A 55-year-old gentleman with a history of diabetes mellitus, systemic hypertension, hypercholesterolemia, and hyperuricemia was admitted to our Medical Intensive Care Unit (MICU)with a 10-day history of shortness of breath, fever, and productive cough. On admission he was found to have a positive COVID-19 PCR with a cycle threshold (CT) value of 21. The patient was not vaccinated against COVID-19 at the time of this hospital admission. He received treatment according to the local COVID-19 protocol. His respiratory failure was managed with oxygen supplementation via Non-re- breathing Mask, then he was shifted to high flow nasal cannula (HFNC) alternating with Continuous Positive Airway Pressure (CPAP). Pulmonary embolism was ruled out with a CT pulmonary Angiogram. As the respiratory functions deteriorated, the patient was Intubated on Day 11. On Day 20; the patient was extubated to be re-intubated again emergently for worsening respiratory failure on day 23. He was finally extubated on day 26. On day 27, the patient developed a prolonged generalized tonic-clonic seizure which lasted for about 10 min aborted with IV midazolam. A subsequent CT head was nonrevealing. Subsequently as the seizure was prolonged (status epilepticus), the patient was loaded and kept on maintenance Levetiracetam. On day 30, he developed 3 discrete episodes of seizures (each lasting approximately 2 min and responding to iv boluses of midazolam). Lacosamide was added for seizure control. The patient's level of consciousness was not improving so he was re-intubated. His respiratory status improved, as reflected by ventilatory setting of 0.4 FIo2 and a PEEP of 5. He was kept off sedation on ventilator, but his level of consciousness did not improve. On day 34 again he developed 2 episodes of complex partial seizure that responded to IV midazolam boluses. EEG was done to rule out non convulsive status epilepticus and it showed generalized slowing suggestive of severe encephalopathy. MRI head (Fig. 1) was done and showed, scattered sporadic high cerebral mainly left sided cortical gyriform pattern with DWI bright signal with ADC map iso signal and FLAIR mild to moderate bright signal seen mainly at left high frontoparietal gyri as well as left cingulate gyrus possibly of post ictal versus early ischemic changes with no established infarction. Multiple punctate micro bleeds showing SWI dark signal are noted within the body and splenium of corpus callosum as well as left parietal subcortical regions likely of COVID-19 related micro thrombotic or hypoxic sequelae. Postcontrast, bilateral cerebral pachymeningeal dural enhancement with no nodularity is seen. Cranial and neck MRA was unremarkable.
Subsequently, lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis was done on day 35 after the MRI result. CSF analysis revealed a colorless CSF with a white blood count (WBC) of 3/microl, Red blood cells (RBC) of 2425/microl, and protein was> 6 gm/L, glucose was 5.44 mmol/L. Gram stain and culture of the CSF were negative. As was the Mycobacterium tuberculosis PCR, AFB Smear and TB culture and other viral panel including EBV and Adenovirus PCRs.
CMV CSF PCR showed; 103,614 copies of the virus DNA (Test method: Altona Diagnostics Real-Time PCR assay for quantitative detection of Cytomegalovirus on ABI 7500 analyser). Subsequently, Ganciclovir treatment was started. One month later a repeat CSF analysis showed absence of CMV DNA. Other investigations including Hepatitis B, Hepatitis C, HIV and Quantiferon TB tests were negative. Connective tissue screen with antinuclear antibodies (ANA) was also negative.
Tracheostomy was done on day 48, in view of persistent low GCS and prolonged intubation.
The patient's ICU course was complicated by Candida Auris and Candida Albicans sepsis and secondary bacterial infection with Pseudomonas Aeruginosa and Klebsiella Pnemoniae of the sputum requiring antifungal and antimicrobial treatment respectively.
Eventually the GCS improved to 15 and the patient was weaned off the ventilator and transferred to the medical ward on day 66. On day 95 he was transferred to the rehabilitation unit with persistent limb weakness.
Our patient received Dexamethasone 8 mg IV Daily D1 to D10 and Methylprednisolone 40 mg BID IV from D19 to D27.