It is assumed that patients with neurological symptoms showed more severe infections. Our patient reported burning headache and paresthesia as the initial symptoms mainly without other signs of viral infection like cough or fever. Such an initial neurological presentation seems to be rare. Most cases have neurological symptoms which can be expected after severe systemic viral infections like fever associated headache , smell loss and even postinfectious GBS . Further strokes, vigilance reduction and seizures, which could be primary to the infection or due to complications like hypoxic brain damage occur [3, 4, 7].
Symptoms and CSF of our patient suggested encephalitis. MRI, however showed no abnormalities. One severely affected patient from Japan with symptoms fitting to meningoencephalitis had 12 cells per microliter in the CSF and the MRI findings indicated a ventriculitis and encephalitis . MRI findings in the report from Helms et al. were leptomeningeal enhancement in 8 patients and perfusion abnormalities in all 11 examined patients . None of these patients had CSF pleocytosis.
Many COVID-19 patients with mild disease are at home and the further course is unknown. Our case shows, that neurological symptoms can be the first manifestation of an COVID-19 disease. While restricted paraesthesia has been reported in SARS-CoV-2 infections, hemisymptoms have not been described as initial symptoms.
The normal MRI disclosed stroke, haemorrhage or demyelination as a cause of the sensory loss on the hemibody. Although very small lesions can be overlooked one might speculate that the symptoms might be due to direct neurotropism of the virus. How the virus selectively reaches the somatosensory system of the brain is not known. Like other Coronaviruses, SARS-CoV-2 probably reaches the nervous system via different routes  , particularly via retrograde axonal path as suggested by taste and olfaction loss.
The present case underlines that it is important to consider a neurological manifestation as the leading symptoms in SARS-CoV-2 infections.