Is Epilepsia Partialis Continua possibly induced by chronic COVID-19 related encephalitis?

• DOI: 10.22533/at.ed.58522240314

• Palavras-chave: Epilepsia Partialis Continua COVID-19 Encephalitis

• Keywords: Epilepsia Partialis Continua COVID-19 Encephalitis

• Abstract:

  Case Presentation: A 72-year-old female, without previous history of epilepsy or other neurological diseases, had laboratory (RT-PCR positive) confirmed diagnosis of COVID-19 and underwent outpatient follow-up in December/2020, with progressive worsening of symptoms along the following weeks, presenting malaise, fever, nausea and vomiting, culminating with mental confusion and continuous right-sided hemiclonic focal motor seizures. She was admitted to the ICU, submitted to status epilepticus standard protocol (diazepam, phenytoin in bolus, followed by midazolam and propofol in continuous infusion), and a diagnosis of encephalitis was made. Bacterial meningitis was ruled out, with cerebrospinal fluid (CSF) showing mild protein elevation only (CSF dated January 5th, 2021: less than 1 cell, protein 83.7 mg/dl, PCR and cultures for usual infectious agents negative). Cranial MRI did not evidence any abnormalities. She also completed an empirical 14-day-protocol of acyclovir. Additional CSF sample was sent to the “Brazilian Autoimmune Network - BrAIN,” which resulted negative to all tested autoimmune encephalitis antibodies. Despite the continuous infusion of midazolam and propofol in full doses for the treatment of status epilepticus for weeks, characterizing super-refractory status epilepticus, her hemiclonic seizures subsided (by 50-60%) only after methylprednisolone pulse therapy (1 g/day, 5 days), and completely remitted after additional intravenous immunoglobulin (0.4 mg/kg daily for 5 days). The patient was discharged from the hospital on February 1st, completely recovered, asymptomatic. On March 20th, the patient was immunized with the first dose of CoronaVac. Approximately 12 days later, she had a recurrence of the continuous right-sided hemiclonic focal motor seizures (Epilepsia partialis continua - EPC), with mental confusion and expressive dysphasia. Cranial MRI from April 16th, 2021, evidenced:  hyperintensity with indefinite borders, without mass effect or perilesional edema, with inflammatory aspect, on the left parietal lobe, involving gray and white matter (postcentral and supramarginal gyri), these findings were absent in the previous MRI (Jan./2021). The patient was hospitalized again, and a repeated cycle of corticoid pulse therapy and intravenous immunoglobulin was prescribed, after which she had 70% remission and discharged home. Approximately 1.5 months later, in June, EPC recurred without any trigger. Video-EEG was performed, evidencing continuous and repeated epileptiform discharges 1/sec over her left temporal region. CSF, dated June 17th, 2021, showed less than 1 cell, protein 53 mg/dl, and a CSF RT-PCR for SARS-COV2 resulted positive. A new intravenous immunoglobulin infusion was started, and antiseizure treatment was optimized (levetiracetam 3 g/day, valproate 2 g/day, and clonazepam as needed). The frequency and intensity of hemiclonic episodes reduced, now alternating 10 brief hemiclonic seizures per day, with lucid periods. Her whole body CT scan was negative for neoplasia.  
  Conclusion: an older woman without previous history of epilepsy or other neurological diseases developed EPC after a laboratory-confirmed diagnosis of SARS-COV2, with recovery after immunotherapy, but recurred after a single-dose vaccine against SARS-COV2 with dead viruses. The significance of a CSF RT-PCR positive result for SARS-COV2 and the EPC due to a direct virus attack or an autoimmune response triggered by the virus is discussed.  

• Número de páginas: 2