COVID-19-related diffuse leukoencephalopathy with microbleed
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Neurological complications of COVID-19 have been well recognised and include acute ischaemic stroke due to large vessel occlusions, intracranial haemorrhages, acute haemorrhagic encephalopathy, Guillain-Barré syndrome and anosmia. Diffuse COVID-19-associated encephalopathy with microhaemorrhages is a rare complication and associated with a poor prognosis. Authors describe a patient with a remarkable recovery after a severe COVID-19 encephalopathy.

A 60-year-old man with only a history of diabetes mellitus type 2 presented with fever, dyspnoea, headache and arthralgia and was tested COVID-19 positive. On day 5, he developed progressive dyspnoea. Chest X-ray and CT demonstrated bilateral predominantly peripheral ground glass opacities, consistent with an interstitial viral COVID-19 pneumonia. Laboratory results showed an increased ferritin level at admission, increased D-dimer, slightly lowered haemoglobin and haematocrit.

Despite dexamethasone (6 mg once a day during 10 days) and additional high-flow oxygen support sedation (isoflurane, maximum 5 mL/hour), mechanical ventilation was needed until day 22. During the admission, there was no relevant hypertension or hypotension (mean blood pressure 130/70 mm Hg), no renal replacement therapy or extracorporeal membrane oxygenation. Medication included nadroparin 5700IE once per day (thrombotic prophylaxis).

After sedation cessation, he remained comatose without any reaction to pain stimuli (Glasgow Coma Score (GCS) 3), but preserved brainstem reflexes. A non-contrast CT of the head showed extensive, fairly symmetrical hypodense areas in the supratentorial white matter with accentuation of grey-white matter differentiation and several subcortical small haemorrhages in the supratentorial hemispheres. MRI showed extensive confluent T2-hyperintensies within these areas in the periventricular and subcortical white matter with sparing of the U-fibres. Besides the subcortical haemorrhages, MRI showed widespread microbleeds (more than 50) in the subcortical white matter, basal ganglia, cerebellum and in particularly involvement of the splenium of the corpus callosum. At that time, neurological prognosis was uncertain and appeared to be poor, but ventilation and maximal supportive care were continued.

Ten days later (day 32), our patient gradually recovered, obeyed commands and was only slightly disoriented in time and place (GCS 14). He was able to use both arms and legs (Medical Research Council score of 4). Seven weeks after admission to the hospital, he was discharged to a rehabilitation centre. Within 1?month after discharge, he was also able to walk independently.