Table 1.
Patient characteristics and pertinent laboratory and radiographic studies (reference ranges are included in square brackets, HD = hospital day, AED = antiepileptic drug, MCA = middle cerebral artery, GTC = generalized tonic–clonic seizure, NCHCT: noncontrasted head computed tomography, CTA = computed tomography angiogram, EEG = electroencephalography, LEV = levetiracetam, PHT = phenytoin, LOR = lorazepam, MDZ = midazolam, ZNS = zonisamide, PPF = propofol, LCM = lacosamide, GRDA = generalized rhythmic delta activity, PCR = polymerase chain reaction).
| Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 | Patient 7 | |
|---|---|---|---|---|---|---|---|
| Age (years), gender | 75, male | 50, male | 88, female | 88, female | 37, female | 81, female | 61, female |
| History of prior epilepsy | Y, last seizure 17 months prior to presentation | Y, last seizure 10 months prior to presentation | N | N | N | Y, last seizure 15 months prior to presentation | N |
| Home AEDs (medications with subtherapeutic levels indicated in bold) | LEV, PHT | VPA, PHT, LEV | N/A (prescribed LOR for anxiety) | N/A | N/A | LEV, ZNS | N/A |
| Additional prior seizure risk factors | Remote left MCA infarct, traumatic brain injury | Subtherapeutic VPA levels | Idiopathic Parkinson's disease | Remote left MCA infarct | Remote infarct secondary to sickle cell disease, developmental delay | History of cardiac arrest | End-stage renal disease on hemodialysis, intellectual disability |
| Presenting symptoms of COVID-19 | Fatigue, coffee-ground emesis | Cough, shortness of breath | None | None | Dry cough, ageusia, fatigue | None | Cough, fatigue, fever |
| Duration of COVID-19 symptoms at the time of seizure (days) | 2 | 7 | N/A | N/A | 5 | N/A | 18 |
| Seizure semiology on presentation | GTC | GTC | GTC | GTC | Focal, unawareness, leftward gaze deviation, and tonic right arm movement followed by postictal confusion | Rightward gaze deviation, rightward head version, rhythmic left arm and leg twitching | GTC |
| Number of seizures and seizure duration | One, unknown duration | One, 20 min | Two, lasting 1–2 min | One, lasting 1 min | Two, lasting 3–5 min | Three, lasting 3–5 min | Multiple focal onset events lasting 3–5 min |
| Treatments administered for seizures | LOR, LEV, PHT | MDZ, VPA | LOR, LEV | LEV | LEV | MDZ, LEV, and ZNS | LEV, LCM, PPF, MDZ |
| Other neurologic deficits | Aphasia, right gaze preference, right-sided hemiplegia; (resolved to baseline aphasia and right hemiparesis) | Leftward gaze deviation and right-sided hemiparesis (resolved to baseline nonfocal examination) | Leftward gaze deviation, increased tone in left leg compared with right leg (resolved to baseline examination with extrapyramidal findings) | Aphasia, right-sided hemiparesis (baseline examination) | Spastic left hemiparesis and left nasolabial fold flattening (baseline examination) | Generalized weakness with no lateralizing sign (baseline examination) | Rightward gaze deviation (resolved) |
| Brain imaging findings on admission | NCHCT with encephalomalacia in left MCA territory, consistent with prior infarct | NCHCT: no acute abnormalities CTA head and neck: no large-vessel occlusion | NCHCT: no acute abnormalities | NCHCT with encephalomalacia in left frontal, parietal, and temporal lobes | NCHCT: confirmed previously known bifrontal and left temporal encephalomalacia | CTA head and neck: no large-vessel occlusion | CTA head and neck: no large-vessel occlusion CT venogram: No sinus thrombosis MRI brain with and without contrast: extensive leukoencephalopathy, gyriform diffusion restriction (Fig. 1) |
| EEG findings | Not obtained | Not obtained | Not obtained | Not obtained | Not obtained | Moderately slow background, frequent sharp waves and focal epileptiform discharges (right parieto-occipital region), occasional independent sharp waves (right posterior temporal region), frequent bifrontal generalized sharp waves with triphasic morphology | Moderate to severe encephalopathy, with frequent short runs of GRDA |
| Cerebrospinal fluid analysis: protein [15–45 mg/dL], glucose [40–70 mg/dL] | Not obtained | Not obtained | Not obtained | Not obtained | Not obtained | Not obtained | < 1 total nucleated cell/μL, 2 red blood cells/μL, protein 19 mg/dL, glucose 92 mg/dL; negative meningitis and encephalitis PCR panel |
| Illness severity | Intubated, required ICU care | Intubated, required ICU care | Hospitalized, no intubation or ICU care required | Hospitalized, no intubation or ICU care required | Hospitalized, no intubation or ICU care required | Intubated, required ICU care | Intubated, required ICU care |
| Temperature °F, initial (max) |
98.4 (102.2) | 99.3 (100.6) | 103.4 (103.4) | 98 (99.1) | 98 | 99.2 (100.6) | 100.6 (102.9) |
| White blood cell count K/μL, initial (nadir) [4.0–11.0 K/μL] |
8.8 (1.6) | 20.2 (13.2) | 6.3 (5.6) | 4.7 (4.7) | 4.9 | 6.7 (5.0) | 5.9 (5.1) |
| Absolute lymphocyte count K/μL, initial (nadir) [1.1–3.5 K/μL] |
1.3 (0.3) | 11.9 (3.7) | 0.4 (0.2) | 1.1 (1.1) | 2.5 | 1.9 (0.4) | 0.9 (0.2) |
| D-dimer ng/mL, initial (peak) [< 243 ng/mL] |
912 (1595) | 1079 (2013) | 752 (823) | 303 (303) | 1495 | 260 (1032) | 915 (4186) |
| CRP mg/L, initial (peak) [0–5 mg/L] |
67.2 (353.2) | 6.4 (198) | 188 (188) | Not obtained | 5.6 | 302.6 (441.5) | 27.3 (382.8) |
| Ferritin ng/mL, initial (peak) [10–109 ng/mL] |
126 (1969) | 175 (260) | 644 (720) | 183 (183) | 302 | 860 (907) | 2754 (17,178) |
| Fibrinogen mg/dL, initial (peak) [180–460 mg/dL] |
190 (> 800) | 304 (648) | 752 (795) | 624 (624) | 277 | 480 (> 800) | 453 (590) |
| Procalcitonin ng/mL, initial (peak) [< 0.50 ng/mL] |
2.6 (11.9) | 0.03 (0.17) | 1.6 (11.6) | 0.02 (0.02) | 0.13 | 0.86 (0.86) | 0.25 (2.13) |
| Additional laboratory derangements | Hyponatremia (108 mEq/L) | Subtherapeutic VPA level ( ) | Elevated blood urea nitrogen (67 mg/dL) | None | None | None | Baseline renal dysfunction |
| Chest X-ray | HD1: Increased interstitial markings. HD2: New hazy airspace opacities. | HD1: Left basilar airspace opacities. HD3: Resolved. | HD1: Bilateral lower lung hazy opacities. | HD1: Subsegmental atelectasis in left lung base, no focal consolidation. | HD1: Curvilinear bibasilar opacities suggestive of scarring. | HD1: Opacity in left lung base. |
HD1: Focal nodular density. |
| Chest CT | HD1: Dense consolidation with air bronchograms HD2: Dense dependent consolidative opacities suggestive of worsening pneumonitis or pneumonia. | Not obtained. | Not obtained. | Not obtained. | Not obtained. | Not obtained. | HD8: Bilateral ground-glass/consolidative opacities, worse in lung bases. |
| Outcome at the time of manuscript submission | Deceased | Discharged home, no recurrent seizures | Discharged to nursing home where she lives at baseline, no recurrent seizures | Discharged home, no recurrent seizures | Discharged home, no recurrent seizures | Extubated, transferred to floor, awaiting rehab, no recurrent seizures | Remains intubated on pressure support |