COVID-19 Epilepsy

New-onset seizures in the context of SARS-CoV-2 infection

This neurology update summarises additional case reports on seizures and status epilepticus associated with COVID-19 in patients without a history of epilepsy.

SARS CoV-2 virus can result in a wide variety of neurological presentations. Following a neurology update in May 2020, we collate further SARS CoV-2-positive cases featuring new-onset seizures.

A 72-year-old man with end-stage renal disease[1] and a 54-year-old woman with a past medical history of anterior communicating artery aneurysm repair[2] developed COVID-19 and new-onset seizures.  The first patient had tonic-clonic movements of all four limbs, which temporarily resolved with levetiracetam but recurred prior to a fatal cardiac arrest.  The second patient had two right frontotemporal-onset seizures controlled with lacosamide, levetiracetam and phenytoin. Brain MRI subsequently revealed new demyelinating lesions of periventricular white matter, bulbo-medullary junction and spinal cord. CSF analysis, including RT-PCR for SARS-CoV-2, was unremarkable. High-dose steroid treatment was associated with a clinical improvement and she later transferred to rehabilitation without any sensorimotor deficits.

Four days after a single focal-to-bilateral tonic-clonic seizure, a 54-year-old man[3] presented with COVID-19. He received non-invasive ventilation and was discharged after two weeks. He remained seizure-free without any anti-seizure medicines.

A 59-year-old man with atrial fibrillation[4] received mechanical ventilation for COVID-19.  Two days after extubation, non-convulsive status epilepticus was recognised. Brain MRI, routine CSF analysis and CSF SARS-CoV-2 RT-PCR were normal, and there was no clinical suspicion of meningitis or encephalitis. 

A 41-year-old woman[5] with diabetes mellitus, and 41-year-old man[6] with well-controlled HIV both developed encephalopathy.  The female patient attended hospital after a first seizure with neck stiffness and photophobia. She started levetiracetam and had no further seizures. The male patient had an in-hospital tonic-clonic seizure with respiratory arrest requiring intubation and ventilation. 

Somani et al.[7] describe two women with COVID-19.  A 49-year-old presented with altered mental status after a witnessed seizure. Admission EEG confirmed status epilepticus. She was intubated and sedated, and given levetiracetam. Following extubation, she developed COVID-19 and eventually returned home on levetiracetam. A 73-year-old with sepsis had EEG-confirmed myoclonic status epilepticus with coma. She was treated with IV levetiracetam, lacosamide, phenytoin, and midazolam. Seizure activity resolved on EEG. However, she deteriorated due to multi-organ failure and died.

 

Key points:

  • Seizures, and even status epilepticus, can be an initial feature of SARS CoV-2 infection, without an encephalopathic picture.
  • Seizures can occur in the context of an encephalopathy.
  • Levetiracetam was used in most of these cases (probably because it allows intravenous use)

 

References:

  1. Sohal S, Mansur M. COVID-19 Presenting with Seizures. IDCases 2020;20:e00782. doi:10.1016/j.idcr.2020.e00782
  2. Zanin L, Saraceno G, Panciani PP, et al. SARS-CoV-2 can induce brain and spine demyelinating lesions. Acta Neurochir (Wien) Published Online First: 4 May 2020. doi:10.1007/s00701-020-04374-x
  3. Fasano A, Cavallieri F, Canali E, et al. First motor seizure as presenting symptom of SARS-CoV-2 infection. Neurol Sci Published Online First: 16 May 2020. doi:10.1007/s10072-020-04460-z
  4. Balloy G, Leclair-Visonneau L, Péréon Y, et al. Non-lesional status epilepticus in a patient with coronavirus disease 2019. Clin Neurophysiol Published Online First: May 2020. doi:10.1016/j.clinph.2020.05.005
  5. Duong L, Xu P, Liu A. Meningoencephalitis without respiratory failure in a young female patient with COVID-19 infection in Downtown Los Angeles, early April 2020. Brain Behav Immun Published Online First: April 2020. doi:10.1016/j.bbi.2020.04.024
  6. Haddad S, Tayyar R, Risch L, et al. Encephalopathy and seizure activity in a COVID-19 well controlled HIV patient. IDCases 2020;21:e00814. doi:10.1016/j.idcr.2020.e00814
  7. Somani S, Pati S, Gaston T, et al. De Novo Status Epilepticus in patients with COVID‐19. Ann Clin Transl Neurol 2020;:acn3.51071. doi:10.1002/acn3.51071