A 34-year-old Asian female first experienced flu-like symptoms of nasal congestion and a mild cough at the end of June 2021 (day 1) with history of close contact with a family member who had been infected by SARS-CoV-2 and lived in the same house. The patient then sought treatment and underwent a nasopharyngeal swab test, with a positive result. Afterward, she received treatment at the closest healthcare facility (day 3) and was treated with oseltamivir, azithromycin, steroids, vitamin C, and zinc for 5 days. The patient felt that her symptoms had resolved after she had taken her medication.
On day 14, the patient underwent another nasopharyngeal swab test, and the result was still positive; therefore, she returned for self-isolation. On day 17, the patient started experiencing pain throughout her body without any respiratory symptoms. On day 18, she had the same symptoms; mid-day, the patient could still communicate with her family about her symptoms, but then she did not remember any of the subsequent events. Based on the information provided by her family member, they found that within approximately 4 hours after the patient complained of pain throughout her body, she started to become verbally aggressive and had a fever of 39 °C. She also had urinary incontinence without any motor seizures. Any history of comorbidities, alcohol intake, or substance abuse was denied. The patient was then taken by her family to the Emergency Department of Pondok Indah – Bintaro Jaya Hospital.
When she was admitted to the Emergency Department, she did not have a fever (body temperature 36.5 °C), her pulse rate was 85 beats/min, her blood pressure was 136/65 mmHg, her respiratory rate was 19 breaths/minute, and her oxygen saturation on room air was 97%. The patient was in the obese category (BMI 43.8 kg/m2) with body weight of 115 kg and height of 162 cm. Her general status was within normal limits. Neurological examination revealed altered consciousness (GCS of E3M5V3) with a propensity for fluctuation and aggressive behavior. Cranial and motor nerve examination found no lateralization. It was difficult to evaluate meningeal irritation signs at this time.
Laboratory examination revealed leukocytosis (17,900/UL), neutrophilia (84%), relative lymphopenia (10.1%), increased C-reactive protein level (25.75 mg/L), and increased D-dimer level (600 ng/mL). Evaluation of anti-HIV, HbSAg, and anti-HCV showed nonreactive results. RT–PCR tests for SARS-CoV-2 using nasopharyngeal and oropharyngeal swab samples showed positive results. Chest X-ray revealed diffuse ground-glass opacity of the left lung with suspected etiology of asymmetrical lung edema and a differential diagnosis of left pleural effusion and left lung pneumonia. Contrast-enhanced magnetic resonance imaging (MRI) of the head revealed a normal image; i.e., no lesion or intracerebral or intracerebellar pathological enhancement was found.
Analysis of the cerebrospinal fluid sample obtained from lumbar puncture revealed that the cerebrospinal fluid was clear and colorless. Pleocytosis was found (leukocyte count 157/µL) with 99% mononuclear and 1% polymorphonuclear cells, with increased protein levels (108 mg/dL), while the glucose level was within the normal limit (glucose level in cerebrospinal fluid 63 mg/dL, serum glucose level 104 mg/dL). Gram and Ziehl Neelsen staining revealed no bacteria or acid-fast bacilli (AFB). PCR examination for herpes simplex virus (HSV) and cytomegalovirus (CMV) showed negative results, while RT–PCR for SARS-CoV-2 revealed positive results.
The patient was admitted to the SARS-CoV-2 isolation unit. Primary care was started in the Emergency Department, including nasogastric tube and Foley catheter insertion and nasal cannula as well as intravenous fluid supplementation. The patient received empiric treatment based on her clinical manifestation using 750 mg acyclovir three times daily, as her prior PCR result on cerebrospinal fluid samples showed viral encephalitis. The treatment was also continued using intravenous remdesivir at a dosage of 200 mg once daily on the first day, which was continued at 100 mg once daily from the second to fifth day. The patient also received 40 mg methylprednisolone twice daily and 0.4 cc enoxaparine sodium.
After 2 days of treatment, the patient regained consciousness with GCS of E4M6V5 and no aggressive behavior. Neurological examination on the third day of treatment revealed that all test results were within normal limits. Treatment for SARS-CoV-2 infection and acyclovir treatment were continued. Positive SARS-CoV results in the cerebrospinal fluid sample were obtained on the 8th day. On the 10th day, RT–PCR of SARS-COV-2 was performed again on samples from both the nasopharynx and oropharynx. The results were negative. The patient was then discharged with a condition of full recovery and continued her treatment at the outpatient clinic.