ABSTRACT
A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation.
Subject(s)
Aspirin/administration & dosage , Atrial Fibrillation , Blindness , Brain Stem Infarctions , Coronavirus Infections , Diplopia , Endocarditis, Bacterial , Ophthalmoplegia , Pandemics , Pneumonia, Viral , Pyrazoles/administration & dosage , Pyridones/administration & dosage , Retinal Artery Occlusion , Atrial Fibrillation/complications , Atrial Fibrillation/drug therapy , Betacoronavirus/isolation & purification , Blindness/diagnosis , Blindness/etiology , Brain Stem Infarctions/diagnostic imaging , Brain Stem Infarctions/drug therapy , Brain Stem Infarctions/physiopathology , COVID-19 , Coronavirus Infections/complications , Coronavirus Infections/diagnosis , Coronavirus Infections/physiopathology , Diplopia/diagnosis , Diplopia/etiology , Endocarditis, Bacterial/complications , Endocarditis, Bacterial/diagnosis , Endocarditis, Bacterial/physiopathology , Factor Xa Inhibitors/administration & dosage , Humans , Magnetic Resonance Imaging/methods , Male , Middle Aged , Ophthalmoplegia/diagnosis , Ophthalmoplegia/etiology , Platelet Aggregation Inhibitors/administration & dosage , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/physiopathology , Retinal Artery Occlusion/diagnostic imaging , Retinal Artery Occlusion/drug therapy , Retinal Artery Occlusion/etiology , Retinal Artery Occlusion/physiopathology , SARS-CoV-2 , Tomography, Optical Coherence/methods , Treatment OutcomeABSTRACT
We document the neuropathologic findings of a 73-year old man who died from acute cerebellar hemorrhage in the context of relatively mild SARS-CoV2 infection. The patient developed sudden onset of headache, nausea, and vomiting, immediately followed by loss of consciousness on the day of admission. Emergency medical services found him severely hypoxemic at home, and the patient suffered a cardiac arrest during transport to the emergency department. The emergency team achieved return of spontaneous circulation after over 17 min of resuscitation. A chest radiograph revealed hazy bilateral opacities; and real-time-PCR for SARS-CoV-2 on the nasopharyngeal swab was positive. Computed tomography of the head showed a large right cerebellar hemorrhage, with tonsillar herniation and intraventricular hemorrhage. One day after presentation, he was transitioned to comfort care and died shortly after palliative extubation. Autopsy performed 3 h after death showed cerebellar hemorrhage and acute infarcts in the dorsal pons and medulla. Remarkably, there were microglial nodules and neuronophagia bilaterally in the inferior olives and multifocally in the cerebellar dentate nuclei. This constellation of findings has not been reported thus far in the context of SARS-CoV-2 infection.