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Frequent Convulsive Seizures in an Adult Patient with COVID-19: A Case Report

Authors:
Iran Red Crescent Med J. 2020 March; 22(3):e102828.
Published online 2020 March 28.
doi: 10.5812/ircmj.102828.
Case Report
Frequent Convulsive Seizures in an Adult Patient with COVID-19: A
Case Report
Narges Karimi 1, * , Athena Sharifi Razavi2and Nima Rouhani 2
1Immunogenetics Research Center, School of Medicine, Clinical Research Development Unit of Bou Ali Sina Hospital, Mazandaran University of Medical Sciences, Sari, Iran
2School of Medicine, Clinical Research Development Unit of Bou Ali Sina Hospital, Mazandaran University of Medical Sciences, Sari, Iran
*Corresponding author: Bou Ali Sina Hospital, Pasdararn Blvd, Postal code: 4815838477, Sari, Iran. Tel: +98-1133343018 , Fax: +98-1133344506, Email: drkarimi_236@yahoo.com
Received 2020 March 18; Revised 2020 March 23; Accepted 2020 March 24.
Abstract
Introduction: Coronavirus disease 2019 (COVID-19) is a novel coronavirus that was extracted from patients with respiratory tract
infections. The most common symptoms of patients are fever and respiratory tract involvement. In this report, we describe one
patient with frequent seizures probably due to COVID-19 infection for the first time.
Case Presentation: A 30-year-old previously healthy female was admitted with generalized tonic-clonic seizure in the neurology
emergency room. The patient complained of dr y cough five days before the admission. She had seizures (five times) approximately
every 8 hours. Brain MRI was normal and chest CT revealed focal ground-glass opacities. The respiratory specimen was positive for
COVID-19 using real-time PCR assay. The symptoms of the patient improved with anticonvulsive and antiviral medications.
Conclusions: Tothe best of our knowledge, this is the first case study to report an association between frequent seizures and COVID-
19. In our opinion, there is a hypothesis about this subject that the etiology of seizure may be due to encephalitis and invasion virus
to the brain or toxic effect of inflammatory cytokines.
Keywords: Seizure, COVID-19, Novel Coronavirus, Case Report, Convulsion
1. Introduction
Coronavirus disease 2019 (COVID-19) is a novel coron-
avirus that was extracted from patients with respiratory
tract infection of unknown causes on December 31, 2019,
in Wuhan, Hubei, China (1-3). The infected patients’ symp-
toms ranged from asymptomatic to severe (4). The most
common complaints of patients are fever (98%), cough
(76%), dyspnea (55%), myalgia, and fatigue (44%) (5-7). Some
pieces of evidence reported gastrointestinal involvement,
acute cardiac injury, and acute kidney injury due to COVID-
19 (7,8). Mao et al. (9) reported neurological manifesta-
tions of patients with COVID-19. The most common symp-
toms were dizziness, headache, hypogeusia, and hypos-
mia (9). Severe patients had ischemic or hemorrhagic
stroke, and loss of consciousness (9). At this time, the like-
lihood of COVID-19 should be considered primarily in pa-
tients with fever and/or respiratory tract symptoms who
had close contact with a confirmed or suspected patient
of COVID-19 (1). Real-time polymerase chain reaction (real-
time PCR) and next-generation sequencing were used for
definitive diagnosis of this novel coronavirus (5). To the
best of our knowledge, up to now, no seizure was reported
due to COVID-19. In this report, we describe one patient
with frequent seizures probably owing to COVID19 for the
first time.
2. Case Presentation
A 30-year-old previously healthy female was admit-
ted with generalized tonic-clonic seizure in the neurol-
ogy emergency room in Bou Ali Sina Hospital, Mazandaran
Province, Iran. The patient had no history of drug and alco-
hol abuse. She complained of dry cough five days before
admission. Three days prior to admission, she had fever
(T = 38°C axillary) and fatigue. The first generalized tonic-
clonic seizure (GTC) of the patient occurred in the sleep,
two days before the admission. Then, recurrent seizures
(five times) happened approximately every 8 hours. Also,
one seizure attack arose in the hospital, at the admission
time. As the seizure ended, the patient was sleepy and con-
fused for thirty minutes to one hour. The patient was con-
scious between attacks. She neither had a history of epilep-
tic seizures nor a family history concerning seizure disor-
ders. At the time of hospitalization in the Emergency De-
partment, the body temperature was 38.8°C, blood pres-
sure 130/70 mmHg, heart rate 98 beats/minute, respiratory
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Karimi N et al.
rate 20/minute and oxygen saturation of 96% on room air.
The bedside serum glucose level was 108 mg/dL. In terms
of neurological examination, the patient was drowsy with
disorientation to time. The cranial nerves were intact.
Pupils were midsize and reactive to light and accommo-
dation. There was no optic disc swelling bilaterally. The
patient was able to move all four extremities and there
was no stiff neck and nuchal rigidity. Deep tendon reflexes
were normal. Considering general examination, no skin
rash was observed and other systems, including cardiac
and abdominal examination, were normal. Primary labo-
ratory tests discovered a normal blood sugar, electrolytes,
calcium, phosphor, magnesium, liver function test, urea,
and creatinine. The blood sample revealed the following
results: white blood cell count 5,500 cells per microliter
with 26% lymphocytes and 70% neutrophils, mildly ele-
vated erythrocyte sedimentation rate (ESR = 35 mm/hour),
and normal C-reactive protein (CRP). Lumbar puncture was
done and the cerebrospinal fluid (CSF) showed normal pro-
tein, glucose, with five cell counts (all of them were lym-
phocytes). There was no bacterial growth after 48 hours of
incubation. Brain MRI was normal. Given that the patient
had cough and fever, the chest computed tomography (CT)
was done and revealed focal ground-glass opacities (Fig-
ure 1). Respiratory specimens, including nasal and phar yn-
geal swabs, and CSF sample were tested for COVID-19 using
real-time PCR in the Health Center no. 5 (Shahid Ghasemi)
Laboratory. This center is under the supervision of Mazan-
daran University of Medical Sciences. Nasal and pharyn-
geal samples were positive for COVID-19. The CSF sample
was unremarkable for COVID-19 infection. The patient was
treated with intravenous phenytoin and levetiracetam. In
addition, the patient received chloroquine 200 mg BD and
Lopinavir-ritonavir 400/100 mg bd. The patient was mon-
itored for one week. Fever and seizure of the patient were
controlled.
3. Discussion
Coronavirus disease 2019 (COVID-19) is beta coron-
aviruses, similar to severe acute respiratory syndrome
coronavirus (SARS-CoV) in 2003 but with a different mono-
phyletic group. Both viruses bind to receptor angiotensin-
converting enzyme 2 (ACE2) to enter the cell (10,11). The
most well-known clinical symptoms of this virus are respi-
ratory symptoms. Moreover, Mao et al. (9) described neu-
rological presentations of infected patients with COVID-19.
The most common reported symptoms were headache and
dizziness. In this report, we reported a case with COVID-19
and frequent seizures, with no past medical history. There
are many different viruses that play a role in the develop-
ment of seizures and convulsions (12). The causes of seizure
Figure 1. Chest computer tomography in the patient with COVID-19 is shown
may be due to a primary infection or due to reactivation of
the latent virus. There are several mechanisms for the eti-
ology of seizure in the patients who suffer from viral infec-
tions, including direct infiltration of brain tissue and pro-
duction of toxins by the virus or production of inflamma-
tory mediators by the brain (13). Huang et al. (2) reported
that COVID-19 provokes the inflammatory cascade and as
a result, releases inflammatory cytokines, including inter-
leukins 2, 6, 7, and 10, tumor necrotizing αand the granu-
locyte colony-stimulating factor. Previous studies reported
that TNF-αand IL-6 cytokines and C3 of the complement
system are the main factors of stimulating the immune sys-
tem. Consecutively, these cytokines can drive neuronal hy-
perexcitability via activation of glutamate receptors and
play a role in the development of acute seizures(14-16).
3.1. Conclusions
To the best of our knowledge, this is the first case study
that reports an association between frequent seizures and
COVID-19. In our opinion, there is a hypothesis about this
subject that the etiology of seizure may be encephalitis
and the invasion of the virus to the brain or toxic effect of
inflammatory cytokines.
Acknowledgments
We thank the patient for her consent to publish the
case report.
2Iran Red Crescent Med J. 2020; 22(3):e102828.
Karimi N et al.
Footnotes
Authors’ Contribution: Study concept and design:
Narges Karimi and Nima Rouhani. Interpretation of
data: Narges Karimi and Athena Sharifi Razavi. Drafting
of the manuscript: Narges Karimi. Critical revision of
the manuscript for important intellectual content: Nima
Rouhani and Athena Sharifi Razavi.
Conflict of Interests: No conflict of interest was reported
regarding this case report.
Ethical Approval: Mazandaran University of Medical Sci-
ences approved the publication of this case report.
Funding/Support: Not applicable.
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Iran Red Crescent Med J. 2020; 22(3):e102828. 3
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Since the SARS outbreak 18 years ago, a large number of severe acute respiratory syndrome-related coronaviruses (SARSr-CoV) have been discovered in their natural reservoir host, bats1–4. Previous studies indicated that some of those bat SARSr-CoVs have the potential to infect humans5–7. Here we report the identification and characterization of a novel coronavirus (2019-nCoV) which caused an epidemic of acute respiratory syndrome in humans in Wuhan, China. The epidemic, which started from 12 December 2019, has caused 2,050 laboratory-confirmed infections with 56 fatal cases by 26 January 2020. Full-length genome sequences were obtained from five patients at the early stage of the outbreak. They are almost identical to each other and share 79.5% sequence identify to SARS-CoV. Furthermore, it was found that 2019-nCoV is 96% identical at the whole-genome level to a bat coronavirus. The pairwise protein sequence analysis of seven conserved non-structural proteins show that this virus belongs to the species of SARSr-CoV. The 2019-nCoV virus was then isolated from the bronchoalveolar lavage fluid of a critically ill patient, which can be neutralized by sera from several patients. Importantly, we have confirmed that this novel CoV uses the same cell entry receptor, ACE2, as SARS-CoV.
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A novel coronavirus (2019-nCov) was identified in Wuhan, Hubei Province, China in December of 2019. This new coronavirus has resulted in thousands of cases of lethal disease in China, with additional patients being identified in a rapidly growing number internationally. 2019-nCov was reported to share the same receptor, Angiotensin-converting enzyme 2 (ACE2), with SARS-Cov. Here based on the public database and the state-of-the-art single-cell RNA-Seq technique, we analyzed the ACE2 RNA expression profile in the normal human lungs. The result indicates that the ACE2 virus receptor expression is concentrated in a small population of type II alveolar cells (AT2). Surprisingly, we found that this population of ACE2-expressing AT2 also highly expressed many other genes that positively regulating viral reproduction and transmission. A comparison between eight individual samples demonstrated that the Asian male one has an extremely large number of ACE2-expressing cells in the lung. This study provides a biological background for the epidemic investigation of the 2019-nCov infection disease, and could be informative for future anti-ACE2 therapeutic strategy development.
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Background: A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods: All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings: By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0-58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0-13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation: The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding: Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
Article
Objective: To analyze the clinical characteristics of 2019 novel coronavirus (2019-nCoV) pneumonia and to investigate the correlation between serum inflammatory cytokines and severity of the disease. Methods: 29 patients with 2019-ncov admitted to the isolation ward of Tongji hospital affiliated to Tongji medical college of Huazhong University of Science and Technology in January 2020 were selected as the study subjects. Clinical data were collected and the general information, clinical symptoms, blood test and CT imaging characteristics were analyzed. According to the relevant diagnostic criteria, the patients were divided into three groups: mild (15 cases), severe (9 cases) and critical (5 cases). The expression levels of inflammatory cytokines and other markers in the serum of each group were detected, and the changes of these indicators of the three groups were compared and analyzed, as well as their relationship with the clinical classification of the disease. Results: (1) The main symptoms of 2019-nCoV pneumonia was fever (28/29) with or without respiratory and other systemic symptoms. Two patients died with underlying disease and co-bacterial infection, respectively. (2) The blood test of the patients showed normal or decreased white blood cell count (23/29), decreased lymphocyte count (20/29), increased hypersensitive C reactive protein (hs-CRP) (27/29), and normal procalcitonin. In most patients,serum lactate dehydrogenase (LDH) was significantly increased (20/29), while albumin was decreased(15/29). Alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (Tbil), serum creatinine (Scr) and other items showed no significant changes. (3) CT findings of typical cases were single or multiple patchy ground glass shadows accompanied by septal thickening. When the disease progresses, the lesion increases and the scope expands, and the ground glass shadow coexists with the solid shadow or the stripe shadow. (4) There were statistically significant differences in the expression levels of interleukin-2 receptor (IL-2R) and IL-6 in the serum of the three groups (P<0.05), among which the critical group was higher than the severe group and the severe group was higher than the mildgroup. However, there were no statistically significant differences in serum levels of tumor necrosis factor-alpha (TNF-α), IL-1, IL-8, IL-10, hs-CRP, lymphocyte count and LDH among the three groups (P>0.05). Conclusion: The clinical characteristics of 2019-nCoV pneumonia are similar to those of common viral pneumonia. High resolution CT is of great value in the differential diagnosis of this disease. The increased expression of IL-2R and IL-6 in serum is expected to predict the severity of the 2019-nCoV pneumonia and the prognosis of patients.
Article
Background The chest CT findings of patients with 2019 Novel Coronavirus (2019-nCoV) pneumonia have not previously been described in detail.PurposeTo investigate the clinical, laboratory, and imaging findings of emerging 2019-nCoV pneumonia in humans.Materials and Methods Fifty-one patients (25 men and 26 women; age range 16-76 years) with laboratory-confirmed 2019-nCoV infection by using real-time reverse transcription polymerase chain reaction underwent thin-section CT. The imaging findings, clinical data, and laboratory data were evaluated.ResultsFifty of 51 patients (98%) had a history of contact with individuals from the endemic center in Wuhan, China. Fever (49 of 51, 96%) and cough (24 of 51, 47%) were the most common symptoms. Most patients had a normal white blood cell count (37 of 51, 73%), neutrophil count (44 of 51, 86%), and either normal (17 of 51, 35%) or reduced (33 of 51, 65%) lymphocyte count. CT images showed pure ground-glass opacity (GGO) in 39 of 51 (77%) patients and GGO with reticular and/or interlobular septal thickening in 38 of 51 (75%) patients. GGO with consolidation was present in 30 of 51 (59%) patients, and pure consolidation was present in 28 of 51 (55%) patients. Forty-four of 51 (86%) patients had bilateral lung involvement, while 41 of 51 (80%) involved the posterior part of the lungs and 44 of 51 (86%) were peripheral. There were more consolidated lung lesions in patients 5 days or more from disease onset to CT scan versus 4 days or fewer (431 of 712 lesions vs 129 of 612 lesions; P < .001). Patients older than 50 years had more consolidated lung lesions than did those aged 50 years or younger (212 of 470 vs 198 of 854; P < .001). Follow-up CT in 13 patients showed improvement in seven (54%) patients and progression in four (31%) patients.Conclusion Patients with fever and/or cough and with conspicuous ground-glass opacity lesions in the peripheral and posterior lungs on CT images, combined with normal or decreased white blood cells and a history of epidemic exposure, are highly suspected of having 2019 Novel Coronavirus (2019-nCoV) pneumonia.© RSNA, 2020.
Article
Background: In December, 2019, a pneumonia associated with the 2019 novel coronavirus (2019-nCoV) emerged in Wuhan, China. We aimed to further clarify the epidemiological and clinical characteristics of 2019-nCoV pneumonia. Methods: In this retrospective, single-centre study, we included all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data. Outcomes were followed up until Jan 25, 2020. Findings: Of the 99 patients with 2019-nCoV pneumonia, 49 (49%) had a history of exposure to the Huanan seafood market. The average age of the patients was 55·5 years (SD 13·1), including 67 men and 32 women. 2019-nCoV was detected in all patients by real-time RT-PCR. 50 (51%) patients had chronic diseases. Patients had clinical manifestations of fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). According to imaging examination, 74 (75%) patients showed bilateral pneumonia, 14 (14%) patients showed multiple mottling and ground-glass opacity, and one (1%) patient had pneumothorax. 17 (17%) patients developed acute respiratory distress syndrome and, among them, 11 (11%) patients worsened in a short period of time and died of multiple organ failure. Interpretation: The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection. Funding: National Key R&D Program of China.