1) A 35-year-old man presented to the emergency room with suicidal attempts, agitation, and altered mental status four days after initially developing fever and cough from a COVID-19 infection three weeks prior. 2) He was admitted to the psychiatry hospital and developed fever, tongue biting, and elevated CK levels. MRI brain showed bilateral temporal lobe abnormalities. 3) He was diagnosed with post-COVID-19 encephalitis and treated empirically with antivirals, antibiotics, and supportive care. He eventually had complete resolution of symptoms and was discharged after 10 days.

1. POST COVID-19 ENCEPHALITIS PRESENTED
INITIALLY BY SUICIDAL ATTEMPT
CASE REPORT AND LESSON LEARNED
Presented by :
Khaled gamal kotb, psychiatric resident
Ebrahim adel Khalil, psychiatric resident
UNDER SUPERVISION OF
Ehab Elbaz, M.D
Consultant psychiatrist
Director of psychiatry hospital, MMMC

2. INTRODUCTION
• COVID 19 pandemic has reshaped the world as we previously know it
• It is primarily a respiratory tract infection , but also has a neuropsychiatric
presentation which is not understood completely
• As the pandemic continued, we experienced a wide variety of neuropsychiatric
clinical presentation that is unusual
• In this case report, we report the initial presentation with suicide for a man with a
recent history of COVID 19 infection

3. CASE PRESENTATION:
• On 17th April 2021, a 35 years old, accountant ,who live in cairo, non smoker ,no history of
substance abuse and no past history of medical importance presented to our ER department
with suicidal attempt ,altered mental status and agitation of acute onset progressive course
starting 4 days ago,
• Informant complaint (His wife) :
4 days ago he became aggressive with insomnia with suicidal attempt trying to jump from 3rd
floor, she reported that he had fever and cough 3 weeks ago and nasal swab PCR for COVID-
19 done and result was +ve for covid-19 infection and he was isolated at home with treatment
azithromycin and paracetamol

4. • Patient in ER was vitally stable with no fever
• Neurological consultation done in ER :patient GCS 15/15 with no neurological abnormalities
detected , MRI brain done on same day with no abnormal findings. for psychiatric
consultation
MSE in ER :
• General appearance and behavior: Adult male, average body built ,average grooming
,hyperactive with agitation
• Thinking and speech : incoherent speech with pressure of speech
• Mood and affect: dysphoric congruent with affect
• Cognitive functions: patient is confused not orientd and inattentive
• For admission at psychiatry hospital .

5. • On 1st day of admission he became more agitated he recived 2 ampules Haloperidol 5
mg and Midazolam 5 mg im
• on 2nd day of admission patient developed fever 38c and tongue bitting with no
recorded fits
• Laboratory investigations were done on 1st Day after admission & were in normal range
except CK 1716
• CT chest revealed biletral ground glass opacities
• nasal swab pcr –ve

6. • following medications Haloperidol 5mg ampules 2x2 im and olanzapine sublingual 1x2
started after admission to psychiatric department on 1st 2 then ttt discontinued and started
Midazolam 5mg 1x2
• then patient was transferred to neuro ICU
• there intravenous fluids was initiated and Midazolam iv twice daily
• Acyclovir 750 Iv started empirically before Obtaining cerebrospinal fluid results
• Bromocriptine 2.5mg 1x3 and dantrolene
• Antibiotics started in icu Meropenem 1gm vial 1x3 and linezolid 600mg 1x2

7. • On 24th April Patient developed vomiting All over the day and the day after and controlled
by anti emetics
• MRI brain done on same day showing biletral temporal lobe T2 hyperintensity
• CSF analysis showing Increase Protein 119 N:23-38 mgdl Glucose 75 N:45-85 LDH 12
N:<5 cells
• Patient became eventually full conscious, alert and coherent with normal cognitive
function With a complete resolution of his agitation after 10 days of admission
• Patient discharged On 1st May on acyclovir 750mg oral 1x3 and pantoperazole 40mg 1x1
with advice for follow up outpatient after 2 weeks And 1 month rest from his work

8. DISCUSSION:
•COVID-19 Post-Infectious Encephalitis

9. INTRODUCTION
(COVID-19) caused by the new coronavirus (severe acute respiratory syndrome-coronavirus-2
[SARS-CoV-2]) in Wuhan, China, in 2019 became a global epidemic in 2020. Although SARS-
CoV-2 causes acute respiratory infections, it is often accompanied by neurological symptoms
such as headache, impaired consciousness, delirium, myopathy, and dyssomnia.
Also, various neurological complications such as cerebral infarction,
encephalitis/encephalopathy, and autoimmune diseases have been reported.

10. POST- VIRAL ENCEPHALITIS
• Encephalitis is an inflammation of the active tissues of the brain caused by an infection
or an autoimmune response ,that has been described as a severe neurological
complication of COVID- 19.
• Symptoms of encephalitis vary depending on the affected area of the brain.

11. INCIDENCE
• the incidence of encephalitis in COVID-19 patients is relatively low (<1%).
• But increases significantly to up to 6.7% in severely ill patients, defined as patients
requiring ICU or HDU care.

12. SYMPTOMS
Physical Symptoms
• Fever
• Seizures
• Headache
• Movement disorders
• Sensitivity to light
• Sensitivity to sound
• Neck stiffness
• Loss of consciousness
Cognitive Symptoms
• Excessive sleepiness
• Confusion and disorientation
• Irritability
• Anxiety
• Psychosis
• Hallucinations
• Memory loss
• Other behavioral changes
• Cognitive impairment

13. In severe cases, encephalitis symptoms may include:
• Weakness or partial paralysis in the arms and legs
• Double vision
• Impairment of speech or hearing
• Coma

14. SYMPTOMS DUE TO SPECIFIC TYPES
OF ENCEPHALITIS
• A sensation of déjà vu (the feeling that one is reliving something already experienced) is a
common finding in early stages of herpes simplex virus encephalitis.
• A type of autoimmune encephalitis affecting NMDA receptors can start with a flu-like illness. It
can then lead to behavioral changes and unusual movement patterns affecting the mouth and
face, cognitive decline and impaired function of the autonomic nervous system.
• Another type of autoimmune encephalitis (LGI1) is associated with seizures or other abnormal
movement of the face or arm.

15. INVESTIGATION
• Neuroimaging, such as a brain MRI or CT scan
• A lumbar puncture (spinal tap) to check for signs of infection in the brain or spinal cord
• Electroencephalogram (EEG) to look for seizures or specific patterns of electrical activity in the
brain
• Blood tests or urine and stool tests to identify organisms or antibodies responsible for an infection

16. IMAGING FINDINGS
• Common MRI Finding: white matter hyperintensities and hemorrhagic lesions on fluid-
attenuated inversion recovery and T2 sequences.
• CT head findings were generally unremarkable.
• Electroencephalography (EEG) in some patients showed patterns of general slowing.
• Although some patients developed seizures during their clinical course, sharp waves
and epileptiform activity were uncommon findings .

18. ADDITIONAL TESTS
• A sputum culture tests the material that is coughed up from the lungs to see if certain infections
are present.
• In rare cases, a biopsy of affected brain tissue may be performed to allow for examination under
a microscope.
• Intracranial pressure monitorin (ICP)
measures the pressure inside the skull to monitor the brain swelling.

19. TREATMENT
• The key to surviving encephalitis is early detection and effective treatment of the
underlying cause. A team of specialists working together is an important factor in optimal
care.
• Encephalitis patients might require a stay in the ICU so that health care providers can
watch for seizures, brain swelling, respiratory failure or heart rhythm changes.

20. PROGNOSIS
• During the encephalitis attack, the inflamed brain tissue can suffer damage, which varies greatly
between patients. In general, the brain doesn’t bounce back as quickly as other body parts such
as bone, skin and muscles, but it does have some capacity to recover.
• Mild cases of encephalitis are usually short and result in a full recovery. However, despite
improvements in diagnosis and treatment, encephalitis still leads to death in about 10% of
patients.
• Patients who suffer from encephalitis as a complication of COVID-19 have much poorer
outcomes compared to the general population of COVID-19 patients.