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.