons), mortality (P = .008), and longer hospital stays (P = .016), but not the underlying comorbidities (P = .376). Unfavorable outcomes were identified in 3 (33.3%) of 9 encephalitis cases and associated with a lower Glasgow coma scale, hypotension, and higher C-reactive protein (P < .05 for all). BA.2.3.7 was the dominant sublineage in children with or without encephalitis.

CONCLUSIONS

Omicron BA.2.3.7 can cause fulminant and lethal encephalitis in healthy children. Depressed consciousness and hypotension at presentation were significant risks of unfavorable outcomes for pediatric COVID-19-associated encephalitis.

SARS-CoV-2 Encephalitis versus Influenza Encephalitis: More Similarities than Differences

BACKGROUND

From time to time, physicians face challenging diagnostic and therapeutic issues concerning the acute management of children with viral encephalitis.

OBJECTIVES

The aim of this article is to provide an updated narrative review on the similarities and differences between SARS-CoV-2 and influenza encephalitis.

METHODS

A PubMed search was performed with the function "Clinical Queries" using the key terms "SARS-CoV-2" OR "Influenza" AND "Encephalitis". The search strategy included metaanalyses, clinical trials, randomized controlled trials, reviews and observational studies. The search was restricted to the English literature and pediatric population. This article compares similarities and contrasts between SARS-CoV-2 and influenza-associated encephalitis.

RESULTS

Encephalitis is an uncommon manifestation of both influenza and SARS-CoV-2. Both viruses are associated with fever and respiratory symptoms. However, SARS-CoV-2 patients may only have mild symptoms or be asymptomatic as silent carriers, rendering the disease spread difficult to control. Influenza patients usually have more severe symptomatology and are often bed bound for several days limiting its spread. Influenza is associated with seasonal and annual outbreaks, whereas SARS-CoV-2 has become endemic. Complications of encephalitis are rare in both viral infections but, when present, may carry serious morbidity and mortality. Many long-term sequelae of COVID- 19 infections (long COVID-19) have been described but not with influenza infections. Mortality associated with encephalitis appears higher with influenza than with SARS-CoV-2. Prophylaxis by immunization is available for both influenza and SARS-CoV-2. Specific efficacious antivirals are also available with oseltamivir for influenza and nirmatrelvir/ritonavir for SARS-CoV-2. Steroids are indicated with more severe SARS-CoV-2 but their role is not distinct in influenza disease.

CONCLUSION

Encephalitis is a rare complication of influenza and SARS-CoV-2 infections. Both carry significant morbidity and mortality. Efficacious vaccines for prophylaxis and antivirals for treatment are available for both viruses.

The specifics of encephalitis after COVID-19

Encephalitis is a group of acute infectious diseases affecting the substance of the brain. They often lead to disability or death, and, therefore, require urgent medical attention. The article discusses the etiology, pathogenesis, and clinical picture of encephalitis, with special attention to the course of this disease after the COVID-19 pandemic. We note the growing number of encephalitis cases, especially of autoimmune variety and those caused by herpes. The possible reason behind this trend is the disruption of operation of the immune system brought by COVID-19, which manifests as a cytokine storm, neuroinflammation, and autoimmune reactions. There are cases of COVID-19-dependent encephalitis described. The pathways taken by SARS-CoV-2 to penetrate into the cells of the central nervous system have not yet been fully studied, although there are hypotheses that this happens both trans-synaptically through mechanoreceptors and chemoreceptors of the respiratory system into the medulla oblongata, and through receptors of the angiotensin converting enzyme 2.

Safety of spinal anesthesia and analysis of cerebrospinal fluid in SARS-CoV-2 pregnant women undergoing cesarean section: an observational prospective study

BACKGROUND

Systemic infection has always been considered a relative contraindication to neuraxial anesthesia, despite the fact that infectious complications are relatively uncommon. Pregnancy-related physiological changes and coronavirus disease (COVID-19) neurotropic features may facilitate the virus' entry into the central nervous system. The principal aim of this study was to test the safety of spinal anesthesia in "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2)-positive pregnant women and to examine cerebrospinal fluid (CSF) characteristics.

METHODS

We conducted a prospective observational single-center study in asymptomatic or paucisymptomatic consecutive pregnant SARS-CoV-2 patients who underwent spinal anesthesia for cesarean section. Women with severe infection were excluded because they underwent general anesthesia. At the time of spinal anesthesia, we collected CSF samples, and then we performed a chemical-physical analysis to look for signs of inflammation and for SARS-CoV-2 genome.

RESULTS

We included 26 women. No spinal anesthesia complications were reported in the perioperative period and after 2 months. All CSF samples were crystal clear, and all physical-chemical values were within physiological ranges: the median concentration of CSF/plasma glucose ratio was 0.66, IQR 0.5500 (0.6000-0.7100), and the average CSF protein concentration value was 23.2 mg/dl (SD 4.87). In all samples, genomes of SARS-CoV-2 and other neurotropic viruses were not detected.

CONCLUSIONS

Spinal anesthesia was safe in SARS-CoV-2 pregnant women with mild disease; no clinical maternal complications were detected, and no CSF changes indicative of inflammatory or infectious diseases that would compromise the safety of the procedure were found.

Exploring the molecular and clinical spectrum of COVID-19-related acute necrotizing encephalopathy in three pediatric cases

Acute necrotizing encephalopathy (ANE) is a rare disease that predominantly affects children and is associated with a high mortality rate. Here we report three cases of COVID-19-related ANE in children, with the mutation detection in two genes associated with mitochondrial dysfunction. The cases exhibited common ANE symptoms, such as fever, impaired consciousness, positive pathological reflex, increased cerebrospinal fluid protein, and multifocal and symmetric brain lesions identified through MRI. Using genotype-phenotype correlation analysis in trio-whole exome sequencing (WES), four potential pathogenic variants were identified in two genes associated with mitochondrial function (RANBP2 and MCCC2). Notably, MCCC2 was identified as being potentially associated with COVID-19-related ANE for the first time, and two of the four variants had not been previously reported. Our findings expand the clinical and mutation spectrum of COVID-19-related ANE in pediatric cases. The finding of these three new cases in our study further supports the previous hypothesis about the role of mitochondrial homeostatic imbalance in COVID-19-related ANE. It is essential to use genetic testing to identify this subset of patients with compromised mitochondrial function in order to improve patient management and prognosis.

Central nervous system complications in SARS-CoV-2-infected patients

OBJECTIVE

To investigate the clinical manifestations, treatment and prognosis of COVID-19-associated central nervous system (CNS) complications.

METHODS

In this single-centre observation study, we recruited patients with COVID-19-associated CNS complications at the neurology inpatient department of the Eighth Affiliated Hospital, Sun Yat-Sen University (Futian, Shenzhen) from Dec 2022 to Feb 2023. Patients were analysed for demographics, clinical manifestations, cerebrospinal fluid properties, electroencephalographic features, neuroimaging characteristics, and treatment outcome. All patients were followed-up at 1 and 2 months after discharge until Apr 2023.

RESULTS

Of the 12 patients with COVID-19-associated CNS complications, the CNS symptoms occur between 0 days and 4 weeks after SARS-CoV-2 infection. The most common CNS symptoms were memory deficits (4/12, 33%), Unresponsiveness (4/12, 33%), mental and behavioural disorders (4/12, 33%). Seven of 12 cases can be categorized as probable SARS-CoV-2 encephalitis, and 5 cases can be described as brainstem encephalitis, acute disseminated encephalomyelitis, optic neuritis, multiple sclerosis or tremor probably associated with SARS-CoV-2 infection. Six patients received antiviral therapy, and 11 patients received glucocorticoid therapy, of which 3 patients received human immunoglobulin synchronously. Nine patients recovered well, two patients had residual neurological dysfunction, and one patient passed away from complications associated with tumor.

CONCLUSION

In this observational study, we found that the inflammatory or immune-related complications were relatively common manifestations of COVID-19-associated CNS complications, including different phenotypes of encephalitis and CNS inflammatory demyelinating diseases. Most patients recovered well, but a few patients had significant neurological dysfunctions remaining.

Prevalence, pathogenesis and spectrum of neurological symptoms in COVID-19 and post-COVID-19 syndrome: a narrative review

Neurological symptoms are not uncommon during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and reflect a broad spectrum of neurological disorders of which clinicians should be aware. The underlying pathogenesis of neurological disease in coronavirus disease 2019 (COVID-19) may be due to four mechanisms of nervous system dysfunction and injury: i) direct viral neurological invasion; ii) immune dysregulation; iii) endothelial dysfunction and coagulopathy; and iv) severe systemic COVID-19 disease. Neurological manifestations of acute COVID-19 include headache, peripheral neuropathies, seizures, encephalitis, Guillain-Barré syndrome, and cerebrovascular disease. Commonly reported long term neurological sequelae of COVID-19 are cognitive dysfunction and dysautonomia, which despite being associated with severe acute disease are also seen in people with mild disease. Assessment of cognitive dysfunction after COVID-19 is confounded by a high prevalence of comorbid fatigue, anxiety, and mood disorders. However, other markers of neuroaxonal breakdown suggest no significant neuronal injury apart from during severe acute COVID-19. The long term impact of COVID-19 on neurological diseases remains uncertain and requires ongoing vigilance.

A case of mild encephalitis associated with COVID-19

We report a case of mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) in a 31-year-old man. He had been diagnosed with mild COVID-19 3 days earlier and presented to the emergency department with altered mental status. Brain magnetic resonance imaging (MRI) showed a high-intensity area confined to the splenium of the corpus callosum on diffusion-weighted imaging, which is consistent with MERS. MERS is characterized by a reversible change in the splenium of the corpus callosum. MERS secondary to COVID-19 has been reported recently. It is important to consider MERS in COVID-19 patients with impaired consciousness.

Neurologic Complications of COVID-19

OBJECTIVE

This article describes the spectrum of neurologic complications occurring in acute or postacute infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as the neurologic risks and benefits of vaccination against SARS-CoV-2.

LATEST DEVELOPMENTS

Early in the COVID-19 pandemic, reports of neurologic complications of COVID-19 began to surface. A variety of neurologic conditions have since been reported in association with COVID-19. Understanding of the underlying mechanism of COVID-19 neurologic involvement continues to evolve; however, the evidence seems to suggest that aberrant inflammatory responses may play a role. In addition to neurologic symptoms in acute COVID-19, neurologic post-COVID-19 conditions are increasingly recognized. The development of COVID-19 vaccines has been essential in preventing the spread of COVID-19. With increasing numbers of vaccine doses administered, various neurologic adverse events have been reported.

ESSENTIAL POINTS

Neurologists must be aware of the potential acute, postacute, and vaccine-associated neurologic complications associated with COVID-19 and be poised to serve as integral members of multidisciplinary care teams for patients with COVID-19-related conditions.

A case report of encephalitis induced by SARS-CoV-2 confirmed by etiology: first case in Qingdao, China

The neurological manifestations of SARS-CoV-2-infected patients are receiving increasing attention with the global spread of SARS-CoV-2. Here, we report the first case of SARS-CoV-2-induced encephalitis in Qingdao, China. We detected SARS-CoV-2 in nasopharyngeal swabs and cerebrospinal fluid from this 68-year-old female patient.

Prognostic Role of Clinical Features of Moderate Forms of COVID-19 Requiring Hospitalization

INTRODUCTION

We aimed to characterize the clinical features of moderate forms of COVID-19 requiring hospitalization and potentially identify predictors for unfavorable outcomes.

METHODS

Pooled anonymized clinical data from 452 COVID-19 patients hospitalized in two regional Romanian respiratory disease centers during the Alpha and Delta variant outbreaks were included in the analysis.

RESULTS

Cough and shortness of breath were the most common clinical features; older patients exhibited more fatigue and dyspnea and fewer upper airway-related symptoms such as smell loss or sore throat. The presence of confusion, shortness of breath and age over 60 years were significantly associated with worse outcomes (odds ratios 5.73, 2.08 and 3.29, respectively).

CONCLUSION

The clinical picture on admission may have a prognostic role for moderate forms of COVID-19. Clear clinical definitions and developing adequate informational infrastructure allowing complex data sharing and analysis might be useful for fast research response should a similar outbreak occur in the future.

Does SARS-CoV-2 Cause Seizures and Epilepsy in COVID-19 via Inflammation or by Direct Infection?

Incidence of Epilepsy and Seizures Over the First 6 Months After a COVID-19 Diagnosis: A Retrospective Cohort Study

Taquet M, Devinsky O, Cross JH, Harrison PJ, Sen A. Neurology. 2023;100:e790-e799. doi:10.1212/WNL.0000000000201595.

Background:

The relationship between COVID-19 and epilepsy is uncertain. We studied the potential association between COVID-19 and seizures or epilepsy in the 6 months after infection.

Methods:

We applied validated methods to an electronic health records network (TriNetX Analytics) of 81 million people. We closely matched people with COVID-19 infections to those with influenza. In each cohort, we measured the incidence and hazard ratios (HRs) of seizures and of epilepsy. We stratified data by age and by whether the person was hospitalized during the acute infection. We then explored time-varying HRs to assess temporal patterns of seizure or epilepsy diagnoses.

Results:

We analyzed 860,934 electronic health records. After matching, this yielded 2 cohorts each of 152,754 patients. COVID-19 was associated with an increased risk of seizures and epilepsy compared with influenza. The incidence of seizures within 6 months of COVID-19 was 0.81% (95% CI, 0.75-0.88; HR compared to influenza 1.55 (1.39-1.74)). The incidence of epilepsy was 0.30% (0.26-0.34; HR compared to influenza 1.87 (1.54-2.28)). The HR of epilepsy after COVID-19 compared with influenza was greater in people who had not been hospitalized and in individuals younger than 16 years. The time of peak HR after infection differed by age and hospitalization status.

Discussion:

The incidence of new seizures or epilepsy diagnoses in the 6 months after COVID-19 was low overall, but higher than in matched patients with influenza. This difference was more marked in people who were not hospitalized, highlighting the risk of epilepsy and seizures even in those with less severe infection. Children appear at particular risk of seizures and epilepsy after COVID-19 providing another motivation to prevent COVID-19 infection in pediatric populations. That the varying time of peak risk related to hospitalization and age may provide clues as to the underlying mechanisms of COVID-associated seizures and epilepsy.

Neuroimaging of COVID-19

We review the wide variety of common neuroimaging manifestations related to coronavirus disease 2019 (COVID-19) and COVID therapies, grouping the entities by likely pathophysiology, recognizing that the etiology of many entities remains uncertain. Direct viral invasion likely contributes to olfactory bulb abnormalities. COVID meningoencephalitis may represent direct viral infection and/or autoimmune inflammation. Para-infectious inflammation and inflammatory demyelination at the time of infection are likely primary contributors to acute necrotizing encephalopathy, cytotoxic lesion of the corpus callosum, and diffuse white matter abnormality. Later postinfectious inflammation and demyelination may manifest as acute demyelinating encephalomyelitis, Guillain-Barré syndrome, or transverse myelitis. The hallmark vascular inflammation and coagulopathy of COVID-19 may produce acute ischemic infarction, microinfarction contributing to white matter abnormality, space-occupying hemorrhage or microhemorrhage, venous thrombosis, and posterior reversible encephalopathy syndrome. Adverse effects of therapies including zinc, chloroquine/hydroxychloroquine, antivirals, and vaccines, and current evidence regarding "long COVID" is briefly reviewed. Finally, we present a case of bacterial and fungal superinfection related to immune dysregulation from COVID.

Encephalopathy in a Young Female With COVID-19: A Case Report

Cases of severe central nervous system (CNS) complications have been reported in relation to coronavirus-19 (COVID-19). Cases of encephalitis have been reported primarily in older patients with multiple comorbidities. We present a case of encephalitis in a young female patient with a history of chronic marijuana use that presented with nausea, vomiting, and acute altered mental status. Extensive testing for infectious and autoimmune causes of encephalitis were negative, except for a positive COVID-19 test. She was treated with steroids and intravenous immune globulin (IVIG) and improved with residual mutism.

Indirect Confirmation of a COVID-19 Encephalitis Case

A 58-year-old man was admitted to the hospital with acute neurological manifestations of encephalitis 15 days after a previous upper respiratory COVID-19 illness. On presentation, he was confused with altered mental status, aggressive behavior, and a Glasgow coma scale score of 10/15. Laboratory investigation, brain computed tomography (CT), and brain magnetic resonance imaging (MRI) were unremarkable with normal results. Although the cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for SARS-CoV-2 was negative, we found increased concentrations of positive immunoglobulin (Ig) A and IgG antibodies in CSF, suggesting acute central nervous system (CNS) infection and indirect confirmation of virus neuroinvasion. There was no evidence of humoral auto-reactivity, and we rejected the hypothesis of autoimmune encephalitis with known autoantibodies. On the fifth day of hospitalization, myoclonic jerks emerged as a new neurological sign until the added levetiracetam led to total remission. The patient achieved full recovery after antiviral and corticosteroid therapy implementation of 10 days in the hospital. This case report emphasizes the importance of the presence of CSF IgA and IgG antibodies to diagnose encephalitis in COVID-19 patients as an indirect confirmation of CNS infection.

Neuroinflammatory syndromes in children

PURPOSE OF REVIEW

Neuropsychiatric symptoms due to paediatric neuroinflammatory diseases are increasingly recognized and reported. Psychiatrists are crucial in front-lines identification, diagnosis and care of individuals with disorders such as autoimmune encephalitis and management of long-term neurobehavioral sequelae. This review summarizes recent literature on autoimmune and post-infectious encephalitis, discusses special considerations in children with neurodevelopmental conditions and presents a paradigm for evaluation and management.

RECENT FINDINGS

There is a growing body of evidence on neuropsychiatric symptom burdens of paediatric neuroinflammatory diseases. A particular development is the evolution of diagnostic and treatment guidelines for conditions such as autoimmune encephalitis, which take into account phenotypes of acute, short-term and long-term sequelae. Interest in inflammatory sequelae of viral illness, such as SARS-CoV-2, in children remains in early development.

SUMMARY

Neuroimmunological disease data are constantly evolving. New recommendations exist for multiple common neuroimmunological disorders with behavioural, emotional, cognitive and neurological sequelae. Anti-NMDA receptor encephalitis now has well-recognized patterns of symptom semiology, diagnostic and treatment recommendations, and outcome patterns. Recognizing psychiatric symptoms heralding autoimmune brain disease and understanding neuropsychiatric sequelae are now a crucial skill set for paediatric psychiatrists. Exploration of inflammatory features of other diseases, such as genetic syndromes, is a burgeoning research area.

Parainfectious autoimmune encephalitis related to SARS-CoV-2 infection, presented with catatonia

OBJECTIVE

SARS-CoV-2 infection commonly affects both the central and peripheral nervous systems. In this way, different neurological and psychiatric clinical pictures emerge. Whereas the effects of SARS-CoV-2 on neuronal structures in the short and long term are still controversial. Neurological involvement secondary to SARS-CoV-2 is heterogeneous in terms of both clinical presentation and treatment responses and prognosis.

METHOD

A case of autoimmune encephalitis developing after SARS-CoV-2 was presented.

RESULTS

This case was admitted to the clinic with classical catatonia signs and encephalopathy together. The emergence of neuropsychiatric problems after the relief of SARS-CoV-2 symptoms, suggests that this picture was primarily related to immune processes. The presented case showed a good clinical response to symptomatic catatonia treatment and immune-modulatory agents and recovered both physically and cognitively without any sequelae.

CONCLUSION

In terms of clinical presentation and treatment response, SARS-CoV-2 infection may create a distinct encephalitic involvement after the infection itself by triggering some defined or not-yet-defined autoimmune pathways.

Herpes simplex virus encephalitis mimicking acute ischemic stroke

BACKGROUND

Infections of the central nervous system might present in an acute form such as to be similar with the clinical characteristics of a stroke. This situation will hamper a correct diagnosis and a prompt treatment that can otherwise be successful.

CASE DESCRIPTION

We present the case of a herpes virus encephalitis that came up in the emergency department with an admission diagnosis of ischemic cerebral accident. Being the symptomatology unclear, the findings of magnetic resonance of the brain oriented versus an infectious disorder. The lumbar tap confirmed the presence of herpes simplex virus (HSV) 1 virus and an antiviral therapy was administered, leading to resolution of the condition within the 3 weeks of hospitalization.

CONCLUSION

HSV infections may mimic stroke and therefore should be included in the differential diagnosis of atypical acute nervous conditions. In neurological events of acute nature, especially in febrile patients whose brain imaging is suspicious or inconclusive, the eventuality of a herpetic encephalitis should be kept in mind. This will lead to a prompt antiviral therapy and to a favorable outcome.

Neurological consequences of SARS-CoV-2 infections in the pediatric population

COVID-19 in the pediatric population is mostly asymptomatic. However, 1 out of 5 children presents non-specific neurologic symptoms such as headache, weakness, or myalgia. Furthermore, rarer forms of neurological diseases are increasingly being described in association to a SARS-CoV-2 infection. Encephalitis, stroke, cranial nerves impairment, Guillain-Barré syndrome or acute transverse myelitis have been reported and account for around 1% of pediatric COVID-19 cases. Some of these pathologies may occur during or after the SARS-CoV-2 infection. The pathophysiological mechanisms range from direct invasion of the central nervous system (CNS) by SARS-CoV-2 itself to postinfectious immune-mediated CNS inflammation. In most cases, patients presenting neurological pathologies related to SARS-CoV-2 infection are at greater risk of life-threatening complications and should be closely monitored. Further studies are needed to acknowledge the potential long-term neurodevelopmental consequences of the infection.

Predisposing factors for admission to intensive care units of patients with COVID-19 infection-Results of the German nationwide inpatient sample

Background

Intensive care units (ICU) capacities are one of the most critical determinants in health-care management of the COVID-19 pandemic. Therefore, we aimed to analyze the ICU-admission and case-fatality rate as well as characteristics and outcomes of patient admitted to ICU in order to identify predictors and associated conditions for worsening and case-fatality in this critical ill patient-group.

Methods

We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany between January and December 2020. All hospitalized patients with confirmed COVID-19 infection during the year 2020 were included in the present study and were stratified according ICU-admission.

Results

Overall, 176,137 hospitalizations of patients with COVID-19-infection (52.3% males; 53.6% aged ≥70 years) were reported in Germany during 2020. Among them, 27,053 (15.4%) were treated in ICU. COVID-19-patients treated on ICU were younger [70.0 (interquartile range (IQR) 59.0-79.0) vs. 72.0 (IQR 55.0-82.0) years, P < 0.001], more often males (66.3 vs. 48.8%, P < 0.001), had more frequently cardiovascular diseases (CVD) and cardiovascular risk-factors with increased in-hospital case-fatality (38.4 vs. 14.2%, P < 0.001). ICU-admission was independently associated with in-hospital death [OR 5.49 (95% CI 5.30-5.68), P < 0.001]. Male sex [OR 1.96 (95% CI 1.90-2.01), P < 0.001], obesity [OR 2.20 (95% CI 2.10-2.31), P < 0.001], diabetes mellitus [OR 1.48 (95% CI 1.44-1.53), P < 0.001], atrial fibrillation/flutter [OR 1.57 (95% CI 1.51-1.62), P < 0.001], and heart failure [OR 1.72 (95% CI 1.66-1.78), P < 0.001] were independently associated with ICU-admission.

Conclusion

During 2020, 15.4% of the hospitalized COVID-19-patients were treated on ICUs with high case-fatality. Male sex, CVD and cardiovascular risk-factors were independent risk-factors for ICU admission.