Coronavirus disease 2019 (COVID-19) is a viral disease that was unknown to humans before December 2019.1 The virus is very similar to middle east respiratory syndrome and severe acute respiratory syndrome (SARS) and can cause viral pneumonia with different severity.2–4 It seems that the clinical spectrum of SARS-coronavirus-2 infection is vast and pervasive, including asymptomatic infection, mild upper respiratory tract infection and severe viral pneumonia associated with respiratory failure and even death.2,3
It is also reported that COVID-19 causes involvement in other organs of the body.5 Some patients with COVID-19 may have neurologic symptoms.6
Meningitis is a neurologic disease characterized by inflammation of the protective membranes of the brain.7 The most common causes of viral meningitis are enteroviruses. However, arboviruses and herpes viruses are also important etiologic factors. Mumps, lymphocytic, choriomeningitis virus, herpes zoster, herpes virus type 6 and influenza virus are the less common causes of meningitis.8 This article is a report of COVID-19–associated viral meningitis in a 9-year-old child.
A 9-year-old Iranian Turkish girl referred to the Emergency Department of Imam Hassan Hospital in Bojnurd with no history of internal disease and the complaint of fever, headache and low back pain, 3 days after the onset of symptoms. The child’s uncle had COVID-19 and contacted the child and his family before the clinical symptoms appeared. Vital signs were controlled and monitored by a pediatrician: temperature: 37.4, pulse rate: 76, blood pressure: 80/50, oxygen saturation: 98%.
In the patient’s clinical examination, head and neck muscle stiffness were evident, and his Brudzinski and Kernig tests were positive. Also, photophobia and diplopia with limited movement in the right eye and sixth nerve paralysis were seen. In blood tests, following results were observed: lactate dehydrogenase: 501 U/L and leukocytosis as white blood cell count: 19,000 with 88% neutrophils, 6% lymphocytes and 6% monocytes. C-reactive protein: ++ and erythrocyte sedimentation rate: 108 mm/h were also specified.
In examining the right eye, brief edema was seen, and he was treated with lumbar puncture with suspicion of bacterial meningitis. Due to the pandemic of COVID-19, the patient underwent a polymerase chain reaction (PCR) test for COVID-19 and enterovirus, which resulted in a positive cerebrospinal fluid (CSF) sample for COVID-19 and negative for enterovirus (Table 1), but his pharyngeal PCR test was negative. He underwent a chest radiograph immediately, which showed no signs of pulmonary involvement (Figure 1).
TABLE 1. -
Findings From the CSF Analysis
RBC indicates red blood cells; RT-PCR, reverse transcription polymerase chain reaction; TCC, terminal complement complex; WBC, white blood cell count.
Since the result of the patient’s initial CSF culture was negative, the Gram-negative bacteria did not grow, and the patient’s general condition improved after drug treatment, lumbar puncture was not performed for CSF reanalysis.
He was prescribed ceftriaxone and vancomycin and oral hydroxychloroquine sulfate. Based on the CSF results analysis, due to neutrophilic pleocytosis, increased CSF protein and decreased CSF glucose and negative bacterial CSF culture and blood culture, the possibility of bacterial meningitis was given. Therefore, the antibiotic medication was discontinued. However, due to the positive CSF PCR for COVID-19, the patient continued receiving hydroxychloroquine sulfate 200 mg tab. Finally, he was diagnosed with viral meningitis.
His headache and fever during hospitalization were controlled by oral acetaminophen after 3 days. Finally, he was discharged after 10 days of hospitalization, regular monitoring of vital signs, reduced initial clinical manifestations, erythrocyte sedimentation rate: 20 mm/h, white blood cell count: 14,100 and without respiratory manifestations of the disease.
COVID-19 was declared an epidemic by the World Health Organization.1 This disease’s symptoms were initially explicitly reported for the respiratory system and acute respiratory diseases.2 However, we have witnessed involvements in other body organs such as the cardiovascular system, kidneys and liver.9,10 Sometimes infected patients may also have no symptoms.2 Reverse transcription-PCR is currently used to identify and diagnose patients with symptoms of COVID-19.11 However, this method was not available at the onset of the pandemic, and the presence of a high false-negative rate can impair the diagnosis.12 However, other paraclinical methods such as lung high-resolution computed tomography can help the diagnose.13
Meningitis is a neurologic disease characterized by inflammation of the protective membranes of the brain.7 Viruses are likely to make up the majority of cases of acute meningitis.14 The most common causes of viral meningitis are enteroviruses. However, even with recent advances in molecular diagnosis, our understanding of the viral causes of meningitis and encephalitis leads to early diagnosis of this disease.15 This disease’s highest incidence is observed in infants under 1-year-old and children between 5 and 10 years old.8 The onset of viral meningitis is sudden and is accompanied by fever. Symptoms begin with euthermia and then neurologic symptoms appear.16 Infants usually show nonspecific findings such as poor nutrition, vomiting, exanthema and respiratory tract findings.8 In older children, adolescents and adults, symptoms may include anorexia, vomiting, headache, myalgia, upper and lower respiratory tract symptoms and abdominal pain.17
This study is a case report of COVID-19–associated with viral meningitis. After the coronavirus pandemic outbreak, we witness a wide range of clinical signs of SARS-coronavirus-2 infection and new symptoms of the disease. The appearance of new symptoms of the disease sometimes interferes with the diagnosis and effective treatment of the disease. Due to human coronaviruses’ nature, we may see other viral diseases associated with it in the future.
The researchers highly appreciate the Pediatric department of the Imam Hassan Medical Educational Center and the vice presidency of North Khorasan University of Medical Sciences research.
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