A PRESING NEUROLOGIC SEQUELA OF COVID-19 INFECTION A Say MD, C Griffin MD Department of Medicine, LSU Health Sciences Center, Baton Rouge, LA
INTRODUCTION: Delirium is a common complication of acute illness that is associated with substantial morbidity and mortality. A crucial component of the management of delirium is to identify the underlying cause, particularly reversible causes, which requires maintaining a broad differential. In this case, we discuss a rare cause of delirium, Posterior Reversible Encephalopathy Syndrome (PRES), that is nevertheless important to recognize as it can be intervened upon successfully with rapid, aggressive blood pressure control. CASE: A 29-year-old woman developed COVID-19 at 30 weeks of gestation. She was admitted at an outside facility and developed a uterine rupture prompting emergency caesarean section, with subsequent concern for an intrabdominal infection. She completed a course of antibiotics and was discharged home, but later returned with wound dehiscence as well as ascending weakness which caused multiple falls and hyperalgesia. Initial workup was notable for lumbar puncture with cerebral spinal fluid WBC of 6. She was transferred for additional neurologic evaluation after there was concern for seizure- like activity and she developed worsening encephalopathy. Vitals at admission were notable for blood pressure 158/87 mmHg, (previously 101/72 mmHg as an outpatient). Exam was notable for profound weakness of both the upper and lower extremities with diffuse hyporeflexia. Shortly after admission she again developed seizure-like activity. Urgent Magnetic Resonance Imaging of the brain noted diffuse, edematous changes bilaterally with diffusion restriction in the parietal and occipital lobes consistent with PRES. Her mental status rapidly improved with intravenous antihypertensives and she ultimately required five oral antihypertensive agents to discontinue parenteral therapy. Her strength slowly improved over the next three weeks following aggressive physical therapy, supportive care, and a trial of IVIG. DISCUSSION: This case demonstrates a rare cause of delirium, likely triggered by a cascade of events following COVID-19 infection. We suspect she developed acute inflammatory demyelinating polyneuropathy (AIDP) in the aftermath of COVID-19 during her pregnancy. In addition to causing motor and sensory changes, AIDP has also been known to cause autonomic dysfunction. We believe this dysautonomia then precipitated her rapid elevation of blood pressure, leading to PRES.
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