Case #2
An 82-year-old male patient with chronic obstructive pulmonary disease, venous thromboembolic disease, complete heart block, and chronic kidney disease presented to the emergency department with a 10-day history of progressive dyspnea, altered mental status, and generalized weakness. He was found to be hypoxic, febrile, and tachycardic. He was intubated for acute hypoxemic respiratory failure with a chest X-ray showing lung infiltrates consistent with pneumonitis. The patient’s laboratory results were significant for lymphopenia (WBC 3.26 k/μl, absolute lymphocyte count 0.70), coagulopathy (international normalised ratio (INR) 2.5, partial thromboplastin time (PTT) 53.9), elevated D-dimer (590 ng/mL), thrombocytopenia (132 k/μl), acute kidney injury (blood urea nitrogen (BUN) 47 mg/dL, creatinine 3.96 mg/dL), and elevated C-reactive protein initially 12.5 mg/L and increased to 26.2 mg/L. A nasopharyngeal swab polymerase chain reaction (PCR) test for COVID-19 was sent on admission and was positive 24 h later. Continuous video electroencephalogram (EEG) monitoring was ordered on day 5 of admission after events of right eyelid and facial twitching were observed by the care team. Frequent EEG seizures were captured independently from the left more than right frontal–temporal regions (Fig. 3) which eventually progressed to focal status epilepticus. The majority of seizures were non-convulsive. Seizure frequency improved after treatment with levetiracetam. A non-contrast CT-brain demonstrated hypodensities within the supratentorial white matter, consistent with mild microvascular disease but without acute intracranial lesion. He was unable to have an MRI brain performed due to an incompatible cardiac pacemaker. Further vessel imaging was unable to be performed due to patients acute on chronic kidney injury. A lumbar puncture was unable to be performed due to worsening coagulopathy (INR 3.8, PTT 73.5). Patient remained on the ventilator, and after 20 days of ICU stay, the family opted for withdrawal of life-sustaining support.
Fig. 3 Electroencephalography. Rhythmic discharges evolving in the left frontotemporal (a) region and spreading anteriorly and posteriorly (b) corresponding to right facial clonic movements