Coronavirus Disease 2019-associated Cytotoxic Lesions of the Corpus Callosum Diagnosis As a Result of Hallucination in a Child With Multisystem Inflammatory Syndrome in Children
Articles > Article · 2021
Authors: Miray Yılmaz Çelebi, Tülay ÖZTÜRK ATASOY, Ela Cem, Şahika Şahinkaya, Elif Kiymet, Nuri Bayram, İlker Devrim
Pediatric Infectious Disease Journal, International, WoS, 2021, vol 40, pp e283-e284
DOI: 10.1097/inf.0000000000003186
Summary
To the Editors: A previously healthy 11-year-old boy with cytotoxic lesions of the corpus callosum (CLOCC) presented with hallucination during hospitalization for coronavirus disease 2019 (COVID-19)-associated multisystem inflammatory syndrome in children (MIS-C). CLOCC is rare in children. The patient was admitted to the University of Health Sciences, Dr. Behçet Uz Children’s Hospital with a history of vomiting for 3 days and fever for 1 day. On examination, he was normal except for bilateral conjunctival hyperemia and fever. The patient’s father had been diagnosed as COVID-19 approximately 45 days earlier. Nasal swab sample for COVID-19 real-time polymerase chain reaction was negative, serum IgG antibody specific to COVID-19 was positive. The laboratory tests revealed lymphopenia, hyponatremia, and elevations in serum levels of C-reactive protein, erythrocyte sedimentation rate, procalcitonin, ferritin, D-dimer, and fibrinogen. Blood cultures were negative, and his chest radiograph and echocardiography were normal. He was diagnosed as MIS-C and administered intravenous immunoglobulin, glucocorticoid, ceftriaxone, and intravenous fluid replacement therapy. On the first day of admission, he had auditory and visual hallucinations. It was learned that he had experienced hallucinations 1 day before the admission. Neurologic examination was normal. Cranial magnetic resonance imaging (MRI) revealed “oval focal lesion and diffusional restriction in splenium part of the corpus callosum and accompanying signal increase in T2-FLAIR-weighted images that were consistent with CLOCC” (Fig. 1). The hallucinations stopped after 2 days. Echocardiography was repeated because of hypotension during follow-up and myocarditis, and pericardial effusion was detected. These findings resolved on the fifth day of the patient’s hospitalization, and all clinical findings and laboratory values were normal the 15th day.FIGURE 1.: Axial T2-weighted magnetic resonance imagining (A) shows an ovoid focal lesion in the splenium of corpus callosum. Axial diffusion-weighted magnetic resonance imagining (B) and apparent diffusion coefficient map (C) show restricted diffusion in the callosal lesion.Neurologic symptoms are rare but have been reported in children with MIS-C. Of these, CLOCC has been observed with both acute COVID-19 or MIS-C.1,2 The diagnosis of CLOCC is established by both clinical and radiologic findings. Our patient had CLOCC with self-limited hallucinations. In the pathogenesis of CLOCC, it is thought that an acute increase in cytokine levels in the blood circulation and cerebrospinal fluid cavity triggers vasodilation with a reversible vasogenic edema in myelin, which contributes to hyponatremia by inappropriate antidiuretic hormone secretion.3 Cognitive impairment, seizures, irritability, confusion, hallucinations, and delirium are the most common neurologic symptoms in CLOCC. In this case, CLOCC manifested with auditory and visual hallucinations in febrile and afebrile period similar with the literature.2 Clinical findings in cases with CLOCC commonly resolve within approximately 10 days without any sequelae.4 Similarly, neurologic findings of this case disappeared completely in 3 days. MRI is the standard in diagnosing CLOCC. In a study evaluating neuroimaging findings of COVID-19 patients with neurologic symptoms, 53% of patients had abnormal MRI findings, mostly including cerebrovascular thrombotic events, in addition to limited diffusion foci within the corpus callosum.5 In conclusion, many of the atypical symptoms of COVID-19 emerge over time. Our case should serve as a reminder for clinicians to keep in mind CLOCC in patients presenting with neurologic and neuropsychiatric symptoms.