Table. Clinical and Paraclinical Characteristics of Teenaged Patients With COVID-19 and Neuropsychiatric Symptoms.
| Characteristic | Patient 1 | Patient 2 | Patient 3 |
|---|---|---|---|
| Age | Mid-teens | Mid-teens | Mid-teens |
| Hospital status | Transitional care unit (step-down unit) | Medical surgery ward | Pediatric intensive care unit |
| Ventilation | No | No | No |
| Blood laboratories at presentation | |||
| Absolute neutrophil count, cells/μL | 9320a | 3590 | 12 810a |
| Absolute lymphocyte count, cells/μL | 2330 | 1020 | 2130 |
| Albumin, g/dL | 4.1 | 4.3 | 5.6a |
| C-reactive protein, mg/dL | 3.9a | 0.6 | 27.6a |
| Erythrocyte sedimentation rate, mm/h | 32 | 2 | ND |
| Fibrinogen | ND | ND | ND |
| Procalcitonin, μg/L | ND | 0.06 | 0.02 |
| D-dimer, ng/mL | ND | ND | 400 |
| Ferritin, ng/mL | 132a | ND | ND |
| Lactic acid dehydrogenase, U/L | 252a | ND | ND |
| Interleukin 6 | ND | ND | ND |
| Neurologic symptoms | Psychosis, delusions, mania, agitation, paranoia, disinhibited, poor attention, lability, and lower-extremity hyperreflexia | Psychosis, paranoia, agitation, feeling of impending doom, impulsivity, depression, suicidal ideation, bradyphrenia, and impaired working memory | Psychosis, insomnia, agitation, memory impairment, orofacial dyskinesias, catatonia, abulia, apraxia, and brisk reflexes |
| Estimated time from SARS-CoV-2 infection to neurologic symptoms | Concurrent | Concurrent | Concurrent |
| Estimated time from onset of neurologic symptoms to LP | 14 d | Approximately 75 d to first LP; approximately 88 d to second LP | 5 d |
| COVID-19 treatment | None | None | None |
| Neurologic treatment | IVIg, solumedrol, prednisone taper | Solumedrol, IVIg | Supportive care |
| Time from neurologic symptom onset to neurologic treatment | 15 d | Approximately 77 d to solumedrol | NA |
| Outcome | Recovered | Partially recovered | Recovered |
| Comorbidities | Substance use disorder, PTSD, and anxiety | Tics and anxiety | None known |
| Neuroimaging | Brain MRI/MRA with and without contrast: few T2/FLAIR hyperintense foci in the white matter of bilateral frontal lobes | Brain MRI with and without contrast: unremarkable (once prior to solumedrol/IVIg, twice after solumedrol/IVIg); MRI of total spine without contrast (after solumedrol, before IVIg): No cord signal abnormality | Brain MRI/MRA with and without contrast: normal for age; MRI of cervical spine without contrast: normal for age |
| EEG | 4-h Video EEG findings normal for age (obtained while taking valproate) | 18 h (76 d After COVID-19 infection) and 15 h (88 d after COVID-19 infection) video EEGs: normal for age | 15 h Video EEG: diffuse beta activity |
| Select additional negative testing | ENS2 and ENC2 panels | ENS2 and ENC2 panels | ENS2 and ENC2 panels |
| CSF profile | |||
| WBC count, /uL | 4 | First LP, 1; second LP, 2; third LP, 1 | 1 |
| Protein, mg/dL | 117.0 (113.0 corrected)b | First LP, 48.0; second LP, 59.0; third LP, 80.0 | 19.0 |
| Restricted OCBs | 0 | First LP, 0; second LP, ND; third LP, 0 | 3 |
| IgG Index (Ref <0.7) | 1.0 | First LP, 0.6; second LP, ND; third LP, 0.6 | 0.6 |
| SARS-CoV-2 | |||
| PCR | |||
| NP | + | − | + |
| CSF | − | ND | − |
| IgG | |||
| Plasma | +c | +d | ND |
| CSF | +c | +c | −c |
Abbreviations: EEG, electroencephalography; FLAIR, fluid-attenuated inversion recovery; IgG, immunoglobulin G; IVIg, intravenous immunoglobulin; LP, lumbar puncture; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; NA, not applicable; ND, not determined; NP, nasopharyngeal; PCR, polymerase chain reaction; PTSD, posttraumatic stress disorder; WBC, white blood cell.
SI conversion factors: To convert neutrophils to ×109/L, multiply by 0.001; lymphocytes to ×109/L, multiply by 0.001; albumin to g/L, multiply by 10; C-reactive protein to mg/L, multiply by 10; D-dimer to nmol/L, multiply by 5.476; ferritin to μg/L, multiply by 1; WBC to ×109/L, multiply by 0.001.
Elevated value.
Protein corrected for red blood cell count of 3075 cells/uL.
Research-based serology.
Clinical serology.