The case is atypical because it occurred in a 26-year-old patient without underlying diseases, when it usually develops in babies or adults. Also, the person was asymptomatic, but the COVID-19 test was positive.
Weeks ago, the Rosales National Hospital responded to a request to admit a 26-year-old patient to the Intensive Care Unit (ICU). The patient had no symptoms of COVID-19, But the symptoms that characterize an encephalitis are: “Behavioral disturbances, agitation, fever and the need for ventilatory support or mechanical respiration,” Carlos Godinez, an intensivist doctor at Rosales and an intensive care specialist, explained to El Diario de Hoy.
This is an unprecedented fact that shows the wide range of affectations that COVID – 19 it can cause in people. So far, cases of encephalitis that are linked to the virus are rare and in El Salvador it is the first case that is attended.
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The fact that it occurred in a 26-year-old patient without underlying diseases makes it even more atypical, since the diagnosis usually occurs in children, adults or other conditions, according to Godinez.
“He called us care that viral encephalitis It occurs most of all in children, immunosuppressed people, who use long-term steroids, those who have HIV or who have cancer, but not a 26-year-old, well-nourished student with no other history of disease, ”he said.
In the absence of COVID symptoms – 19 It was decided to attend to encephalitis: the first step was to extract the fluid from the lumbar spine, a procedure known as a moon puncture, to do the analysis and determine if the cause was viral or due to tuberculosis.
“We were struck by the fact that he also had kidney failure. We entered it, sent a study to an outside laboratory to identify the most common types of viruses that we have in our country and it was negative. So even though I had no lung symptoms, the fact that I came from a place where COVID -19 had been previously diagnosed and had certain elevated tests like keratin made me think about the possibility of COVID. We sent him to do the test and it came out positive ”, he explained.
However, given the patient’s conditions, It was of utmost importance to apply treatment for kidney failure, work to deflate the brain, and reduce intracranial pressure. Therefore, he was kept in an induced coma for 72 hours; When the brain showed symptoms of inflammation, the patient began to wake up. The young man’s recovery was rapid, since he reacted well to the treatment, knew who he was and obeyed orders.
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“Fortunately the whole process was a success, that gave us a lot of hope. We managed to extubate it and it had a good evolution. ”Godinez said.
One of the difficulties of the case is that he was diagnosed as a COVID-19 patient in the general ICU of the Hospital and does not have adequate conditions for these cases. However, the patient was isolated and given the mechanical ventilation he needed. Then, with the improvement, he was transferred to the special area for patients who have SARS-CoV-2 coronavirus disease.
How did COVID – 19 influence a picture of encephalitis?
Godinez explained that in countries like China they have increased encephalitis cases due to COVID – 19, but they are not yet very common and, unlike pneumonia caused by the disease, where there is a standardized treatment and protocol, for COVID encephalitis there is not.
After we, together with the intensive care residents of the Rosales hospital, successfully diagnose and treat the first case of COVID encephalitis in our country, I want to make a recommendation.
– Dr. Carlos Godinez. Project director. (@ CARLOSGODINEZ5) July 22, 2020
The specialist assured that this condition could be caused by the reaction that the patient’s immune system has to defend itself against the virus, being an indirect response to the virus.
“It is not a direct attack on the brain. COVID generates an autoimmune response. The immune system itself attacks the brain, inflames it, which is why deflating the brain and treating high intercranial pressure has a good response. In patients who has done the study has found that the virus it does not lodge in the cerebrospinal fluid; that is, it is an indirect response to virus infection ”, explained the health professional.
“It is an exaggerated and disproportionate response of the body to the virus that produces a condition of the brain,” he said.
He assured that taking into account this neurological affection, in addition to the symptoms that are already known are frequent in patients with COVID-19, one should also be aware of confusions, inconsistent ideas and intense headaches, especially if you do not have no underlying illness or recent illness.
In this specific case, In the absence of a care protocol, we decided to treat brain inflammation, blood imbalance and kidney failure, then the COVID-19 protocol was applied. This procedure could be effective in other patients with the same conditions, since he assured that it should not be ruled out that similar conditions will continue to be experienced.
In addition, he considered that the kidney failure that accompanied the condition was also an “exaggerated immune response” to the virus or caused by dehydration in people.
Genetic and neurological-type factors
For Godinez, the wide range of symptoms that COVID has – 19 and the different reactions in each patiente may also be influenced by genetic aspects, and neurological influence should be included in the list because not only cases of encephalitis are occurring, but there have also been cases of patients with Guillain-Barré syndrome linked to the disease.
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“In the types (of COVID -19) they do not mention the neurological and it is one that should be considered because it is not only encephalitis, but it gives a Guillain-Barré syndrome. I think there is a genetic component in people that makes it easier for the virus to enter or not and that makes it easier for people to attack more or not. In this case, since she had no neurological symptoms, it was clinical suspicion that led us to the diagnosis. Intensivists know the process of encephalitis, we focus on deflating the brain and preventing other complications such as seizures. Then encephalitis is given treatments while other causes are investigated, “he concluded.
Recent studies have shown a possible link between COVID -19 and this neurological syndrome that occurs when the body’s own immune system attacks and injures nerves outside the spinal cord or brain, the peripheral nervous system. Most often, the injury involves the protective sheath, or myelin, that wraps around the nerves and is essential for nerve function.
According to the report of Journal of Clinical Neuromuscular Disease published in June, In countries such as China, Italy and Spain, which have been most affected by the pandemic, the cases of this syndrome have also increased and given the appearance of Guillain-Barré syndrome in previous pandemics with other coronaviruses such as SARS and MERS, now The possible link between Guillain-Barré and COVID-19 is being investigated.
Guillain-Barré Syndrome is a rare phenomenon but serious possibly related to COVID-19. More than 10.7 million cases have been reported for COVID-19, so far 10 cases of patients with COVID-19 with Guillain-Barré Syndrome have been reported, only two cases reported in the United States, five in Italy, two cases in Iran and one from Wuhan, China, ”says the study.
“Common to the cases reported in the literature, as well as in our patient, it was noted that GBS symptoms occur within a few days of COVID-19 infection. This onset is similar to the report of a case of acute Zika virus infection with concurrent GBS, suggesting a parainfectious complication, ”the report concluded.