Acute necrotizing encephalopathy and myocarditis in a young patient with COVID-19

A 33-year-old woman, previously healthy was admitted with generalized status epilepticus. Four days before, she had developed generalized fatigue, fever, headache, and nasal congestion. On hospital arrival, she was comatose (Glasgow coma scale 5 [E1/V1/M3]), febrile (38.6°C), tachycardic (145/min) with a blood pressure of 100/60 mm Hg, and tachypneic (35/min) with hypoxemia (pulse oximetry 80%). She was emergently intubated and started on mechanical ventilation and received IV midazolam and valproic acid for seizure control. Chest x-ray showed mild edema. The initial blood test results showed elevated myocardial enzymes; high-sensitivity troponin-I, 2,210 pg/mL; probrain natriuretic peptide, 992 pg/mL; creatine phosphokinase, 1858 mcg/L; and creatine kinase-MB, 22.5 ng/mL. Blood count revealed a white blood cell count of 14550/μL with absolute lymphopenia of 0.92/μL. C-reactive protein and erythrocyte sedimentation rate levels were high, whereas procalcitonin and lactic acid were normal. ECG showed sinus tachycardia and diffuse ST segment elevation. Bedside echocardiography showed diffuse myocardial dyskinesia with low left ventricular ejection fraction (29%) and small pericardial effusion. Head CT showed diffuse brain edema.