Encephalitis Associated with COVID-19 Infection in an 11 Year-Old Child

Abstract

To the Editor, Neurologic complications associated with COVID-19 infection are not well understood in children or adults. An adult with acute necrotizing encephalitis associated with COVID-19 (1) and a child with acute disseminated encephalomyelitis (ADEM) and non-COVID coronavirus (2) have been reported. The infection is typically mild in children and no neurologic complications were reported in the 171 children from Wuhan Children’s Hospital (3). From preliminary data from U.S. cases, headache was the only neurologic symptom (4). We report an 11 year old previously well child who presented with status epilepticus requiring four anticonvulsant medications and CSF evidence for encephalitis (921 red cell, 16 white cells, 8% neutrophils (normal 0-6%) with protein of 97 (normal: 40-170 mg/dl) and glucose of 92 (normal: 20-100 mg/dl)). He had a two day history of generalized weakness, no respiratory symptoms and was afebrile at home; emergency room temperature was 102.7. Head CT was negative. EEG noted frontal intermittent delta activity. Nasopharyngeal swab was positive for COVID-19 as well as rhinovirus/ enterovirus but the latter was absent in cerebrospinal fluid-PCR. Recovery without treatment was complete in 6 days. We believe this is the first child reported with COVID-19 viral encephalitis, and the condition was reversible. How coronavirus would affect the brain is not known. This child raises the possibility that direct brain infection may be possible. An autoimmune process may also be possible. The acuteness of our patient’s neurological syndrome with the development of fever and generalized systemic weakness mitigates against a post-infectious process. Because the virus binds to the surface spike protein to the human angiotension-converting enzyme 2 receptor (ACE-2), and the fact that ACE2 is present in the brain vascular endothelium, a vascular process with clotting and infarction may also be possible although this was not the mechanism in our patient (5,6,7). Although preliminary, we recommend screening children presenting with encephalitis for COVID-19 as infected patients require special precautions to prevent further spread.