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Título

Encephalitis associated with Covid-19 and thunderclap headache: an unusual association

RESUMO

CASE: 51 years-old woman, previous history of depression and systemic arterial hypertension reporting sudden holocranial headache that has progressed to severe intensity within minutes at onset (thunderclap headache) started seven days be¬fore, which progressed with mental confusion, inattention inability to meet family members and difficulty of communication at the day of admission. General physical examination, including respiratory auscultation and oxygen saturation, was normal except for the presence of borderline pyrexia (37.7 °C). Neurological examination showed only mental and cognitive alterations described as inattention, somnolence, disorientation in time and space, inability to say her own name or recognize her husband and language disturbance, characterized by relative fluent speech, incapacity to name objects, repeat words or phrases and to obey commands. Computed angio¬tomography (CTA) of the brain excluded bleeding but showed one aneurysm in the supraclinoid internal carotid artery. Cerebrospinal fluid had no xanthochromia and evidenced a lymphomonocytic pleocytosis with discrete hyperproteinorraquia. Electroencephalogram showed symmetrical and disorganized brain electrical, theta rhythm diffuse and presence of triphasic waves. Due to hospital protocol during the Covid-19 pandemic, the patient underwent computed tomography of thorax and we found ground-glass opacities suggesting viral infection. Then, RT-PCR for Sars-CoV-2 with nasopharyngeal swab and in CSF was performed with both positives. Therefore, the diagnosis was encephalitis associated with Covid-19. We opted for supportive care. Patient evolved with many complications, need of ventila¬tory support and renal replacement therapy with discharged of the hospital after 35 days, with no symptoms. At follow-up, two months later, the only finding was mild inattention. DISCUSSION: Covid-19 is characterized mainly by respiratory symptoms, however this virus frequently damages the nervous system, although the mechanism involved is still unclear. Headache is the most common neurological symptom and has a great hete¬rogeneity, including thunderclap headache, which is a red flag and investigation is mandatory. FINAL COMMENTS: headache is common in patients with Covid-19 and can be the first signal of this infection or of a complication of that, like encephalitis. In addition, the spectrum of the pain is range and includes thunderclap headache mimicking an SAH, as we approach here.

Palavras Chave

Encephalitis; Covid-19; SARS-CoV-2; thunderclap headache.