Case No 4
Patient no 4 is a 52 years old male who presented with complaints of
fever and drowsiness for the last 8 days. He also had 3 episodes of
seizures in the last 2 days. He had a history of well controlled
hypertension. He was having shortness of breath and body aches from the
last 8 days. On examination he had a fever of 104.3 F, blood pressure of
130/85 mm Hg, pulse rate of 112 bpm and respiratory rate of 18/min. he
had a GCS 0f 11/15 and was not oriented in time place or person. He did
not show any evidence of neck stiffness or any focal neurological
deficit. His chest examination showed bilateral crepitations as well.
His lab and upon suspected encephalitis spinal fluid was done whose
reports are as follows in Table 4.
Autoimmune workup, including anti-N-methyl D-aspartate (NMDA) receptor
antibodies, anti-Ro antibodies, anti-La antibodies, antineutrophil
cytoplasmic antibodies (ANCA) antibodies, and anti-Hu antibodies, were
negative. All common causes of encephalitis were ruled out through these
lab investigations. His chest x ray was done which showed bilateral
opacities and nasal swab COVID-19 Polymerase Chain Reaction (PCR) came
out positive. His CSF COVID-19 Polymerase Chain Reaction (PCR) was also
ordered but it came back negative. He was suspected of having COVID-19
encephalitis as all the common causes of encephalitis had been ruled out
in this patient making it a diagnosis of exclusion. MRI brain was also
carried out which is given in Figure 4.
Patient was then treated with a single dose of IV Tocilizumab 400 mg
(4-8 mg/kg) followed by IV methylprednisolone 1g (0.5-2 mg/kg) IV for 5
days. Patient initially did not respond very well to treatment. His
fever settled down but his conscious level did not improve and he
further had an episode of seizure in the hospital. Patient was then
given another dose of IV Tocilizumab 400 mg and a further 5 days course
of IV methylprednisolone 1 g was given. Patient responded very well to
this treatment and his conscious level improved and he became oriented
to time place and person. Patient outlook improved very much and was
then discharged to nursing care at home and after a follow up period of
one month, patient was totally oriented. There were no further episodes
of seizures and there were no residual neurological signs as well.