SCIENTIFIC
COVID-19 Encephalitis Associated Myoclonus : a Case Report and Literature Review
AUTHORS : Richa Tripathi 1
Badria Munir 2 , 3 Matthew Smith 2 , 3
1
Emory University Department of Neurology
2
West Virginia University Department of Neurology
3
West Virginia University Rockefeller Neuroscience Institute
CASE PRESENTATION
A 64-year-old man presented to the emergency department with altered mental status , sudden onset of jerking in bilateral upper and lower extremities as well as truncal jerking . Approximately 20 days prior to presentation , the patient developed nasal congestion , shortness of breath , sore throat , and cough . At the time , his primary care physician treated his symptoms with amoxicillin-clavulanic acid for a presumed diagnosis of a bacterial upper respiratory tract infection . He was tested for coronavirus disease 2019 ( COVID-19 ) via a polymerase chain reaction ( PCR ) about 10 days prior to presentation and it was positive . As an outpatient , he was treated with casirivimab ( 600mg ) and imdevimab ( 600mg ) infusions . One week after the treatments , the patient developed nausea and vomiting , along with jerky movements involving his hands and legs , and experienced visual hallucinations . These symptoms progressively worsened over the next few days until the patient presented to our facility . On presentation , he did not appear toxic with normal vitals and no fever . His neurological examination was notable for disorientation to time , place , and person . His cranial nerves were intact to brainstem reflexes without obvious deficit . The patient localized to painful stimuli but was unable to follow up commands . His Glasgow coma scale was E4V4M6 . He was noted to have sudden brief involuntary jerky movements involving the trunk and both upper and lower extremities . Right-sided jerking was
ABSTRACT
notably worse than the left . Any purposeful movement made by the patient exacerbated myoclonic jerks . Muscle tone was noted to be normal . Reflexes were 2 + throughout with down-going toes on plantar stimulation . The patient ’ s medical history was significant for coronary artery disease , hypertension , hyperlipidemia , atrophic left kidney , diabetes mellitus , obstructive sleep apnea , and lumbar disc laminectomy .
Initial serum laboratory studies , including complete blood count , basic metabolic panel , magnesium , phosphorus , thyroid stimulating hormone , and ammonia levels , were within normal limits . Extensive cerebrospinal fluid ( CSF ) testing was performed ( Table 1 ) and results were negative . Chest radiograph revealed bilateral multifocal patchy opacities and small pleural effusions .
The patient was placed on continuous video electroencephalogram ( EEG ) to assess for epileptic correlate . Myoclonic movements did not have any electrographic correlate . However , EEG recording captured one event of generalized tonic-clonic ( GTC ) convulsions , lasting for about two minutes . This episode clinically manifested as a blank stare and oral automatisms , followed by eye blinking and then GTC movement of his whole body . Correlating EEG patterns were significant for polyspikes with inter ictal frontal poly-spike and spike-wave discharges . Background EEG showed delta and theta frequency indicating generalized cerebral dysfunction . Magnetic resonance imaging ( MRI ) of the
Coronavirus disease 2019 ( COVID-19 ) has been associated with significant morbidity and mortality . Early recognition of the disease process can aid in improved clinical outcomes . Atypical presentations of the infection , especially in a hospital setting , should be considered since this can considerably change clinical management and treatment . Here we present a case of a 64-year-old man who presented to our institute for sudden onset of multifocal myoclonic jerking and altered mentation . The patient responded to high dose steroid and plasmapheresis clinically with improved motor and cognition symptoms . Early recognition of abnormal movements associated with COVID-19 infection is critical as such movements can significantly affect the patient ’ s quality of life .
brain with and without contrast was then obtained with normal findings . Computerized tomography ( CT ) scan of his chest , abdomen , and pelvis was also obtained to assess for underlying malignancy , which was also unremarkable .
Due to the above findings , the patient was diagnosed with COVID associated encephalitis . The patient was treated with intravenous methylprednisolone ( 1g / day for five days ). By day three of treatment , the patient had improved in mentation , becoming oriented to self , time , and place . His myoclonic jerks also decreased with improved ability to do simple tasks and the ability to feed himself with minimal assistance . However , by day five , myoclonic movements and mentation worsened . Due to this worsening , he was treated with clonazepam ( 1 mg three times per day ) since his movements were disruptive to him . Repeat MRI of the brain did not show any new changes . He was then treated with five sessions of plasmapheresis for 10 days , which required sedation and transfer to intensive care unit ( ICU ). His ICU course was complicated by methicillin-resistant Staphylococcus aureus infection , Neisseria meningitidis pneumonia , and uncomplicated urinary tract infections .
After approximately four days of completion of plasmapheresis , the severity of his myoclonic jerks reduced significantly , so that he was able to use his right hand to feed himself . The patient was eventually discharged to a rehabilitation center while being treated with clonazepam ( 1.25 mg
24 • www . wvsma . org