Focal status epilepticus as unique clinical feature of COVID
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The spectrum of COVID-19 ranges from asymptomatic or mild infection to rapidly progressive, acute respiratory distress syndrome and death. This report presents a patient affected by COVID-19 whose primary presentation was a focal status epilepticus. On 12th March 2020 a 78-year-old woman was admitted to Emergency Department for ongoing myoclonic jerks of the right face and right limbs. She suffered from hypertension and postencephalitic epilepsy and was steadily under treatment with valproic acid and levetiracetam and remained seizure-free for more than two years. She was under regular neurologic follow-up and the last electroencephalogram performed ten days prior to admission was normal.

The electroencephalogram revealed semi-rhythmic, irregular, high amplitude delta activity, predominantly lateralized over the left fronto-centro-temporal regions, consistent with focal status epilepticus. The antiepileptic treatment resolved the status epilepticus. Computed Tomography (CT) scan of the brain was negative for acute lesions. Brain MRI confirmed extensive gliosis and atrophy involving the left temporo-parietal lobe, in the absence of new cerebral lesions as documented by both diffusion weighted imaging and post-gadolinium sequences. Laboratory analysis revealed lymphocytopenia and thrombocytopenia.

Nasopharyngeal and oropharyngeal swabs specimen of the patient were then obtained and Real Time Polymerase Chain Reaction (RT-PCR) assay was performed, which tested positive for SARS-CoV2. The patient was transferred to the Infectious Disease Unit and treated with lopinavir-ritonavir plus hydroxychloroquine. After initiation of the treatment, the clinical conditions of the patient improved, with resolution of the fever. A further chest X-ray and a lung ultrasound were negative for interstitial pneumonia. Since then, no other seizures occurred. During the hospitalization, she did not require oxygen therapy. On 28th March she was discharged in stable condition, afebrile after two negative swabs for SARS-CoV-2.

This case describes the first patient to develop a focal status epilepticus as a presenting symptom of SARS-CoV-2 infection. Even in the absence of fever or respiratory symptoms, the recurrence or worsening of paroxysmal neurological events should raise the diagnostic hypothesis of SARS-CoV-2 infection.


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