Bickerstaff encephalitis after COVID-19
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LETTER TO THE EDITORS
Bickerstaff encephalitis after COVID‑19 Lucía Llorente Ayuso1 · Pedro Torres Rubio2 · Rafael Fernando Beijinho do Rosário3 · María Luisa Giganto Arroyo4 · Fernando Sierra‑Hidalgo1 Received: 12 July 2020 / Revised: 27 August 2020 / Accepted: 29 August 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Sirs, A 72-year-old woman with a history of hypertension, hyperlipidemia, smoking, and depression presented on early April 2020 with delirium and fever. A cranial CT scan was normal. A chest X-ray showed bilateral interstitial pneumonia, and nasopharyngeal exudate polymerase chain reaction (PCR) testing was positive to SARS-CoV-2. Cerebrospinal fluid (CSF) was normal. She was admitted and started on hydroxychloroquine, azithromycin, ceftriaxone, and IV methylprednisolone. A few days later she was transferred to the intensive care unit due to a cardiogenic shock caused by a myocardial infarction. Further hemodynamic and respiratory evolution was good, and she was discharged without delirium or cognitive impairment on day 22 after admission. She was readmitted eight days later due to a 48-h history of dizziness, oscillopsia, and unsteadiness. Her vital signs were normal, and she was afebrile. Systemic examination was unremarkable. She was conscious, and her language and speech were normal, but slight inattention and disorientation were present. A downbeat nystagmus in all gaze positions and impairment of smooth pursuit eye movements were present. Horizontal and vertical eye movements showed no limitation. Motor and sensory examinations were normal, and deep tendon reflexes were all present and symmetrical. The left plantar response was extensor. There was no limb dysmetria, but severe truncal ataxia was present. Reflex * Fernando Sierra‑Hidalgo [email protected] 1
Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031 Madrid, Spain
2
Department of Radiology, Unidad Central de Radiodiagnóstico, Hospital Universitario Infanta Leonor, Madrid, Spain
3
Emergency Department, Hospital Universitario Infanta Leonor, Madrid, Spain
4
Department of Cardiology, Hospital Universitario Infanta Leonor, Madrid, Spain
myoclonus in the face and both arms could be induced by sound and tactile stimuli. Upon admission, PCR to SARS-CoV-2 was negative. Brain magnetic resonance imaging (MRI) showed hyperintense lesions in the caudal vermis and right flocculus, and contrast enhancement was observed in the floor of the fourth ventricle (Fig. 1). An electroencephalogram was normal. The CSF examination then showed a leukocyte count of 0/mm3, glucose level of 70 mg/dl, protein level of 41 mg/dl, sterile cultures, IgG index of 0.5, and the absence of oligoclonal bands. Blood serological tests for HIV and Treponema pallidum were negative, as well as IgM for Varicella-zoster virus, Epstein Barr virus, Cytomegalovirus, Mycoplasma pneumoniae, and Borrelia burgdorferi. Anti-glutamic acid decarboxylase, antithyroid, anti-transgluta
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