Dados do Trabalho

Título

Relapse of Anti-NMDAR encephalitis in COVID-19 infection: a case report.

RESUMO

Case Presentation: A 19-year-old male presented with visual and auditory hallucinations, insomnia, confusion, and mood oscillations, as well as three episodes of fever in the week prior. A day before hospital entry, he had four episodes of stereotyped movements on the left side of his body, as well as sialorrhea, sweating and visual hallucinations, lasting 9 minutes. At examination, he was afebrile, agitated, disoriented, without focal deficits or meningeal signs. He had been diagnosed with anti-NMDAR encephalitis in our service (confirmed by serum antibody dosage) in 2014, when he exhibited severe agitation, autonomic signs, chorea, and status epilepticus, having undergone treatment with two courses of methylprednisolone 1g, one course of immunoglobulin 1g, followed by 1g of cyclophosphamide, having remitted completely of the symptoms at discharge. He was on carbamazepine 200mg 8/8h from 2014 to 2020, having suspended the medication himself, with no epileptic events until the day prior to admission. He underwent diagnostic testing with unremarkable head CT, MRI, and lumbar puncture. His SARS-CoV-2 PCR test was positive, and sequential EEGs showed diffuse slowing, without epileptic activity. Considering an anti-NMDAR encephalitis relapse triggered by COVID-19 infection, he was treated with two courses of methylprednisolone 1g for five days, two days of cyclophosphamide (1g/d), and one course of immunoglobulin (0,4mg/kg/d) for five days and kept on 30mg/d of prednisolone after discharge, with progressive tapering. At the time of discharge, the patient had mild executive dysfunction and echolalia, and was oriented to return for 6 monthly courses of cyclophosphamide. Discussion: COVID-19 has been described as trigger to autoimmune or autoinflammatory conditions; anti-NMDAR encephalitis is a multistage acute autoimmune disease, progressing from psychiatric symptoms to memory disturbances, dyskinesias, seizures, and catatonia. Several cases of anti-NMDAR encephalitis associated to the infection by the novel coronavirus have been reported, many confirmed by SARS-CoV2 PCR and anti-NMDAR dosage in CSF/Serum. Given our patient response to treatment and unremarkable laboratory and image, we believe this might be the case. Final Comments: The coronavirus pandemic gave rise to neurological manifestations, including triggering of Anti-NMDAR encephalitis or their relapses, which should be considered in the differential diagnosis of patients in this context.

Palavras Chave

COVID-19, Encephalitis, Anti-NMDAR.