First case of Covid-19 presented with cerebral venous thrombosis: A rare and dreaded case.

Background

The corona virus disease 2019 (COVID-19) is a newly recognized infection which is pandemic [1], Patients with COVID-19 commonly have neurological manifestations [2]. COVID-19 presents with a variety of phenotypes range from asymptomatic to severe, rapid multiorgan dysfunction and death. The mechanisms are multifactorial but may include a hypercoagulable state with micro- and macro-circulatory thrombosis. The virus can bind to endothelial cells, damage the vessels and lead to platelet aggregation. The coagulation function is deranged [3]. Clots in the small vessels of all organs were described [4]. In this study we report an unusual presentation of COVID-19 with cerebral venous thrombosis (CVT).

Case report

A 65-year-old previously healthy male was admitted to the emergency department in ALzahra hospital, Isfahan, Iran with complaint of loss of consciousness, upward gaze and tongue biting. Upon arrival, he was drowsy .He had no focal neurological sign. Vital signs were remarkable for oxygen saturation of 90% on room air but otherwise stable. He didn’t have any complain of respiratory symptom. Blood investigation showed an increased white cell count with 6% lymphocytes, normal CRP and ESR but increased CPK and LDH. Brain imaging demonstrated hemorrhagic infarct in right temporal and right sigmoid and transverse sinus thrombosis (Fig. 1 ).

Fig. 1

A.computed tomography (CT) image showed hemorrhage in right temporal lobe B. Fluid-attenuated inversion recovery images showed hemorrhagic infarct. C. Magnetic resonance venography demonstrates right sigmoid and transverse sinus thrombosis.

Screening tests for a thrombophilic state were within normal amounts. Given that the patient had lymphopenia and low oxygen saturation, the chest CT was done which showed ground glass opacity (Fig. 2 ), also the real time PCR-test for COVID-19 was positive. Considering the diagnosis, he underwent anticoagulant, Levetiracetam, hydroxychloroquine and Co-amoxiclav. At day 10, he was discharged with good health. Patient's written consent was obtained for publication.

Fig. 2

Chest computed tomography.

Discussion

Coronaviridae members can cause neurological disease [5] but there are few studies about neurologic complications of COVID_19.ACE2 was identified as the receptor for COVID-19, which is present in nervous system and skeletal muscles so this virus infect these systems as well as the respiratory tract [2]. COVID-19 wildly reported to cause cytokine storm syndromes, which may cause acute cerebral disease. According to Mao et al., 36.4% of COVID-19 infected cases showed neurological manifestations. Acute cerebrovascular disease was reported in 5.7%. To our knowledge our patient is the first case of CVT associated with COVID-19.Our patient was a healthy male without any CVT susceptible conditions. He did not have common COVID-19 infection's symptoms. Considering lymphopenia and low oxygen saturation, evaluation of COVID-19 was done. Mao et al found that the lymphocyte count were lower for patients with CNS symptoms as described in our patient, this finding may be indicate of the immunosuppression in this group [2]. Elevated CPK and LDH was reported due to muscle injury in COVID-19, [2], but we do not know elevated CPK in our patient is resulting the seizure or muscle involvement. Our case highlights the importance of identifying CVT as a presenting sign of COVID-19.

Disclosure of interest

The authors declare that they have no competing interest.