Fatal Central Nervous System Co-Infection with SARS-CoV-2 and Tuberculosis in a Healthy Child

doi:10.21203/rs.3.rs-33272/v1

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Case Report

Fatal Central Nervous System Co-Infection with SARS-CoV-2 and Tuberculosis in a Healthy Child

https://doi.org/10.21203/rs.3.rs-33272/v1

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Background. Central and peripheral nervous system symptoms and complications are being increasingly recognized among individuals with pandemic SARS-CoV-2 infections, but actual detection of the virus or its RNA in the central nervous system has rarely been sought or demonstrated. Severe or fatal illnesses are attributed to SARS-CoV-2, generally without attempting to evaluate for alternative causes or co-pathogens.

Case presentation. A five-year-old girl with fever and headache was diagnosed with acute SARS-CoV-2-associated meningoencephalitis based on the detection of its RNA on a nasopharyngeal swab, cerebrospinal fluid analysis, and magnetic resonance imaging findings. Serial serologic tests for SARS-CoV-2 IgG and IgA showed seroconversion, consistent with an acute infection. Mental status and brain imaging findings gradually worsened despite antiviral therapy and intravenous dexamethasone. Decompressive suboccipital craniectomy for brain herniation with cerebellar biopsy on day 30 of illness, shortly before death, revealed SARS-CoV-2 RNA in cerebellar tissue using the Centers for Disease Control and Prevention 2019-nCoV Real-Time Reverse Transcriptase-PCR Diagnostic Panel. On histopathology, necrotizing granulomas with numerous acid-fast bacilli were visualized, and Mycobacterium tuberculosis complex DNA was detected by PCR. Ventricular cerebrospinal fluid that day was negative for mycobacterial DNA. She had no known exposures to tuberculosis and no chest radiographic findings to suggest it. All 6 family members had normal chest radiographs and negative interferon-γ release assay results. The source of her tuberculous infection was not identified, and further investigations by the local health department were not possible because of the State of Michigan-mandated lockdown for control of SARS-CoV-2 spread.

Conclusion. The detection of SARS-CoV-2 RNA in cerebellar tissue and the demonstration of seroconversion in IgG and IgA assays was consistent with acute SARS-CoV-2 infection of the central nervous infection. However, the cause of death was brain herniation from her rapidly progressive central nervous system tuberculosis. SARS-CoV-2 may mask or worsen occult tuberculous infection with severe or fatal consequences.

Critical Care & Emergency Medicine

SARS-CoV-2

CNS tuberculosis

meningoencephalitis

pediatric infections

case report

Pandemic SARS-CoV–2 has been regarded as a milder respiratoryand/or gastrointestinal infection in children, with lower rates ofhospitalization and death as compared with adults [1,2].Coronaviruses have been shown to be neuroinvasive in humans andanimal models [3,4]. In a retrospective study of 214 Chinese adultswith COVID–19, many of whom had chronic underlying diseases, 78(36.4%) exhibited neurologic symptoms including headache,dizziness, hyposmia, ischemic stroke, and cerebral hemorrhage [5].In another series from France, 84% of 58 consecutive adults (medianage, 63 years) admitted to the hospital with acute respiratorydistress syndrome due to COVID–19 had neurologic symptoms such asagitation, corticospinal tract signs, and dysexecutive syndrome.MRI of the brain was performed in 13, of whom 8 had leptomeningealenhancement and all exhibited perfusion abnormalities.Cerebrospinal fluid (CSF) analysis was only done in 7, and all hadnegative reverse transcriptase PCR assays for SARS-CoV–2 RNA [6].Demonstration of SARS-CoV–2 RNA in the central nervous system (CNS)has only been documented in three adults, one with a positive CSFRNA result, one using genome sequencing in CSF, and anotherutilizing transmission electron microscopy on brain tissue obtainedpost-mortem [4,7,8]. Pulmonary co-infections with common viral,bacterial, and fungal pathogens have been described in COVID–19patients, but there is a paucity of literature on mycobacteria,including members of the Mycobacterium tuberculosiscomplex with which a third of the world population is infected[9–12]. We describe the unique case of a previously healthy childwith acute SARS-CoV–2 infection, fever, and headache, withlaboratory and imaging evidence of meningoencephalitis who rapidlydeteriorated two weeks into her illness and was found to have bothSARS-CoV–2 RNA and Mycobacterium tuberculosis complex DNAon a cerebellar biopsy with histopathology consistent withtuberculous meningitis. This report illustrates the need toconsider that the toll of COVID–19-associated morbidity andmortality may not all be due to the virus.

A healthy five-year-old African American girl was admitted onthe sixth day of fever (>39°C) and severe headache after threedays of amoxicillin treatment for group A streptococcalpharyngitis. Initial laboratory data included a white blood cellcount of 10.8 bil/L (lymphocytes 1.8 bil/L), Westergrensedimentation rate 30 mm/h, sodium 133 mmol/L, normal liver enzymeconcentrations, and clear chest radiograph. Nasopharyngeal swab waspositive for SARS-CoV–2 RNA using the NxTAG® CoV Extended Panel(Luminex). Her parents were recently ill with respiratory tractinfections and SARS-CoV–2 IgG positive after their recovery. Dailyfever and headache persisted. A head CT scan on day 9 of illnesswas normal. She was discharged on day 10 but then readmitted laterthat evening following an episode of confusion and associatedextremity stiffening with the appearance of staring into space,which lasted for two minutes. On readmission, CSF studies showed awhite blood cell count of 24/μL (96% lymphocytes), red blood cellcount 152/μL, protein 85 mg/dL, and glucose 22 mg/dL.Meningitis/encephalitis nucleic acid amplification panel usingFilmArray® ME (Biofire) was negative for herpes simplex virus,human herpes virus VI (HHV–6), varicella-zoster virus, enterovirus,cytomegalovirus, parechovirus, Cryptococcusneoformans/gatti, Escherichia coli K1,Haemophilus influenzae type b, Listeriamonocytogenes, Neisseria meningitidis,Streptococcus agalactiae, and Streptococcuspneumoniae. SARS-CoV–2 RNA was not detected in CSF using theCenters for Disease Control and Prevention 2019-nCoV Real-TimeReverse Transcriptase-PCR Diagnostic Panel (CDC qPCR). CSFbacterial culture was sterile. Her peripheral blood white bloodcell count was 11.1 bil/L (lymphocytes 1.1 bil/L), platelet count366 bil/L, sodium 130 mmol/L, ferritin 137 ng/mL, lactatedehydrogenase (LDH) 411 U/L, d-dimer 972 ng/mL, fibrinogen 316mg/dL, troponin I <0.01 ng/mL, and interleukin 6 level <5pg/mL. Oral hydroxychloroquine (6.5 mg/kg/dose every 12 hours fortwo doses and then 3.5 mg/kg/dose per dose every 12 hours for fourmore days) plus oral azithromycin 10 mg/kg/day for five days werestarted. Magnetic resonance imaging (MRI) of the brain withgadolinium on day 12 of illness revealed a 7 mm area of restrictiondiffusion involving the subcortical white matter of the medialaspect of the left anterior frontal lobe with increased T2 FLAIRsignal without pathological enhancement (Figure 1A). Mildleptomeningeal enhancement was noted. She developed SIADH (syndromeof inappropriate secretion of antidiuretic hormone) that wasmanaged with fluid restriction and frequent 3% saline boluses. Herfever persisted but she was neurologically stable with waxing andwaning cognition and headache, until day 15 when she became morelethargic and developed asymmetric pupils. Head CT scan showedenlargement of the lateral, third, and fourth ventricles. On day16, repeat lumbar puncture showed an opening pressure of 35 cm ofwater. CSF studies revealed a white blood cell count of 160/μL (44%neutrophils, 51% lymphocytes, 5% monocytes), red blood cell count7/μL, glucose 30 mg/dL, and protein 112 mg/dL; HHV–6 DNA wasdetected but not SARS-CoV–2 RNA. An external ventricular drain wasplaced the same day and the CSF was negative for both HHV–6 DNA andSARS-CoV–2 RNA. She had no HHV–6 DNA in plasma and her HHV–6 IgMwas <1:20 and HHV–6 IgG 1:320 (negative if <1:10), suggestingthat the detection of HHV–6 DNA on lumbar CSF was a false-positiveresult. MRI of the brain showed extensive progression of themeningoencephalitis to her cerebellum and corpus callosum, withleptomeningeal enhancement especially over the surface of thebrainstem and into the auditory canals. Magnetic resonanceangiography (MRA) was normal (Figures 1B-D). Intravenousdexamethasone was initiated. On day 17, she was intubated forworsening encephalopathy and intravenous remdesivir started. Herchest radiograph showed early perihilar streaky opacities.Ferritin, interleukin 6, and LDH were again normal.

The subsequent clinical course over the ensuing days wasturbulent. She had ongoing SIADH, severe hypertension requiringmultiple intravenous antihypertensive medications, worsening chestradiographic findings with development of bibasilar opacities onday 27, electroencephalography consistent with severeencephalopathy, and gradual neurologic worsening with minimallyreactive and dilated pupils.

On day 30 of illness, MRI of the brain showed marked progressionof inflammation with supratentorial and infratentorial edema,hypoxic/ischemic changes, cerebellar tonsillar herniation, and lackof normal flow at the circle of Willis (Figures 1E-F). A midlinesuboccipital craniectomy and C1 laminectomy were performed. Thecerebellum was necrotic and edematous, and herniated out of thesurgical defect. She passed away on day 32 of illness.

Additional Laboratory Data.The absolute lymphocytecounts ranged between 0.4–1.8, and all were ≤1.0 during the last 2weeks of her life. Her platelet count was normal throughout exceptfor day 31 of illness (96 bil/L). AST, ALT, and total bilirubinconcentrations between days 5 and 31 of illness (24 measurementseach) were consistently normal.

Ventricular CSF studies from days 23 and 28 were similar, withwhite blood cell counts of 1–10/μL, red blood cell counts of30–127/μL, glucose 75–83 mg/dL, and protein 53–55 mg/dL. On day 30,when she developed brain herniation, ventricular CSF glucose was 21mg/dL, protein 130 mg/dL, white blood cell count 6/μL, and redblood cell count 174/μL.

Human immunodeficiency virus (HIV) types 1/2 antibodies and p24antigen were negative. Antinuclear cytoplasmic antibody wasundetectable.

Stored CSF from day 16 of illness was later tested forautoantibodies (CSF Autoimmune Evaluation, Mayo ClinicLaboratories, Rochester, MN). Immunofluorescence antibody assaydetected glial fibrillary acidic protein (GFAP) autoantibody at atiter of 1:8 (normal, <1:2).

Microbiologic and Immunologic Studies.Nasopharyngealswabs remained positive for SARS-CoV–2 RNA, including one collectedon her last day of life. Tracheal aspirate SARS-CoV–2 RNA wasnegative on day 22.

Tracheal aspirates collected on days 22 and 27 of illness weresterile on mycobacterial culture, and the sample from day 22 wasnegative for M. tuberculosis complex DNA.Mycobacterial culture from ventricular CSF collected on day 25 wassterile. Mycobacterial DNA detection on ventricular CSF from day 28of illness was negative.

The cerebellar brain biopsy was positive for SARS-CoV–2 RNA (CDCqPCR). It was also positive for M. tuberculosiscomplex DNA using an hsp65 amplified probe and negative foratypical mycobacterial DNA (University of Washington MedicalMicrobiology Laboratories, Seattle, WA).

SARS-CoV–2 IgA and IgG responses on day 11 of illness wereweakly positive and negative, respectively. A strong antibodyresponse evolved when re-tested on days 22 and 32 (Figure 2). Thefindings were consistent with an acute SARS-CoV–2 infection.

The child lived with her mother, father, and maternalgrandmother, all of whom were positive for SARS-CoV–2 IgG but hadnegative interferon-γ release assays and normal chest radiographs.She was also in frequent contact with her maternal aunt’s family,consisting of 3 adults, all of whom had normal chest radiographsand negative SARS-CoV–2 IgG and interferon-γ release assays.Schools had closed in Michigan because of the COVID–19 pandemic aweek before her symptoms began. The source of her tuberculousinfection has not yet been identified.

Histopathology.The cerebellar biopsy on day 30 ofillness showed patchy areas of necrotizing granulomatousinflammation and vasculitis. Stains showed endothelial injury,muscle wall injury, and lost elastic lamina. Acid fast bacilli wereidentified (Figure 3).

SARS-CoV–2 neurotropism is believed to be mediated by binding ofits spike protein to its receptor angiotensin-converting enzyme 2which is expressed in glial cells and neurons [13]. Neurologicabnormalities are increasingly recognized in SARS-CoV–2 infectedindividuals, but our knowledge is hampered by a dearth ofinformation on associated CSF and neuroradiologic correlates ofpathology and how they might evolve during a severe illness.Contributing to this knowledge gap are resource limitationsincluding insufficient reagents for broader molecular testing andinfection control concerns that limit diagnostic evaluations suchas imaging studies, tissue biopsies, and autopsies. Severe or fatalillnesses are generally attributed to SARS-CoV–2, which may beinaccurate.

This child’s clinical course was that of progressive clinicaland radiologic worsening. She was shown to have an acute SARS-CoV–2infection based on evolution of her serologic responses (Figure 2).The CSF abnormalities were consistent with acute viralmeningoencephalitis, although her initial CSF glucose was unusuallylow. While tuberculous meningitis was considered during the courseof her illness, it was deemed improbable given the lack of knownexposures to tuberculosis (later confirmed by evaluation of allfamily members who proved to be free from infection), normal chestradiographs during the first two weeks of illness, and CSF findingsthat were uncommon for this diagnosis (commonly white blood cellcounts of 100–500/µL and protein >100 mg/dL) [14]. Trachealaspirate and CSF molecular tests and cultures were negative formycobacteria.

We hypothesize that this child was asymptomatically infectedwith one of the M. tuberculosis complex memberspecies when she acquired her SARS-CoV–2 infection. SARS-CoV–2meningoencephalitis was confirmed by the positive cerebellar tissuePCR assay. The immunologic response to SARS-CoV–2 may havecontributed to CNS spread of mycobacteria, as detailed below. Thecause of death was brain herniation secondary to rapidlyprogressive CNS tuberculosis.

Type I interferons (e.g., IFN-α, IFN-β) are produced earlyduring a viral infection and are critical in antiviral immunity.After attachment to the interferon α/β receptor and ensuingintermediary biochemical steps, interferon stimulated genes (ISGs)are activated [15]. Wei and colleagues demonstrated that genesfunctioning in viral defense, such as ISGs, are highly expressed inperipheral blood mononuclear cells of SARS-CoV–2 infectedindividuals requiring intensive care [16]. In one study, peak IFNα2levels occurred on days 8–10 of symptom onset and graduallydecreased over the following 2–3 weeks in critically ill adults[17].

Multiple studies have shown that viruses such as influenza, HIV,and measles can impair the ability of macrophages to containmycobacterial growth, including Mycobacterium tuberculosis[18,19]. In a mouse model of influenza A and M.tuberculosis, co-infection resulted in enhancedmycobacterial growth in the lungs and decreased survival mediatedby type I IFN signaling [20].Type I interferons also reduce theability of macrophages to respond to IFN-γ and control ofintracellular growth of M. tuberculosis [21].This child additionally had persistent lymphopenia, which is a riskfactor for severe tuberculosis [22].

The detection of a high CSF GFAP autoantibody titer isindicative of an astrocytopathy. This autoantibody is oftendetected in individuals with meningoencephalitis [23]. Severe SIADHhas previously been observed in a few adults with SARS-CoV–2pneumonia [24].

This child’s fatal illness raises broader concerns given theintersection of a global SARS-CoV–2 pandemic and an infection thatafflicts a third of the world population. He and colleaguesdescribed 2 adults with a history of treated tuberculosis and onewith a 50-year history of untreated but stable infection whoacquired SARS-CoV–2 infection and had severe pulmonary disease withprotracted hospital stays, but survived; all were placed onanti-tuberculous drug therapy, but no microbiologic or molecularstudies for Mycobacterium tuberculosis were attempted[11]. Further investigation into the role of co-infection with anyof the 10 species comprising the Mycobacteriumtuberculosis complex on COVID–19 severity or mortality isneeded.

CDC qPCR: Centers for Disease Control and Prevention 2019-nCoVReal-Time Reverse Transcriptase-PCR Diagnostic Panel

CNS: Central nervous system

CSF: Cerebrospinal fluid

CT: Computed tomography

HIV: Human immunodeficiency virus

IFN: Interferon

ISGs: Interferon stimulated genes

Ethics approval and consent to participate: Notapplicable.

Consent to publish: Written informed consent wasobtained from the parent for the publication of this case reportand any accompanying images. A copy of the written consent isavailable for review by the Editor of this journal.

Availability of data and material: Not applicable as nodatasets were generated or analyzed for the current case report.Patient data are part of the protected electronic healthsystem.

Conflicts of interest/Competing interests: None.

Funding: None.

Authors’ contributions:

All authors read and approved the manuscript.

BJF prepared the initial and final drafts of the paper.

AMW selected and provided the imaging studies (Figure 1).

MA and JMF prepared and selected the histopathology image(Figure 3).

BJF, BMG, RT, AMW, JG, NE, GH, PMP, KAL, MA, and JMF revised thepaper critically for important intellectual content, approved thefinal version to be published, and agree to be accountable for allaspects of the work in ensuring that questions related to theaccuracy and integrity of any part of the work are appropriatelyinvestigated and resolved.

Acknowledgements: We thank Barbara Robinson-Dunn,Ph.D., for her critical review of the manuscript.

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Journal Publication

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Fatal Central Nervous System Co-Infection with SARS-CoV-2 and Tuberculosis in a Healthy Child

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