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Journal of Clinical Laboratory Analysis logoLink to Journal of Clinical Laboratory Analysis
. 2022 Apr 18;36(5):e24426. doi: 10.1002/jcla.24426

Clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis: A systematic review of case reports and case series

Maryam Koupaei 1, Negar Shadab Mehr 2, Mohamad Hosein Mohamadi 2, Arezoo Asadi 3,4, Sajjad Abbasimoghaddam 2, Amirhosein Shekartabar 2, Mohsen Heidary 5,6,, Fazlollah Shokri 7,
PMCID: PMC9102669  PMID: 35435264

Abstract

Introduction

Since COVID‐19 outbreak, various studies mentioned the occurrence of neurological disorders. Of these, encephalitis is known as a critical neurological complication in COVID‐19 patients. Numerous case reports and case series have found encephalitis in relation to COVID‐19, which have not been systematically reviewed. This study aims to evaluate the clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis.

Methods

We used the Pubmed/Medline, Embase, and Web of Science databases to search for reports on COVID‐19‐associated encephalitis from January 1, 2019, to March 7, 2021. The irrelevant studies were excluded based on screening and further evaluation. Then, the information relating diagnosis, treatment, clinical manifestations, comorbidities, and outcome was extracted and evaluated.

Results

From 4455 initial studies, 45 articles met our criteria and were selected for further evaluation. Included publications reported an overall number of 53 COVID‐19‐related encephalitis cases. MRI showed hyperintensity of brain regions including white matter (44.68%), temporal lobe (17.02%), and thalamus (12.76%). Also, brain CT scan revealed the hypodensity of the white matter (17.14%) and cerebral hemorrhages/hemorrhagic foci (11.42%) as the most frequent findings. The IV methylprednisolone/oral prednisone (36.11%), IV immunoglobulin (27.77%), and acyclovir (16.66%) were more preferred for COVID‐19 patients with encephalitis. From the 46 patients, 13 (28.26%) patients were died in the hospital.

Conclusion

In this systematic review, characteristics of COVID‐19‐associated encephalitis including clinical symptoms, diagnosis, treatment, and outcome were described. COVID‐19‐associated encephalitis can accompany with other neurological symptoms and involve different brain. Although majority of encephalitis condition are reversible, but it can lead to life‐threatening status. Therefore, further investigation of COVID‐19‐associated encephalitis is required.

Keywords: COVID‐19, encephalitis, SARS‐CoV‐2, systematic review


At the first screening, 4455 papers were retrieved. In the second phase, after removing duplicates, 2171 papers remained. These papers were screened by title and abstract, and 119 were selected for detailed full‐text evaluation. Applying the criteria to the full‐text documents, 45 articles were eligible for inclusion in the systematic review.

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1. INTRODUCTION

Humans have been struggling with the COVID‐19 epidemic for nearly 2 years. 1 As of early August 2020, more than 17.5 million cases of COVID‐19 were identified in 188 countries, including 680,000 deaths. 2 The disease that often has respiratory symptoms but sometimes also has extrapulmonary manifestations such as neurological symptoms. 1 On average, neurological symptoms appear three weeks after respiratory symptoms. 3 Less common clinical manifestations of COVID‐19 include headache, brain status alteration, chest pain, abdominal pain, diarrhea, and nausea. 2 Nervous manifestations can range from a mild nervous agitation to severe encephalitis. 4 The roll of central nervous system in SARS‐CoV‐2 epidemic has been determined. 3 Ischemic stroke, central nervous system (CNS) inflammation, encephalopathy, and myelitis are common clinical manifestations of the CNS in COVID‐19 patients. 5 Encephalitis means inflammation of the brain, 6 which is mainly caused by the autoimmune process and/or the viral infection. 5 Encephalitis is one of the main and devastating complications associated with CNS. 7 In previous epidemics, MERS‐CoV and SARS‐CoV viruses have caused brain complications such as polyneuropathy, ischemic stroke, encephalitis, and brain status change in patients with Middle East respiratory syndrome coronavirus and severe acute respiratory syndrome coronavirus. 8 , 9 Several case reports and case series have reported the patients with COVID‐19‐associated encephalitis, which in some cases have been fatal. 4 , 10 , 11 The pooled mortality rate from COVID‐19‐associated encephalitis is reported to be 13.4%. 12 In a multicenter study by Pilotto et al. in Italy, 25 out of 45 people with encephalitis tested positive for SARS‐CoV‐2. They found that there is a wide range of clinical manifestations in patients and the response to treatment depends on the specific CNS manifestations. 13 Due to the importance of encephalitis in COVID‐19 patients and the risk of death for them, it is necessary to conduct a detailed systematic review on this study. Therefore, the aim of this study was to evaluate the clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis.

2. MATERIALS AND METHODS

This systematic review was performed according to “Preferred Reporting Items for Systematic Reviews and Meta‐Analyses” (PRISMA) statement. 14

2.1. Search strategy

We used Pubmed/Medline, Embase, and Web of Science databases for this literature. The articles included were only those published in English from January 1, 2019, to March 7, 2021. The search keywords used were “encephalitis,” “brain,” “neurologic,” “COVID‐19,” “severe acute respiratory syndrome coronavirus 2,” “SARS‐CoV‐2,” “2019‐nCoV,” “nCoV disease,” “coronavirus disease‐19,” “2019 novel coronavirus,” and “Wuhan pneumonia.”

2.2. Inclusion/exclusion criteria

Case reports and case series reporting encephalitis in patients with COVID‐19 were included. These studies met the following inclusion criteria: (i) COVID‐19 patients were confirmed and diagnosed with RT‐PCR as suggested by WHO; (ii) the raw data for clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis were addressed. Studies without enough data, review article, modelling study, commentary, correspondence, editorial, guideline, and news were excluded. All potentially relevant articles were then screened for eligibility. Two reviewers independently screened the records by title, abstract, and full texts to exclude those not related to the current study.

2.3. Data collection

The extracted data included first author name; country where the study was conducted; year of publication; type of study; number of patients investigated; distribution of age and sex in the population; diagnosis methods; data for clinical, radiological, and laboratory findings; therapy, and the patient outcome.

2.4. Quality assessment

We used the case reports/case series appraisal checklist supplied by the Joanna Briggs Institute (JBI) to evaluate the quality of the studies. 15

3. RESULTS

3.1. Study selection and general characteristics

As shown in Figure 1, at the first screening, 4455 papers were retrieved. In the second phase, after removing duplicates, 2171 papers remained. These papers were screened by title and abstract, and 119 were selected for detailed full‐text evaluation. Applying the criteria to the full‐text documents, 45 articles were eligible for inclusion in the systematic review. The results of various studies including participants’ clinical manifestations, comorbidities, diagnosis, treatment, and outcome are reported in Tables 1 and 2. Moreover, a summary of the case report and case series findings are reported in Table 3.

FIGURE 1.

FIGURE 1

Flow diagram detailing review process and study selection

TABLE 1.

Characteristics of the case series studies

First author Country Published time No. of patients Median age (years) Male/female Encephalitis diagnosis method CT results MRI results Special encephalitis treatment SARS‐CoV‐2 diagnosis method COVID‐19 treatment Clinical manifestations SARS‐CoV‐2 diagnosis in CSF sample Comorbidities Outcomes
Lopes CCB 32 Brazil December 2020 2 50 1M, 1F 2 brain CT scan, 2 brain MRI, 2 EEG 2 bilateral lesions in the centrum semiovale/1 focal lesions in globus pallidus and internal capsule/1 signal abnormalities in the white matter, including corpus callosum 2 multifocal hyperintensity in centrum semiovale, 1 lesions in the cerebellar white matter and globus pallidus NM 2 RT‐PCR 1 hydroxychloroquine 2 fever, 2 RS, 1 renal failure, 2 delayed awakening after sedation withdrawal, 2 DC, 1 coma, 1 four‐limb weakness 2 negative 2 hypertension, 1 diabetes, 1 obesity, 1 smoking 1 death, 1 partial recovery
Kihira S 33 USA October 2020 5 48.6 3M, 2F MRI, head CT, EEG 5 unremarkable 5 hyperintensity in the white matter, 3 confluent diffusion restriction in the cerebral white matter, 2 hyperintensity in the splenium of corpus callosum/1 scattered frontoparietal hyperintensity/1 microhemorrhages in corpus callosum/1 intraventricular hemorrhage 1 plasma exchange 5 RT‐PCR NM 1 myocardial infarction, 2 fever, 5 RS, 3 acute renal failure, 1 cardiogenic shock, 1 abdominal pain, 1 cardiac arrest, 1 nausea, 1 vomiting, 1 chills, 5 AMS, 1 focal seizures, 1 lower limbs paralysis 3 negative, 1 NP, 1 NM 1 Hypertension, 1 diabetes mellitus type 2, 1 pyelonephritis, 1 gestation, 1 obesity NM
Barreto‐Acevedo E 34 Peru June, 2020 2 50.5 1M, 1F MRI, CSF analysis, brain tomography 2 unremarkable 1unremarkable, 1 NP Dexamethasone RT‐PCR, serological test NM 2 fever, 2 chills, 1 malaise, 1 headache, 2 AMS, 2 seizures NP 1 obesity 1death, 1 transferred to other hospital
Delorme C 35 France August 2020 4 66.75 2M, 2F

Brain MRI, CSF analysis, brain

FDG‐PET/CT imaging, EEG

4 NP

1 unremarkable/1 non‐specific

Hyperintensity of the white matter/1 right T2 orbitofrontal

Hyperintensity

3 IV immunoglobulin, 3 IV corticosteroids 4 RT‐PCR NM 4 cognitive impairment, 2 cerebellar syndrome, 1 myoclonus, 1 psychiatric symptoms, 4 fever, 3 RS, 2 anosmia, 1 ageusia, 1 diarrhea, 2 fatigue, 2 agitation, 1 psychomotor slowing, 1 convulsive status, 1 apraxia, 1 dysexecutive syndrome 4 negative 1 temporal lobe epilepsy (hippocampal sclerosis), 1 diabetes mellitus type2, 1 hypertension 4 discharged

TABLE 2.

Characteristics of case report studies

First author Country Published time Age (years) Sex Encephalitis diagnosis method CT results MRI results Special encephalitis treatment SARS‐CoV‐2 diagnosis method COVID‐19 treatment Clinical manifestations SARS‐CoV‐2 diagnosis in CSF sample Comorbidities Outcomes
Kumar N 36 India October 2020 35 M Head CT Hypodensities in both thalami and left caudate nucleus NP Propofol infusion, mannitol, IV methylprednisolone RT‐PCR Hydroxychloroquine, azithromycin, IV amoxicillin‐clavulanic acid Fever, vomiting, DC NP Invasive meningioma Death
Novi G 37 Italy September 2020 64 F Brain and spine MRI, CSF analysis NP Multiple enhancing lesions of the brain, bilateral optic nerve enhancement IV methylprednisolone, prednisone RT‐PCR, antibody testing IV immunoglobulin RS, anosmia, ageusia, visual impairment, behavioral changes, headache, hyperreflexia Positive Vitiligo, hypertension, monoclonal gammopathy Discharged
Ayuso LL 38 Spain September 2020 72 F Brain MRI, immunoblot analysis NP Hyperintensity in cerebellum, contrast enhancement on the floor of the fourth ventricle IV methylprednisolone, prednisone RT‐PCR, chest CT Hydroxychloroquine, azithromycin, ceftriaxone Psychiatric symptoms, fever, AMS, dizziness, visual impairment, unsteadiness, cerebellar signs NP Hypertension, hyperlipidemia, smoking, depression Discharged
Khan Z 39 USA November 2020 30 M Head CT Opacifications of paranasal sinuses, hypodensity of the white matter Hyperintensity in the white matter of cerebral hemispheres Acyclovir RT‐PCR, chest CTy NM Seizure, DC, behavioral changes, myoclonus, AMS, psychiatric symptoms NP Obesity Still hospitalized
Westhoff TH 40 Germany July 2020 69 M Brain MRI, CSF analysis NP Linear meningeal enhancement/hyperintensity in the white matter NM RT‐PCR, chest CT Hydroxychloroquine Fever, RS, diarrhea, pancreas and kidney allograft dysfunction, seizure, hemi‐neglect, fatigue Positive Immunosuppression Discharged
Kamal YM 41 United Arab Emirate September 2020 31 M CSF analysis, head CT, brain MRI Bilateral hypodensities in the external capsules, the insular cortex and white matter of the frontal lobes Bilateral diffusion restriction in the temporal and frontal lobes/bilateral hyperintensity in the temporal lobe cortex IV acyclovir sodium RT‐PCR Chloroquine, lopinavir–ritonavir Behavioral changes, AMS, agitation, drowsiness Positive None Discharged
Rebeiz T 21 USA September 2020 NM M CSF analysis, brain MRI Subarachnoid hemorrhage within the mesial parietal region/nonspecific hypo‐attenuation in the splenium of the corpus callosum Diffusion restriction and hyperintensity of the corpus callosum, left thalamus and frontal cortex Acyclovir, ceftriaxone, vancomycin RT‐PCR NM Behavioral changes, fever, AMS, psychiatric symptoms NP None Death
Zoghi A 42 Iran June 2020 21 M CSF analysis, brain and cervical MRI NP Hyperintensity in the internal capsule, cerebral peduncles, pons and the corpus callosum IV vancomycin, meropenem, acyclovir Chest CT, antibody testing Plasma exchange Anorexia, vomiting, food intolerance, malaise, lower limbs paralysis, weakness, urinary retention, drowsiness Negative None NM
Moriguchi T 9 Japan May 2020 24 M Brain MRI NP Hyperintensity along the wall of right lateral ventricle, right temporal lobe and hippocampus, slight hippocampus atrophy IV ceftriaxone, vancomycin, acyclovir, steroids Chest CT, RT‐PCR Favipiravir Fatigue, fever, headache, RS, seizure, unconsciousness Positive NM Still hospitalized
Haqiqi A 43 United kingdom January 2021 56 M Head CT, brain MRI, CSF analysis Diffuse hypodensity of the white matter/multiple bilateral white matter hemorrhagic foci involving the corpus callosum Hyperintensity of the white matter/diffuse hemosiderin staining throughout the white matter and the corpus callosum/some cystic hemorrhagic areas within both cerebral hemispheres None RT‐PCR Supportive care RS, acute kidney injury, DC Negative Hypertension, chronic kidney disease, hypercholesterolemia, asthma, obesity Discharged
Pizzanelli C 44 Italy January 2021 74 F Brain MRI, total body PET/TC Unremarkable Hyperintensity in the temporal lobes, mild hippocampal thickening IV methylprednisolone, oral prednisolone Chest CT, RT‐PCR Remdesevir, dexamethasone Fever, RS, seizure, AMS, oral automatism, weakness, ideo‐motor slowing Negative None Discharged
Al Mazrouei SS 1 United Arab Emirates September 2020 43 M Head CT, brain MRI Hypodensity of bilateral thalami Hyperintensity in the frontal lobes, insula, thalamus and globus pallidus NM RT‐PCR, Chest CT NM Fever, RS, weakness, fatigue, DC NP Diabetes mellitus type2 Death
Sirous R 2 USA August 2020 50 M MRI, magnetic resonance angiography, magnetic resonance venography Mild cerebral generalized parenchymal volume loss with sulcal enlargement Cerebral edema with mass effect, downward cerebellar tonsillar herniation/compression and displacement of the brainstem and 4th ventricle NM RT‐PCR IV hydroxychloroquine Fatigue, headache, nausea, vomiting, lethargy, AMS NP None Death
Mardani M 45 Iran July 2020 64 F CSF analysis Unremarkable NP NM RT‐PCR, CSF analysis IV ceftriaxone, clindamycin, hydroxychloroquine, lopinavir/ritonavir RS, weakness, DC Positive Hypertension, ischemic heart disease, metastatic colorectal cancer NM
Vandervorst F 46 Belgium July 2020 29 M Brain MRI Unremarkable Hyperintensity of the left temporal cortex/mild gyral expansion NM RT‐PCR, chest CT IV acyclovir, hydroxychloroquine Weakness, RS, anorexia, Anosmia, ageusia, AMS, short‐term memory deficits, psychiatric symptoms Negative None Discharged
Freire‐Álvarez E 31 Spain October 2020 39 M Brain MRI Unremarkable Hyperintensity at the cortical and subcortical right frontal regions, right thalamus and mammalary body, temporal lobes and cerebral peduncles IV immunoglobulin, tocilizumab RT‐PCR, chest CT Lopinavir/ritonavir, subcutaneous interferon beta‐1b Fatigue, DC, malaise, fever, AMS, headache, drowsiness, minimal stiff neck, language disorder, paraphasia Negative NM Clinical improvement, Still hospitalized
Parsons T 47 Germany May 2020 51 F Brain MRI, EEG NP Hyperintensities in the white matter Methylprednisolone, IV Immunoglobulin RT‐PCR, chest CT NM RS, fever, vomiting, unresponsiveness, flaccid muscles Negative NM NM
Al‐olama M 48 United Arab Emirates May 2020 36 M Brain CT, CT angiography Hematoma in the right frontal lobe with surrounding edema/extracerebral hemorrhage/cortical swelling/bilateral supratentorial leptomeningeal increased enhancement NP NM PCR NM Fever, RS, headache, body pain, diarrhea, vomiting, drowsiness, AMS NP None Still hospitalized
Goodloe TB 49 Alabama January, 2021 52 M Bead CT, EEG Unremarkable Unremarkable Vancomycin, ceftriaxone, azithromycin, acyclovir RT‐PCR NM AMS, agitation, fever NP Hypertension, diabetes mellitus type2, end‐stage renal disease, coronary artery disease Discharged
Sattar SBA 23 USA September 2020 44 M Brain MRI, head CT, CSF analysis Few scattered foci of white matter hypo‐attenuation Abnormal medial cortical signals in the bilateral frontal lobes NM RT‐PCR, chest CT Hydroxychloroquine, azithromycin Fever, RS, seizure, AMS, unresponsiveness Positive None Discharged
Haider A 29 USA March 2020 66 M EEG, brain MRI Unremarkable Small lacunar infarcts and a patchy area of bright signals in the cortical and lateral periventricular regions Tocilizumab, IV immunoglobulin, rituximab RT‐PCR NM Seizure, AMS, behavioral changes NP Benign prostatic hypertrophy, fatty liver disease, hypertension Discharged
Cariddi LP 50 Italy June, 2020 64 F Head CT, brain MRI Bilateral hypodensity of the white matter/a small left occipital parenchymal hemorrhage Bilateral edema with bilateral occipital foci of subacute hemorrhage NM RT‐PCR Hydroxychloroquine, darunavir/cobicistat Fever, RS, visual impairment, AMS, drowsiness, reduced tendon reflexes Negative Hypertension, gastroesophageal reflux disease, hyperuricemia, dyslipidemia, obstructive sleep apnea, atrial fibrillation Partial recovery
Sofijanova A 51 Republic of Macedonia November 2020 9 month NM Head CT, biochemical blood test Enlargement of the lateral ventricles, with intraventricular masses, internal hydrocephalus NP Anti‐edematous therapy NM Cephalosporin, aminoglycoside, antiviral drug RS, convulsive status, fever, DC, vomiting, seizure NP NM Transferred to another hospital
Ghosh R 11 India August 2020 44 F Brain MRI, CSF analysis NP T2‐weighted hyperintensity in the parietal lobes with peri‐lesional edema IV methylprednisolone RT‐PCR Ceftriaxone, vancomycin, acyclovir Myalgia, RS, hypogeusia, hyposmia, AMS, seizure, unconsciousness, reduced tendon refluxes, loss of sphincter control NP None Death
Pilotto A 52 Italy August, 2020 60 M EEG, brain MRI, CSF analysis Unremarkable Unremarkable Methylprednisolone RT‐PCR, chest CT Ritonavir/lopinavir, hydroxychlroroquine Fever, RS, cognitive fluctuations, DC, AMS, behavioral changes, asthenia Negative None Discharged
Azab MA 3 Egypt February, 2021 89 M MRI, post‐mortem biopsy NP Hyperintensity near the basal ganglia and thalami NM Serological test Acyclovir, acetaminophen Rash, seizure, tremors, RS, cerebellar signs, fever, headache, dizziness, myalgia NP NM Death
Abdi S 53 Iran June, 2020 58 M Brain MRI, CSF analysis NP Hyperintensity of the white matter/involvement of cortical and deep gray matter and midbrain IV dexamethasone RT‐PCR, chest CT NM Drowsiness, gait disturbance, DC Negative NM Death
Dharsandiya M 54 India August, 2020 68 M Head CT, blood test, CSF analysis Age‐related cortical atrophy (unremarkable) NP Methylprednisolone, tocilizumab RT‐PCR, chest CT Azithromycin, hydroxychloroquine, gamma globulin Fever, RS, renal failure, viral sepsis, autonomic disturbance, AMS, seizure NP Diabetes, hypertension Death
Babar A 55 USA October, 2020 20 F Brain MRI, CSF analysis, EEG Unremarkable Unremarkable Methylprednisolone RT‐PCR Levofloxacin, acyclovir RS, ageusia, insomnia, Fever, AMS, psychiatric symptoms Negative Obesity, anxiety Discharged
Virhammar J 56 Sweden June, 2020 55 F Head CT, CSF analysis, EEG, brain MRI Hypodensities in the thalami and midbrain Hyperintensity in subinsular regions, thalami, and brainstem/involvement of temporal lobes, hippocampi, and cerebral peduncles IV immunoglobulin RT‐PCR, chest CT Acyclovir, plasma exchange Fever, myalgia, impaired brain stem reflexes, myoclonus, lethargy, DC Positive None Discharged to rehabilitation
Farhadian S 57 USA June, 2020 78 F Brain MRI, EEG, CSF analysis NP Generalized atrophy/hyperintensity in white matter NM RT‐PCR, chest CT Hydroxychloroquine Seizure like activity, RS, fever, AMS Negative Immunosuppression due to kidney transplantation Discharged
de Miranda Henriques‐Souza AM 58 Brazil October, 2020 12 F Brain and spine MRI, CSF analysis NP Bilateral restricted diffusion in the white matter/hyperintensity of the corpus callosum Methylprednisolone RT‐PCR NM Tetraplegia, fever, deep areflexia, skin rash, headache, RS, acute motor weakness, numbness Negative None Discharged
Afshar H 59 Iran August 2020 39 F Brain MRI NP Hyperintensities in bilateral thalami, temporal lobes and pons IV immunoglobulin, IV methylprednisolone Chest CT Meropene, levofloxacin, linezolide, hydroxychloroqine, atazanavir, IV immunoglobulin Fever, myalgia, anorexia, drowsiness, RS, DC, headache, seizure Negative None Discharged
Crosta F 60 Italy December 2020 79 M EEG, brain MRI Unremarkable Hyperintensity of the left temporal cortex, with mild gyral expansion NM RT‐PCR Clarithromycin, dexamethasone Fever, AMS, anosmia, RS, ageusia, DC, short‐term memory deficits, psychiatric symptoms NP Hypertension, diabetes, chronic heart failure Discharged
Sangare A 61 France November 2020 56 M EEG, brain MRI NP Hemorrhagic lesions in the pontine tegmentum and subinsular regions, including corpus callosum IV methylprednisolone, plasma exchange with albumin RT‐PCR, chest CT Cephalosporin linezolide, trimethoprime‐sulfamethoxazole, meropenem aminosid Fever, RS, reversible acute kidney failure, visual impairment, unresponsiveness Negative Hypertension Discharged
El‐Zein RS 62 USA September 2020 40 M EEG, blood tests, CSF analysis Unremarkable Unremarkable IV immunoglobulin Simplexa SARS‐CoV‐2 assay Hydroxychloroquine Fever, fatigue, AMS, RS, psychiatric symptoms, increased agitation Negative None Discharged
Etemadifar M 4 Iran September 2020 51 M Head CT, brain MRI Generalized brain edema/signs of brain herniation Generalized brain edema, downward herniation of cerebellar tonsils and brainstem, hyperintensities in bilateral cerebral cortices and corpus striatum NM RT‐PCR Hydroxychloroquine, lopinavir/ritonavir, IV acyclovir, IV dexamethasone Headache, drowsiness, nausea, vomiting, RS, seizure, cardiac arrest, impaired brain stem reflexes NP Hypothyroidism migraine Death
Peng LV 63 China February, 2021 90 F CSF analysis, physical and neurological examination Unremarkable NP Mannitol and anti‑viral therapy (Ganciclovir) RT‑PCR, Chest CT NM Fever, RS, fatigue, unconsciousness, unresponsiveness, increased muscle tension Negative Cerebral lacunar infarction with no neurological deficits‐ live in a healthcare unit Death (irrelevant cause)
Hayashi M 10 Japan August 2020 75 M Neurological examination, brain MRI NP Hyperintensity in the splenium of corpus callosum Corticosteroid pulse, meropenem RT‐PCR Favipiravir, corticosteroid pulse Urinary incontinence, diarrhea, DC, cerebellar signs, fever, AMS, tremor, gait disturbance NP

Mild

Alzheimer's disease

Death
Kumar A 64 USA November 2020 35 F Brain MRI, EEG, CSF analysis Unremarkable Hyperintensity in the white matter involving bilateral cerebral peduncles Methylprednisolone, IV immunoglobulin, plasma exchange RT‐PCR, serological tests NM Anosmia, ageusia, gait disturbance, neuropathy, weakness, drowsiness, lethargy Negative Gastric bypass surgery, anemia Discharged to a long‐term care facility
Muccioli L 65 Italy September 2020 47 F EEG, brain MRI NP Hyperintensity in the white matter Tocilizumab Chest CT, RT‐PCR NM Asthenia, RS, ageusia, hyposmia, language disturbance, pain in the extremities, fever, AMS, headache, agitation Negative None Discharged

TABLE 3.

Summary of the case reports and case series findings

Variables No. of studies n/N %
Gender
Male 29 32/53 60.38
Female 19 21/53 39.62
Age
<30 (years old) 6 6/53 11.32
31–50 (years old) 16 18/53 33.96
>51 (years old) 25 29/53 54.72
Age/sex
<30 (years old)
Male 4 4/6 66.67
Female 2 2/6 33.33
31–50 (years old)
Male 11 12/18 66.67
Female 6 6/18 33.33
>51 (years old)
Male 15 16/29 55.17
Female 12 13/29 44.83
Clinical manifestation
Neurological manifestations
Decreased consciousness/unconsciousness 17 18/54 33.33
Behavioral changes 6 6/54 11.11
Altered mental status 24 29/54 53.70
Cerebellar signs 4 5/54 9.25
Seizure 15 16/54 29.62
Agitation 5 6/54 11.11
Headache 11 11/54 20.37
Memory deficits 2 2/54 3.70
Unresponsiveness 4 4/54 7.40
Convulsive status 2 2/54 3.70
Cognitive impairment 2 5/54 9.26
Language disturbance 2 2/54 3.70
Paraphasia 1 1/54 1.85
Tremors 2 2/54 3.70
Lower limbs paralysis 2 2/54 3.70
Gait disturbance 3 3/54 5.55
Unsteadiness 1 1/54 1.85
Hemi‐neglect 1 1/54 1.85
Impaired brain stem reflexes 2 2/54 3.70
Pain 3 3/54 5.55
Coma 1 1/54 1.85
Apraxia 1 1/54 1.85
Dysexecutive syndrome 1 1/54 1.85
Psychomotor slowing 1 1/54 1.85
Ideo‐motor slowing 1 1/54 1.85
Oral automatism 1 1/54 1.85
Neuropathy 1 1/54 1.85
Reduced tendon reflexes 2 2/54 3.70
Loss of sphincter control 1 1/54 1.85
Deep areflexia 1 1/54 1.85
Psychiatric symptoms
Psychiatric symptoms 8 8/54 14.81
General symptoms
Fever 32 38/54 70.37
Vomiting 8 8/54 14.81
Nausea 3 3/54 5.55
Diarrhea 4 4/54 7.40
Anosmia/hyposmia 7 8/54 14.81
Ageusia/dysgeusia 8 8/54 14.81
Dizziness 2 2/54 3.70
Malaise 3 3/54 5.55
Fatigue 8 9/54 16.66
Drowsiness 9 9/54 16.66
Weakness/asthenia 10 10/54 18.51
Lethargy 3 3/54 5.55
Chills 2 3/54 5.55
Anorexia 3 3/54 5.55
Food intolerance 1 1/54 1.85
Insomnia 1 1/54 1.85
Numbness 1 1/54 1.85
Neuromuscular symptoms
Myalgia 4 4/54 7.40
Hyperreflexia 1 1/54 1.85
Myoclonus 3 3/54 5.55
Neck stiffness 1 1/54 1.85
Flaccid muscles 1 1/54 1.85
Tetraplegia 1 1/54 1.85
Increased muscle tension 1 1/54 1.85
Other
Respiratory symptoms 30 37/54 68.51
Visual impairment 4 4/54 7.40
Renal dysfunction 8 10/54 18.51
Cardiac dysfunction 2 4/54 7.40
Rash 2 2/54 3.70
Viral sepsis 1 1/54 1.85
Delayed awakening after sedation 1 2/54 3.70
Autonomic disturbances 1 1/54 1.85
Comorbidities
Hypertension 13 14/48 29.16
Diabetes mellitus 7 7/48 14.58
Obesity 6 6/48 12.50
Neurologic disorders 5 5/48 10.41
Cardiologic disorder 4 4/48 8.33
Dyslipidemia 2 2/48 4.16
Anemia 1 1/48 2.08
Psychiatric disorders 2 2/48 4.16
Renal dysfunction 3 3/48 6.25
Immunosuppressive state 2 2/48 4.16
Smoking 2 2/48 4.16
Hypercholesterolemia 1 1/48 2.08
Hypothyroidism 1 1/48 2.08
Vitiligo 1 1/48 2.08
Monoclonal gammopathy 1 1/48 2.08
Asthma 1 1/48 2.08
Colorectal cancer 1 1/48 2.08
Fatty liver disease 1 1/48 2.08
Gastroesophageal reflux disease 1 1/48 2.08
Hyperuricemia 1 1/48 2.08
Obstructive sleep apnea 1 1/48 2.08
Benign prostatic hypertrophy 1 1/28 3.57
Gestation 1 1/20 5.00
No comorbidities 15 15/48 31.25
Presence of SARS‐CoV‐2 RNA in the CSF sample
Positive 7 7/34 20.58
Negative 21 27/34 79.41
SARS‐CoV‐2 diagnosis method
RT‐PCR 40 49/53 92.45
Chest CT 20 20/53 37.73
Serological testing (anti‐SARS‐CoV‐2 antibody) 5 6/53 11.32
Simplexa SARS‐CoV‐2 assay 1 1/53 1.88
Encephalitis diagnosis method
Brain MRI 36 44/54 81.48
Head CT scan 15 20/54 37.03
CSF analysis 21 25/54 46.29
Electroencephalogram 15 23/54 42.59
Total body PET/TC 1 1/54 1.85
FDG‐PET/CT imaging 1 4/54 7.40
CT angiogram 1 1/54 1.85
Magnetic resonance angiography and venography 1 1/54 1.85
Biochemical blood tests 3 3/54 5.55
Post‐mortem biopsy 1 1/54 1.85
Physical and neurological examination 2 2/54 3.70
Immunoblot analysis 1 1/54 1.85
Brain tomography 1 1/54 1.85
Special encephalitis treatment
Dexamethasone 2 3/36 8.33
Plasma exchange 3 3/36 8.33
IV methylprednisolone/oral prednisone 13 13/36 36.11
IV immunoglobulin 8 10/36 27.77
Corticosteroids 2 4/36 11.11
Steroids 1 1/36 2.77
Propofol infusion 1 1/36 2.77
Mannitol 2 2/36 5.55
Acyclovir 6 6/36 16.66
Ceftriaxone 3 3/36 8.33
Vancomycin 4 4/36 11.11
Meropenem 2 2/36 5.55
Tocilizumab 4 4/36 11.11
Azithromycin 1 1/36 2.77
Rituximab 1 1/36 2.77
Anti‐edematous therapy 1 1/36 2.77
COVID‐19 treatment
Hydroxychloroquine 15 15/30 50.00
Chloroquine 1 1/30 3.33
Azithromycin 4 4/30 13.33
IV amoxicillin‐clavulanic acid 1 1/30 3.33
IV immunoglobulin 2 2/30 6.66
Ceftriaxone 3 3/30 10.00
Dexamethasone 3 3/30 10.00
Favipiravir 2 2/30 6.66
Ritonavir/lopinavir 5 5/30 16.66
Plasma exchange 2 2/30 6.66
Remdesevir 1 1/30 3.33
Clarithromycin 1 1/30 3.33
Corticosteroid pulse 1 1/30 3.33
Clindamycin 1 1/30 3.33
Interferon beta‐1b 1 1/30 3.33
Darunavir/cobicistat 1 1/30 3.33
Cephalosporin 2 2/30 6.66
Aminoglycoside 1 1/30 3.33
Vancomycin 1 1/30 3.33
Linezolide 2 2/30 6.66
Acyclovir 6 6/30 20.00
Acetaminophen 1 1/30 3.33
Gamma globulin 1 1/30 3.33
Levofloxacin 2 2/30 6.66
Meropene 1 1/30 3.33
Atazanavir 1 1/30 3.33
Trimethoprime‐sulfamethoxazole 1 1/30 3.33
Meropenem aminosid 1 1/30 3.33
Outcome
Death 13 13/46 28.26
Discharged 20 23/46 50.00
Discharged to rehabilitation/partial recovery 4 4/46 8.69
Still hospitalized 4 4/46 8.69
Transferred to another hospital 2 2/46 4.34
Brain MRI pattern
Unremarkable 6 6/47 12.76
Hyperintensity in the white matter 15 21/47 44.68
Hyperintensity in the corpus callosum 5 6/47 12.76
Hyperintensity in the cerebellum 3 3/47 6.38
Hyperintensity of the thalamus 6 6/47 12.76
Hyperintensity in the temporal lobe 8 8/47 17.02
Hyperintensity in the frontal lobe 5 5/47 10.63
Hyperintensity in the brainstem 3 3/47 6.38
Hyperintensity in the parietal lobe 2 2/47 4.25
Hyperintensity along the wall of lateral ventricle 1 1/47 2.12
Hemorrhagic/microhemrorrhagic areas 4 5/47 10.63
Signs of brain edema 4 4/47 8.51
Confluent diffusion restriction in the white matter 2 4/47 8.51
Compression and displacement of the brainstem and fourth ventricle 1 1/47 2.12
Downward cerebellar tonsilar herniation 2 2/47 4.25
Mild gyral expansion 2 2/47 4.25
Involvement of cortical and deep gray matter and midbrain 1 1/47 2.12
Diffuse hemosiderin staining throughout the white matter and corpus callosum 1 1/47 2.12
Linear meningeal enhancement 1 1/47 2.12
Contrast enhancement on the floor of the fourth ventricle 1 1/47 2.12
Bilateral optic nerve enhancement 1 1/47 2.12
Slight hippocampus atrophy 1 1/47 2.12
Mild hippocampal thickening 1 1/47 2.12
Generalized brain atrophy 1 1/47 2.12
Head CT scan pattern
Unremarkable 15 20/35 57.14
Hypodensity of the white matter 6 6/35 17.14
Hypodensity of the thalamus 3 3/35 8.57
Hypodensity of the corpus callosum 2 2/35 5.71
Hypodensity in the cerebellum 2 3/35 8.57
Cerebral hemorrhages/hemorrhagic foci 4 4/35 11.42
Brain swelling and edema 2 2/35 5.71
Brain herniation 1 1/35 2.85
Opacification of paranasal sinuses 1 1/35 2.85
Internal hydrocephalus 1 1/35 2.85
Parenchymal hematoma with surrounding edema 1 1/35 2.85
Cerebral parenchymal volume loss with sulcal enlargement 1 1/35 2.85
Enlargement of the lateral ventricles with intraventricular masses 1 1/35 2.85
Increased supratentorial leptomeningeal enhancement 1 1/35 2.85

3.2. Study population

From a total of 45 studies, 53 patients with COVID‐19‐associated encephalitis were enrolled from 18 countries. Forty‐one (93.18%) studies were case reports and 4 (6.82%) were case series. The most significant number of studies was conducted in the USA (n = 10), followed by Italy (n = 6) and Iran (n = 5).

3.3. Demographic data

Demographic information of the individuals with COVID‐19‐associated encephalitis can be found in Tables 1 and 2. The patients were 21 female and 32 male with mean age of 52.12 years ranged between 9 months and 89 years. The highest incidence of COVID‐19‐associated encephalitis was observed in people over 50 years of age (54.72%).

3.4. Diagnostic methods

COVID‐19 was most often diagnosed by RT‐PCR (92.45%) and chest CT (37.73%). In addition, serological tests (11.32%) and simplexa assay (1.88%) were used to detect SARS‐CoV‐2 virus (Table 3). Brain MRI (81.48%), CSF analysis (46.29%), electroencephalography (42.59%), and head CT (37.03%) were the most frequently used methods to diagnose encephalitis (Table 3). The most common brain MRI patterns were hyperintensity in the white matter (44.68%), hyperintensity in the temporal lobe (17.02%), and hyperintensity of the thalamus (12.76%). In addition, hypodensity of the white matter (17.14%) and cerebral hemorrhages/hemorrhagic foci (11.42%) were the most common head CT scan patterns.

3.5. Clinical manifestations

Clinical manifestations were reported in five categories including (A) neurological manifestations such as altered mental status (53.70%), decreased consciousness/unconsciousness (33.33%), and seizure (29.62%); (B) psychiatric symptoms (14.81%); (C) general symptoms such as fever (70.37%), headache (20.37%), weakness/asthenia (18.51%), and drowsiness (16.66%); (D) neuromuscular symptoms such as myalgia (7.40%), myoclonus (5.55%); and (E) other clinical manifestation such as respiratory symptoms (68.51%), renal dysfunction (18.51%), and visual impairment (7.40%).

3.6. Comorbidities

The most common comorbidities were hypertension (29.16%), diabetes mellitus (14.58%), obesity (12.50%), and neurologic disorders (10.41%). The less common comorbidities were anemia (2.08%), hypercholesterolemia (2.08%), hypothyroidism (2.08%), vitiligo (2.08%), and asthma (2.08%).

3.7. Treatment options

A wide range of treatment options was used to treat COVID‐19. The most common of which were hydroxychloroquine (50%), acyclovir (20%), and ritonavir/lopinavir (16.66%), respectively. Common encephalitis treatment modalities included IV methylprednisolone/oral prednisone (36.11%), IV immunoglobulin (27.77%), acyclovir (16.66%). In Table 3, we summarize all of the drugs used.

3.8. Outcomes

In total, 58.69% of the patients with COVID‐19‐associated encephalitis discharged and 13.05% of them were still hospitalized. The pooled mortality rate of these patients was 28.26%.

3.9. Risk of bias assessment

The results of the critical appraisal (JBI checklist) of included studies are summarized in Table S1. Overall, 45 articles were identified as having a low risk of bias (quality assessment score >7).

4. DISCUSSION

Encephalitis is one of the specific neurological manifestations of COVID‐19 that can cause severe damage to the patient. 16 In this study, we reviewed case series and case reports to evaluate the clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis.

The patients with COVID‐19‐associated encephalitis can show encephalitis weeks after the onset of symptoms of COVID‐19 or to have symptoms of COVID‐19 and encephalitis at the same time. 12 Our study indicated that the clinical manifestations in patients with COVID‐19‐associated encephalitis can be both central nervous system symptoms (i.e., headache, dizziness, and impaired consciousness) and peripheral nervous system symptoms (i.e., hypogeusia, hyposmia, etc.). The most common symptoms were related to altered mental status (53.7%), decreased consciousness/unconsciousness (33.3%), and seizure (29.6%).

These results were consistent with a systematic review performed by Siow et al. They also reported that decreased level of consciousness (77.1%), alter in mental state (72.3%), and seizures (38.2%) were the most common symptoms in patients with COVID‐19‐associated encephalitis. 12

Correia et al. 17 conducted a systematic review on the neurological manifestations of patients with COVID‐19. The rate of altered consciousness in their study was reported to be 11.2%. The difference in the results of their study with us could be due to differences in the time frame of each study and the number of patients admitted.

Furthermore, headache (20.37%) and weakness/asthenia (18.51%) were other clinical symptoms of COVID‐19‐associated encephalitis in the present study. Correia et al. 17 and Siow et al. 12 reported headache rates of 16.8% and 27.3%, respectively.

In this study, myalgia (7.4%) was the most frequent neuromuscular symptom. The prevalence of myalgia in a meta‐analysis done by Li et al. 18 was 35.8%.

Fever (70.37%) and respiratory failure (68.51%) were the most common symptoms of COVID‐19 in our evaluation. Heidary et al. 19 achieved the same results in their study. They reported that clinical symptoms of COVID‐19 included coughing (81.3%), fever (62.8%), and dyspnea (60%). Also, Koupaei et al. 20 demonstrated that the COVID‐19 patients mostly suffered from fever (78.8%), cough (63.7%), and respiratory distress (22.6%).

So far, several cases of COVID‐19‐associated encephalitis have been reported in people who did not have symptoms of COVID‐19. The presence of asymptomatic people with encephalitis recommends that performing the diagnostic tests is necessary to prevent the spread of the disease. 21 , 22 On the contrary, CNS involvement is similar in the SARS‐CoV‐2, SARS‐CoV, and MERS‐CoV viruses. Thus, it is recommended that more sensitive and specific tests be performed. 23

In this study, the most common methods used to diagnose encephalitis were MRI (81.48%), CSF analysis (46.29%), electroencephalogram (42.59%), and head CT scan (37.03%). Among the analysis performed on CSF, only 79.41% were positive and showed the presence of viral RNA. This may be due to the mechanism of encephalitis that the virus has not entered CSF and cannot be detected. Moreover, in the early stages of the disease, CSF may have a normal level and cause a false‐negative result. 5

The most common MRI findings included hyperintensity in the white matter, hyperintensity in the temporal lobe, and hyperintensity in the corpus callosum, respectively. Although the CT findings of patients with COVID‐19‐associated encephalitis usually are not remarkable, 24 our study showed that the most findings are hypodensity of the white matter (17.14%) and cerebral hemorrhages/hemorrhagic foci (11.42%).

Probably, some of the signs in the imaging are related to the subcortical white matter hyperintensities and microbleeds in the deep gray nuclei caused by underlying diseases. 12

The association between underlying diseases such as hypertension, diabetes, chronic obstructive pulmonary disease (COPD), cardiovascular disease, and cerebrovascular disease has been identified with COVID‐19. People with the above underlying diseases are more likely than others to develop COVID‐19 and the severity of the disease. 25 In the present study, patients with COVID‐19‐associated encephalitis had a higher percentage of hypertension (29.16%) and diabetes mellitus (14.58%).

Angiotensin‐converting enzyme 2 (ACE2), the receptor for SARS‐CoV‐2, is abundant in various organs. 3 Diabetes can increase the serum ACE2. Thus, it is not surprising that diabetes is a common comorbidity in patients with COVID‐19‐associated encephalitis. 26

In this study, COVID‐19‐associated encephalitis was more common in people over 50 years of age (54.72%). It seems that elderly people with several underlying diseases are less able to physiological rearrangement, which makes them more prone to encephalitis. 27

Although various treatments have been used to treat COVID‐19‐associated encephalitis, none of them can be used with certainty. At the time of the COVID‐19 epidemic, physicians should suspect SARS‐CoV‐2 as a differentiating factor when certain diseases and neurological symptoms occur. 21 Our survey showed that IV methylprednisolone/oral prednisone (36.11%), IV immunoglobulin (27.77%), and acyclovir (16.66%) were the common treatment options to treat encephalitis. The healing role of IV immunoglobulin in severe cases of COVID‐19 has been confirmed in several studies. 28 , 29 , 30 , 31

There are some limitations in this study. First, only case reports and case series were enrolled in this systematic review. Thus, the existence of publication bias should be considered. Second, since our search was limited to articles published in English, some relevant articles in other languages have missed. Third, some studies lacked sufficient data.

5. CONCLUSION

In this systematic review, various aspects of COVID‐19‐associated encephalitis including clinical symptoms, diagnosis, treatment, and outcome were studied. COVID‐19‐associated encephalitis is one of the complications of SARS‐CoV‐2, which may accompany with other neurological symptoms and make the patient's condition worse. It usually occur in severe cases and can increase the mortality rate. Thus, it is recommended to pay special attention to neurological symptoms during the COVID‐19 epidemic. Lack of proper attention causes problems such as delay in COVID‐19 diagnosis, virus transmission, and increased mortality. Therefore, further studies on COVID‐19‐associated encephalitis are suggested.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

AUTHORS’ CONTRIBUTION

Maryam Koupaei, Negar Shadabmehr, Mohamad Hosein Mohamadi, Arezoo Asadi, Sajjad Abasi Moghadam, Amirhosein Shekartabar, Mohsen Heidary, and Fazlollah Shokri contributed in revising and final approval of the version to be published. All the authors agreed and confirmed the study for publication.

Supporting information

Table S1

Koupaei M, Shadab Mehr N, Mohamadi MH, et al. Clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis: A systematic review of case reports and case series. J Clin Lab Anal. 2022;36:e24426. doi: 10.1002/jcla.24426

Koupaei and Shadab Mehr contributed equally to this work.

Mohamadi and Asadi contributed equally to this work.

Abbasimoghaddam and Shekartabar contributed equally to this work.

Contributor Information

Mohsen Heidary, Email: mohsenheidary40@gmail.com.

Fazlollah Shokri, Email: f.shokri_sbmu@yahoo.com.

DATA AVAILABILITY STATEMENT

All the data in this review are included in the study.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1

Data Availability Statement

All the data in this review are included in the study.


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