Coronavirus disease 2019 (COVID-19) is typically manifested by fever and respiratory symptoms caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although SARS-CoV-2 is a respiratory infection agent, various neurological syndromes have been reported with central and peripheral nervous system involvement, which may be associated with COVID-19. Most recently, a case diagnosed with multiple sclerosis (MS) after an optic neuritis (ON) attack associated with COVID-19 infection has been published.
In this case series we would like to to discuss the posibility of COVID-19-associated inflammatory / demyelinating disease.
We present 3 new cases admitted to our clinic with various neurological findings that all cases were affected by COVID-19. Imaging studies have shown that inflammatory / demyelinizing lesions appeared in different areas of the central nervous system which were accepted as an atypical demyelinating spectrum associated with SARS-CoV-2.
Case 1
A 28-year-old man presented with left hemiparesia. Brain magnetic resonance imaging (MRI) showed hyperintense lesions adjacent to the lateral ventricles on T2-weighting with diffusion restriction and contrast enhancement. Chest CT scan was compatible with viral pneumonia and nasopharyngeal swab with a realtime polymerase chain reaction (RT-PCR) test resulted positively for SARS-CoV-2. After management of the infection, intravenous methylprednisolone (IVMP) treatment was given to the patient and neurological deficits were fully recovered.
Case 2
An 18-year-old woman presented with severe acute visual loss in the left eye and retrobulbar ON was diagnosed. Brain and cervical spine MRI showed multiple demyelinating lesions without gadolinium enhancement. SARS-CoV-2 PCR analysis of nasopharyngeal swab and immunological testing for IgG was negative whereas she was positive for IgM, compatible for a possible active infection. She was started on IVMP and despite completion to 10 days, recovery was only achieved by 70%.
Case 3
A 48-year-old man presented with right hemiparesia. He was hospitalized with the diagnosis of Covid-19 10 days ago. Brain MRI showed T2- FLAIR hyperintense lesions in the supratentorial area and posterior fossa with diffusion restriction and contrast enhancement. Control MRI after 2 months revealed that the lesions significantly regressed spontanously and complete recovery was observed in neurological deficits.
With increasing experience, it has been understood that the SARS-CoV-2 also has a neurotropic effect. These 3 cases suggest that the virus plays a role in the clinical onset of the inflammatory / demyelinating disease. The responsible mechanism here is probably not as a result of direct infectious effect of the virus rather a trigger role in autoimmune processes like other viral agents. Further long-term studies relating to the pathophysiology of COVID-19 is warranted.