Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus can affect both the central and peripheral nervous system, and SARS neurological manifestations have also been rarely reported in children. We herein report COVID-19 encephalitis in a 13-year-old girl, who presented with status epilepticus and altered sensorium and had complete resolution of neurological symptoms in 48 hours.

A 13-year-old girl presented with fever for 2 days associated with headache and an episode of generalized tonic clonic seizures on day 2 of fever lasting for more than 30 minutes. She was treated with intravenous lorazepam and phenytoin sodium and in view of persistence of seizures and altered sensorium, she was referred to our center for further care. There was no history of cough, vomiting, head trauma, rash or drug ingestion. She was first born to non-consanguineous parents and developmentally normal for age. There was no past or family history of seizures. On examination at admission, she was febrile (100°F), irritable and had altered sensorium. She had brisk deep tendon reflexes with an extensor plantar response. There were no signs of meningeal irritation. Her pupils were equal and reacting to light. There was no papilledema or focal neurological deficits. Cardiopulmonary and abdomen exami-nation were normal. Her investigations revealed normal white cell counts and negative CRP. Her serum electrolytes including calcium and magnesium, liver function tests were normal. MRI brain was normal. Cerebrospinal fluid (CSF) analysis showed 200 white blood cells/mm3 all lymphocytes with protein, 86 mg/dL, sugar, 77 mg/dL (corresponding blood sugar:126 mg/dL). CSF gram stain, AFB stain, bacterial culture and Xpert gene TB were negative. CSF biofire film array multiplex PCR was negative for viruses (CMV, HSV, entero and varicella). Nasopharyngeal aspirate for SARS-CoV-2 by qualitative RT-PCR was positive (cycle threshold: 27.26). Computed tomography (CT) chest showed patchy peripheral ground glass opacities involving the posterior segment of the right upper lobe and lateral segment of right middle lobe (COVID score 5/40). However, RT-PCR in CSF sample was negative for SARS -CoV- 2 virus. Her EEG was normal. She was treated with leveti-racetam and ceftriaxone. Within 48 hours of admission, she became afebrile, her sensorium improved and had no recurrence of seizures and ceftriaxone was stopped once CSF and blood cultures were reported sterile and was discharged home in a normal neurological state.

COVID-19 viral encephalitis was probably first reported by McAbee, et al. [1] in a 11-year- old male child whose nasopharyngeal swab was positive for COVID-19, whereas CSF was negative and the boy recovered without any specific treatment in six days. SARS-CoV-2 from the nose reaches CSF either by olfactory ensheathing cells, olfactory receptor neuron or by disrupting the respiratory epithelium then enters the blood stream and then enters brain through disrupted blood brain barrier, either caused by inflammation or by using angiotensin converting enzyme-2 (ACE-2) receptors present in the blood brain barrier endothelial cells, thereby resulting in viral proliferation, neuronal injury and damage [2]. Virus induced immunologic response also leads to swelling of the brain resulting in increasing cerebrospinal fluid pressure thereby resulting in alteration in consciousness. Abdel-Mannan, et al. [3] from UK had reported four children aged 8-15 years who had new onset encephalopathy and proximal muscle weakness. All of them were positive for SARS-CoV-2 virus in nasopharyngeal samples, and CSF (done only in 2 children) was negative for COVID-19 [3]. Neurologic improvement was seen in all of them. Acute splenial lesions were seen in four children [4] whereas, in our case, we could not identify any changes in the splenium of the corpus callosum. The neurological mani-festations reported in COVID 19 are protean [4]. CSF pleocytosis (>5 WBC with predominant lymphocytes) that is characteristically seen in viral encephalitis, was seen in this girl. RT-PCR assays of the CSF samples being negative for SARS-CoV-2 in patients with neurological manifestations has not only been described in children [1,3] but even in adult patients and this dependes on the severity of the systemic illness, the neurotropic properties of the virus, and immune-mediated inflammatory mechanisms [5,6]. It has been earlier reported that RT-PCR of nasopharyngeal specimen for SARS-CoV-2 appears to be a useful investigation for confirmation of COVID-19 even in children with neurological presentation and children have a favorable outcome [7], as seen in our cases.

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