Neurologic Presentations of COVID-19: A Case Series

1. Introduction

Coronavirus disease 2019 (COVID-19) can present with various respiratory, gastrointestinal, and cardiac symptoms. Neurological symptoms can be the first symptoms in patients with COVID-19. It is important to note that many of these patients might have had brief symptoms of this infectious disease in recent weeks or days that the patient may have forgotten (1).

In general, it is not evident whether these patients are more likely to develop persistent neurological symptoms over time; hence, further studies are needed. A few of these neurologic presentations were proven to be COVID-19 by polymerase chain reaction (PCR) test of cerebrospinal fluid (CSF) or neuronal tissues.

In this case series of COVID-19 patients, we present typical cases of neurologic involvement as characteristic findings of COVID-19, mainly without other disease-related symptoms in adult patients with documented bronchopulmonary SARS-CoV2 infection to globally unify signs and symptoms as a multisystem disease.

The University of Medical Sciences Institutional Review Board approved this study. Informed written consent was obtained from the patients or their relatives.

2. Case Presentation

2.1. Case 1

An 85-year-old man presented to the emergency department complaining of a seizure occurring three times in the past week, the latter manifested last night. The seizure episodes were in the form of typical generalized tonic colonic seizures. He had no history of seizures in the past, and the patient's neurological examination was otherwise unremarkable. He did not complain of any respiratory or gastrointestinal symptoms. Vital signs were normal. Past medical history was negative. The bedside glucometer and the electrocardiogram (ECG) taken from the patient at the emergency room were normal. The patient underwent a brain computed tomography (CT) scan, which was unremarkable. The metabolic causes of seizure were obviated, including normal blood sugar, electrolytes, and renal function tests. He delivered an intravenous phenytoin infusion of 20 mg/kg in the emergency department. Cerebrospinal fluid (CSF) analysis and PCR were negative for conventional bacterial, coronavirus, and herpes simplex virus (HSV), respectively. Brain magnetic resonance imaging (MRI) was reported to be normal, lung CT scan incidentally showed ground glass opacities, and the patient was isolated due to suspicion of COVID-19, and SARS-CoV2 PCR of the nasopharynx specimen was positive. Finally, the patient was transferred to the COVID-19 ward for three days, after which he was discharged due to the appropriate general condition and non-recurrence of seizures.

2.2. Case 2

A 65-year-old woman complained of numbness in the right side of her body. The right-side paresthesis started 6 hours before entering the emergency room, and gradual right hemiplegia developed. The patient had no history of neurological or any other disease. The bedside glucometer and ECG were normal. A brain CT scan was requested, which showed hypodensity in the territory of the left middle cerebral artery in favor of an ischemic stroke. The patient also complained of generalized body pain within the last months with no respiratory complaints. The patient was referred late to deliver thrombolysis. On chest CT scan, peripheral grand glass opacities were seen. The COVID-19 nasopharynx PCR test was positive. Echocardiography and color Doppler ultrasonography of cervical arteries were reported normal, looking for etiology of acute ischemic stroke. Finally, the patient was admitted and isolated in the COVID-19 ward.

2.3. Case 3

A 60-year-old woman was found unconscious in her room and transferred by EMS to the emergency department with a decreased level of consciousness to the extent that she did not respond to verbal or painful stimuli. She had no fever and no signs of trauma or meningismus. Pupils were slightly miotic with sluggish reactions to light. Thus, she was intubated and mechanically ventilated. The blood glucose level was high, and ECG was unremarkable. She was initially resuscitated in the emergency room. A brain CT scan showed evidence of ischemic stroke in the pons. She did not receive thrombolytic therapy as the stroke onset was not evident. A pulmonary CT scan exhibited ground glass consolidations in favor of COVID-19 disease. The COVID-19 PCR test of the patient was positive though she had not expressed any respiratory complaints and had no history of respiratory problems in the last few days, according to her relatives. Hyperglycemia was controlled, and she did not have a remarkable acid-base abnormality. Due to respiratory compromise, the patient was transferred to the intensive care unit and, unfortunately, deceased after two days.

2.4. Case 4

A 64-year-old woman was brought to the emergency room with altered mental status. She exhibited headaches followed by unexplained agitation lasting for several hours, after which two episodes of generalized tonic colonic seizures occurred. The patient seemed to be in the post-ictal period, becoming more agitated and fearful of their surroundings in the emergency room. Past medical history was unremarkable except for hypertension, for which losartan potassium was consumed. The bedside glucometer and brain CT scan were normal. Serum electrolyte levels were within normal limits. She underwent a lumbar puncture which revealed normal cerebrospinal fluid analysis, and PCR was negative for Coronavirus and HSV. In the pulmonary CT scan, evidence of several ground glass consolidations was seen, which raised suspicion of COVID-19 disease, although the patient had not expressed any respiratory complaints in the last few days. The nasopharyngeal PCR test was positive for COVID-19. Brain MRI did not show pathologic findings. After several hours of observation, she was alert and oriented and in the baseline mental status and referred to a neurologist for further outpatient assessment.

Table 1 expresses the detailed clinical findings and laboratory and imaging investigations performed on these patients. All the patients belonged to the same ethnicity.

3. Discussion

In this study, various neurologic presentations of COVID-19 are presented. Although similar to other studies, sufficient data for histopathology involvement is lacking (1, 2).

Recently, seizures, demyelinating disease, encephalopathy, polyneuropathy, CNS vasculitis, encephalitis, ischemic or hemorrhagic stroke, and Guillain-Barre disease have been reported to be presented in COVID-19 patients along with pulmonary involvement or diagnosed by positive PCR without any other respiratory complaints (1, 3-5). Some neuropsychiatric disorders were reported, including psychosis, neurocognitive (dementia-like) syndrome, and affective disorders (6). Many patients with neurologic involvement did not acquire worse prognostic factors (7).

It is prudent to screen patients for COVID-19 presenting with new neurological symptoms who have no previous history of these attacks during the pandemic. Reports of generalized seizures, despite normal MRI, may raise probable idiopathic generalized epilepsy without structural or metabolic etiology, although an acute symptomatic seizure due to SARS-CoV-2-associated encephalitis should be excluded, as observed in cases 1 and 4.

3.1. Conclusions

It is necessary to consider various presentations by taking a suggestive medical history and clinical suspicion of COVID-19 to make a proper diagnosis. Addressing the neurologic presentations is also helpful to timely isolate involved patients in order to prevent the disease from spreading in hospital wards.

3.2. Limitations

As several presentations are emerging, there are still new horizons for the management of neurologic involvement in these patients, and these can be further assessed.