SYNOPSIS Encephalopathy and Encephalitis Associated with Cerebrospinal Fluid Cytokine Alterations and Coronavirus Disease, Atlanta, Georgia, USA, 2020 Karima Benameur,1 Ankita Agarwal,1 Sara C. Auld, Matthew P. Butters, Andrew S. Webster, Tugba Ozturk, J. Christina Howell, Leda C. Bassit, Alvaro Velasquez, Raymond F. Schinazi, Mark E. Mullins, William T. Hu There are few detailed investigations of neurologic unnecessary staff exposure and difficulties in estab- complications in severe acute respiratory syndrome lishing preillness neurologic status without regular coronavirus 2 infection. We describe 3 patients with family visitors. It is known that neurons and glia ex- laboratory-confirmed coronavirus disease who had en- press the putative SARS-CoV-2 receptor angiotensin cephalopathy and encephalitis develop. Neuroimaging converting enzyme 2 (7), and that the related coro- showed nonenhancing unilateral, bilateral, and midline navirus SARS-CoV (responsible for the 2003 SARS changes not readily attributable to vascular causes. All 3 outbreak) can inoculate the mouse olfactory bulb (8). patients had increased cerebrospinal fluid (CSF) levels If SARS-CoV-2 can enter the central nervous system of anti-S1 IgM. One patient who died also had increased (CNS) directly or through hematogenous spread, ce- levels of anti-envelope protein IgM. CSF analysis also rebrospinal fluid (CSF) changes, including viral RNA, showed markedly increased levels of interleukin (IL)-6, IgM, or cytokine levels, might support CNS infec- IL-8, and IL-10, but severe acute respiratory syndrome coronavirus 2 was not identified in any CSF sample. tion as a cause for neurologic symptoms. We report These changes provide evidence of CSF periinfectious/ clinical, blood, neuroimaging, and CSF findings for postinfectious inflammatory changes during coronavirus 3 patients with laboratory-confirmed COVID-19 and disease with neurologic complications. a range of neurologic outcomes (neuro-COVID). We also show the presence of SARS-CoV-2 antibodies in he pandemic caused by severe acute respiratory the blood and CSF of these patients, consistent with Tsyndrome coronavirus 2 (SARS-CoV-2) has led CNS penetration of disease. to >1.5 million infections in the United States (30% of global cases) and >90,000 deaths as of May 20, Methods 2020 (1). Coronavirus disease (COVID-19, the clini- We describe the clinical, laboratory and radiologic cal syndrome associated with SARS-Cov-2) is most findings for 3 patients with respiratory failure and commonly characterized by respiratory illness and neurologic complications caused by COVID-19. This viral pneumonia with fever, cough, and shortness of case series was reviewed and exempted from Emory breath, and progression to acute respiratory distress Institutional Review Board approval. Medical re- syndrome in severe cases (2). cords were reviewed by 4 of the coauthors (K.B., A.A., Although neurologic complications have been M.E.M., and W.T.H.). noted in previous human coronavirus infections (3– 5), there are few in-depth investigations for neurolog- CSF Serologic Analysis, Cytokines, and ic syndromes associated with SARS-CoV-2 infection Molecular Testing (6). This deficiency can result from the need to reduce We assessed CSF IgM by using an in-house ELISA against SARS-CoV-2 S1 or envelope (E) protein. This Author affiliation: Emory University School of Medicine, Atlanta, ELISA was modified from an in-house blood-based Georgia, USA DOI: https://doi.org/10.3201/eid2609.202122 1These authors contributed equally to this article. 2016 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 9, September 2020 Encephalopathy/Encephalitis and Coronavirus Disease ELISA with 90% sensitivity and 89% specificity for hydroxychloroquine (400 mg daily) and peramivir confirmed COVID-19 against 78 pre-2020 controls. CSF (100 mg daily), but acute kidney injury and progres- was serially diluted from 1:2 to 1:16, and CSF from 1 sive hypoxemic respiratory failure developed. She was case-patient who had HIV infection (hospitalized dur- intubated and transferred to our institution on day 11. ing March 2020) and from 3 pre-2020 healthy subjects Her paralysis and sedation were discontinued on day (9) were included for comparison. We measured levels 13 after improved oxygenation, but she remained co- of plasma IgG against the receptor-binding domain of matose with absent brainstem reflexes on day 15. S1 by using a commercial ELISA (GenScript, https:// Brain magnetic resonance imaging (MRI) showed www.genscript.com) at a 1:16 dilution. nonenhancing cerebral edema and diffusion weighted We analyzed CSF inflammatory proteins (Milli- imaging abnormalities predominantly involving the poreSigma, https://www.emdmillipore.com) by us- right cerebral hemisphere, as well as brain herniation ing a Luminex-200 platform and a modified manufac- (Figure 1). An occlusive thrombus was identified in the turer’s protocol as described (9). These proteins include right internal carotid artery, and edema was also identi- interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-6, IL-7, IL-8, fied in the cervical spinal cord. The overall appearance IL-9, IL-10, IL12-p40, IL12-p70, interferon-gamma–in- was most consistent with encephalitis and myelitis, with duced protein 10 (IP-10), monocyte chemoattractant superimposed hypoxic ischemic changes. CSF showed protein 1 (MCP-1/CCL2), macrophage-derived che- high opening pressure of 30 cm of water, 115 nucleated mokine (MDC/CCL22), fractalkine (CX3CL1), and tu- cells/mL, 7,374 erythrocytes/mL, an increased protein mor necrosis factor α (TNF-α). level (>200 mg/dL), and a glucose level within a stan- We performed molecular testing for SARS-CoV-2 dard range (Table). Her nucleated cell count remained by using real-time quantitative reverse transcription strongly increased even after correction for the trau- PCR (qRT-PCR). We extracted total nucleic acid from matic tap (≈1 nucleated cell/700 erythrocytes). Given 120 µL of CSF from each person by using the EZ1 Vi- a grave prognosis, the family withdrew life-sustaining rus Mini Kit version 2.0 and the EZ1 Advanced XL In- care and the patient died on day 16. strument (QIAGEN, https://www.qiagen.com) after Patient 2, a 34-year-old African-American man lysis with AVL lysis buffer (QIAGEN). We performed who had hypertension, showed development of fever, a 1-step qRT-PCR by using 2019-nCoV_N1 or 2019- shortness of breath, and cough. Computed tomog- nCoV_N2 combined Primer/Probe Mix (Integrated raphy of the chest showed bilateral, diffuse ground DNA Technologies, Inc., https://www.idtdna.com) glass infiltrates. A nasopharyngeal swab specimen in a Roche LightCycler 480 II (https://lifescience. obtained on day 1 showed SARS-CoV-2. He was roche.com), an endogenous control, and an in vitro given a 6-day course of hydroxychloroquine, but hy- transcribed full-length RNA of known titer (Integrat- poxic respiratory failure developed, which required ed DNA Technologies, Inc.) as a positive control. We intubation, followed by encephalopathy with myoc- followed the same procedure for influenza A virus lonus on day 9. His neurologic examination showed except using a primer/probe mixture (10) and a mito- profound encephalopathy, absent corneal and gag chondrial cytochrome oxidase subunit 2 DNA endog- reflexes, multifocal myoclonus involving both arms, enous control (11). We tested all samples in duplicate. and absent withdrawal to painful stimuli. Electroen- cephalography showed diffuse slowing with a sug- Results gestion that the myoclonus was seizure-related. Brain MRI on day 15 showed a nonenhancing hyperintense Clinical, Radiologic, and Laboratory Assessment lesion within the splenium of the corpus callosum Patient 1, a 31-year-old African-American woman on fluid-attenuated inversion recovery and diffusion who had sickle cell disease (SCD) and was receiving weighted imaging sequences (Figure 1). CSF showed dabigatran for a recent pulmonary embolus, came to high opening pressure of 48 cm H2O, no pleocytosis, a community hospital after 5 days of progressive dys- 27 erythrocytes/mL, a mildly increased protein level, pnea. An initial chest radiograph showed a right lower and glucose level within the reference range. lobe infiltrate, and she was given a blood transfusion Patient 3, a 64-year-old African-American man and antimicrobial drugs for presumed SCD crisis and who had hypertension, showed development of cough, pneumonia. Her breathing became more labored, and dyspnea, and fever with multifocal, patchy, ground a repeat chest radiograph showed worsening bilat- glass opacities on chest computed tomography and eral infiltrates. A nasopharyngeal swab specimen was a nasopharyngeal swab specimen positive for SARS- positive for SARS-CoV-2 and influenza A virus (nega- CoV-2. His symptoms progressed to hypoxic respira- tive for influenza B virus). She was empirically given tory failure requiring intubation, and his multifocal Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 9, September 2020 2017 SYNOPSIS myoclonus began soon after starting to take hydroxy- Serologic Analysis of Plasma and CSF chloroquine. His neurologic examination showed pro- Plasma anti-S1 receptor-binding domain IgG levels found encephalopathy, absent oculocephalic reflex, were increased for all 3 patients, consistent with se- multifocal myoclonus affecting bilateral arms and vere COVID-19 (T. Ozturk et al., unpub. data). An in- legs, absent withdrawal to pain, and diminished deep direct ELISA for plasma showed an increased level of tendon reflexes.