By: RSNA (pubs.rsna.org)

Since its introduction to the human population in December 2019, the coronavirus disease 2019 (COVID-19) pandemic has spread across the world with over 330,000 reported cases in 190 countries (1). While patients typically present with fever, shortness of breath, and cough, neurologic manifestations have been reported, although to a much lesser extent (2). We report the first presumptive case of COVID-19–associated acute necrotizing hemorrhagic encephalopathy, a rare encephalopathy that has been associated with other viral infections but has yet to be demonstrated as a result of COVID-19 infection.

A female airline worker in her late fifties presented with a 3-day history of cough, fever, and altered mental status. Initial laboratory work-up was negative for influenza, with the diagnosis of COVID-19 made by detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral nucleic acid in a nasopharyngeal swab specimen using the U.S. Centers for Disease Control and Prevention (CDC) 2019-Novel Coronavirus (2019-nCoV) Real-Time Reverse Transcriptase-Polymerase Chain Reaction assay. The assay was performed on a Roche thermocycler at our institution following “emergency use authorization” from the CDC. Cerebrospinal fluid (CSF) analysis was limited due to a traumatic lumbar puncture. However, CSF bacterial culture showed no growth after 3 days, and tests for herpes simplex virus 1 and 2, varicella zoster virus, and West Nile virus were negative. Testing for the presence of SARS-CoV-2 in the CSF was unable to be performed. Noncontrast head CT images demonstrated symmetric hypoattenuation within the bilateral medial thalami with a normal CT angiogram and CT venogram (Fig 1). Images from brain MRI demonstrated hemorrhagic rim enhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions (Fig 2). The patient was started on intravenous immunoglobulin. High-dose steroids were not initiated due to concern for respiratory compromise.

Read more: https://pubs.rsna.org/doi/full/10.1148/radiol.2020201187