First Presumptive Case of Acute Necrotizing Hemorrhagic Encephalopathy Associated with COVID-19

Doctors at Henry Ford Health, Detroit, Michigan, have reported the first ever presumptive case of acute necrotizing hemorrhagic encephalopathy associated with COVID-19. The case has been published in Radiology.

Case Details

According to history, a 58-year-old woman presented with a 3-day history of fever, cough, and muscle aches ― symptoms consistent with COVID-19. She showed signs of confusion, lethargy, and disorientation when she reached the hospital.

The woman tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with a rapid COVID-19 test. She was later diagnosed with acute hemorrhagic necrotizing encephalopathy. Her CT and MRI scans helped reach the diagnosis.

Imaging Findings

• Noncontrast head CT revealed "symmetric hypoattenuation within the bilateral medial thalami with a normal CT angiogram and CT venogram," the team reports in their article.
• Brain MRI showed "hemorrhagic rim enhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions."

Elissa Fory, MD, a neurologist with Henry Ford who was part of the team of medical experts that made the diagnosis, said the patient was started on intravenous immunoglobulin but not high-dose steroids, because of concern for respiratory compromise. As of April 1, the patient was hospitalized in serious condition.

Background on Acute Necrotizing Encephalopathy (ANE)

Acute necrotizing encephalopathy (ANE) is a rare complication of influenza and other viral infections and has been related to intracranial cytokine storms, which result in blood-brain-barrier breakdown, but without direct viral invasion or parainfectious demyelination. A recent report in The Lancet suggested that a subgroup of patients with severe COVID-19 might develop a cytokine storm syndrome.

Clinical Implications

"As the number of patients with COVID-19 increases worldwide, clinicians and radiologists should be watching for this presentation among patients presenting with COVID-19 and altered mental status," the clinicians advise.

Brent Griffith, MD, a radiologist with Henry Ford and senior author of the case report, said the case shows "the important role that imaging can play in COVID-19 cases."

"This is significant for all providers to be aware of and looking out for in [COVID-19] patients who present with an altered level of consciousness. This complication is as devastating as severe lung disease," Elissa Fory, MD, a neurologist with Henry Ford who was part of the team of medical experts that made the diagnosis, said in a statement.

Further Reference

For further reference, log on to: https://doi.org/10.1148/radiol.2020201187