Acute hemorrhagic encephalitis in a pregnant woman

Introduction

The outbreak of coronavirus disease 2019 (COVID-19) has received much attention due to its multi-systemic effects, including COVID-19-related neurologic features. Recent evidence highlights a relatively high percentage (36%) of central nervous system symptoms, including headache, altered mental status, acute cerebrovascular disease, and epilepsy, in patients with COVID-191,2. Due to immunosuppression, pregnant women are considered to be at high risk for COVID-19 infection. A case of acute hemorrhagic encephalitis(AHE) in a pregnant woman was reported in Mardin State Hospital, Diyarbakir, Turkey.

Case report

A 32-year-old pregnant woman with a 12-day history of fever and cough was admitted to the emergency department for confusion and severe headache at 24 weeks of gestation. The patient experienced hypoxic respiratory failure, which worsened into severe acute respiratory distress syndrome, necessitating intubation and mechanical ventilation while the patient was heavily sedated. She reported deterioration for 5 days with headache, confusion, and dyspnea. A polymerase chain reaction test from the nasopharyngeal swab confirmed the diagnosis of coronavirus disease (COVID-19). A computed tomography (CT) scan of the chest was also suggestive of COVID-19. Neurological examination showed dysarthria and mild hemihypoesthesia. The unenhanced axial and reformatted coronal thorax computed tomography (CT) images show peribronchovascular and subpleural ground-glass opacities and vascular dilatation in the bilateral lung, which was also highly suggestive of COVID-19. Magnetic resonance imaging (MRI) of the brain showed bilateral periventricular, thalamic, parahippocampal, and mesencephalic lesions with hyperintensity in axial fluid-attenuated inversion recovery (FLAİR) and T2WI, internal hemorrhage that caused susceptibility changes in susceptible-weighted imaging (SWI) images. The baby was delivered by cesarean section.

Discussion

Preterm births are more prevalent in pregnant mothers with COVID-19. An uncommon and frequently fatal neurological side effect of COVID-19 is AHE3,4. Findings of MRI are suggestive of underlying AHE2. In differential diagnoses of patients presenting with neurological symptoms who have COVID-19, AHE should be considered. High clinical suspicion and early imaging diagnosis of this condition can enable clinicians to pursue more aggressive treatment options to reduce fatal outcomes4,5.

References

1. Mao, Ling et al. “Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China.” JAMA neurology vol. 77,6 (2020): 683-690.
2. Kandemirli, Sedat G et al. “Brain MRI Findings in Patients in the Intensive Care Unit with COVID-19 Infection.” Radiology vol. 297,1 (2020): E232-E235.
3. Gheysarzadeh, A et al. “Case series of four pregnant women with COVID-19 in Ilam, Iran.” New microbes and new infections vol. 38 (2020): 100783. 
4. Haqiqi, Ala et al. “Acute haemorrhagic leukoencephalitis (Hurst disease) in severe COVID- 19 infection.” Brain, behavior, & immunity - health vol. 12 (2021): 100208.
5. Yong, Ming Hui et al. “A Rare Case of Acute Hemorrhagic Leukoencephalitis in a COVID-19 Patient.” Journal of the neurological sciences vol. 416 (2020): 117035.