A 36 years old male patient presented to one of the peripheral healthcare centers on 15/4/2020 with two days history of fever, headache, body pain, cough, diarrhea and vomiting. On physical examination, pharyngitis only was found. Blood tests showed normal full blood count. The patient was submitted to NOVEL CORONAVIRUS RNA PCR swab that resulted negative. He was diagnosed as gastroenteritis and discharged.
On 19/4/2020, the patient visited the emergency department of a central hospital as he was still complaining of the same symptoms; additionally, he presented drowsiness and appeared mildly confused. The patient denied head trauma or seizure.
On examination, Glasgow Coma Scale (GCS) scored 13/15; the patient was drowsy but arousable, he showed mild confusion although he was still oriented to time and place. Pupils were isochoric (3 mm diameter) and reactive. Cranial nerves were normal. He presented no signs of trauma, no overt weakness, no nuchal rigidity (mild stiffness) or pain while moving the neck.
Blood tests (Table 1-4) showed high WBC count 12.9 10^3/uL; CRP was normal, Procalcitonin was high 0.10 ng/mL, D-Dimer high 0.79 ug/ml FEU. Random Glucose was high 165 mg/d.
NOVEL CORONAVIRUS RNA PCR swab was repeated and resulted positive.
Chest x-ray was performed and did not show any pathological findings.
Based on neurological examination, the patient was investigated with Brain CT (Figure 1). The study showed a right frontal intracerebral hematoma associated with subarachnoid hemorrhage in the ipsilateral sylvian fissure, frontal and temporal lobes; a thin, acute subdural hematoma was also evident. The hematoma appeared surrounded by edema and caused midline shift. The radiologist attributed the described findings to encephalitis and viral etiology was suspected.
Diagnostic workup was completed with CT-angio on the same day (Figure 2a and 2b). The investigation did not show any arteriovenous malformation or aneurysms, it also ruled out the possibility of venous thrombosis. Bilateral supratentorial leptomeningeal increased enhancement was detected and further supported the diagnosis of COVID-19 related meningoencephalitis (Figure 3a and 3b).
The evidence of midline shift on the CT scans contraindicated a lumbar puncture to assess the presence of Coronavirus in the CSF.
MRI could not be performed as in our facility it is not allowed for COVID 19 patients.
EEG was also ruled out to prevent further exposure with the COVID-19 patient and because CT and CTA were reckoned conclusive
The patient was admitted to the ICU with close neuro-observation. He remained stable and several chest x-rays were all normal.
On 2/5/2020, the patient was still neurologically stable (GCS 14/15) yet on brain CT- follow up (Figure 4), the right subdural hematoma had become chronic, the intracerebral hematoma was re-reabsorbing with persistent perilesional brain oedema and midline shift. Based on radiological findings, indication for surgery was advocated; evacuation of the chronic subdural hematoma was performed on 5/5 via burr hole. The fluid from the chronic subdural hematoma was sent for PCR. Novel Coronavirus RNA PCR-fluid (CSF) was positive.