This is a 26-year-old male patient, he recently experienced symptoms of generalized weakness and headache for one week, after which he tested positive for SARS-CoV-2. After 10 days, he received the Sputnik V vaccine, which caused a strange euphoric state. Two days later, his relatives reported he was feeling weak and had no energy. With medical history of anaplastic medulloblastoma, treated with 28 sessions of radiotherapy and 4 sessions of chemotherapy with cisplatin and etoposide, as well as two surgical interventions.
By August 2021, his condition had worsened, with increased dysarthria and difficulty walking, with cerebellar ataxic gait to the left, as well as tension-type headaches of variable intensity reaching 10/10 on the VAS scale without associated nausea or vomiting. With no improvement in their symptoms, they went to a private doctor, who requested a computerized axial tomography of the skull (Fig. 1). This revealed a hypodense lesion in the right thalamus with a hyperdense border and punctiform hemorrhage extending to the posterior arm of the internal capsule, measuring 4.3 x 3.5 x 2.2 cm in its three axes. This lesion was compressing the interventricular foramen and third ventricle, resulting in increased lateral ventricle amplitude.
Diagnostic challenges (such as access to testing, financial, or cultural)
Upon evaluation at the emergency department one week later, the patient was found to be awake, oriented, and focused, and could maintain attention for periods. Mixed dysarthria persisted, characterized by being flaccid and hypokinetic. Examination of the cranial nerves was without alterations. Motor exploration revealed increased reflexes of +++ and left patellar clonus. Gait was supported, but with an expanded support base and instability when standing in multiple directions. In addition to ataxia, limb dysmetria was seen in the upper limbs when performing the nose-finger test, with left-sided predominance. Generalized dysdiadochokinesia and dyssynergia of the four extremities were observed when performing the overshooting and Steward-Holmes maneuvers.
A cerebrospinal fluid analysis was performed, which revealed only a few reactive and mature lymphocytes with no evidence of microorganisms or neoplastic cells in the sample. Magnetic resonance imaging of the skull (Fig. 2) showed multiple hemorrhagic lesions with surrounding edema in the right thalamus with an extension to the posterior arm of the internal capsule, smaller one, in the left thalamus and another expanded to the ipsilateral peduncle. All sequences showed heterogeneous hypointense behavior, indicating chronic bleeding coupled with the presence of perilesional edema.
After analyzing the imaging studies and performing positive PCR for SARS-CoV-2 in the cerebrospinal fluid, the diagnosis of post-covid hemorrhagic encephalitis was established, and treatment with methylprednisolone boluses was initiated, showing signs of improvement.
The patient relatives first opted to discharge him for him to undergo private therapy. They eventually changed their minds and brought him back to our facility, where he was readmitted. Despite receiving plasmapheresis five times, there was no discernible clinical improvement in his condition. Additionally, the existence of supratentorial hydrocephalus exacerbated his degree of consciousness. As a result, it was decided to place a ventriculoperitoneal shunt to address the condition.
Due a poor secretion management, lung infection was corroborated by an imaging study (Fig. 3), so broad-spectrum antibiotic treatment, mechanical ventilation, and management with amines due to circulatory compromise was initiated, which evolved satisfactorily after 7 days, and this treatment was withdrawn. For discharge, a gastrostomy probe was placed, and control magnetic resonance imaging with follow-up in outpatient consult was requested for monitoring of both the medulloblastoma and the hemorrhagic encephalitis processes.