Sima Patel, BS
Kendall Regional Medical Center
Orlando, Florida
Disclosure information not submitted.
Nida Hameedi, MD
Critical Care Fellow
AdventHealth Orlando, Florida, United States
Disclosure information not submitted.
Gilbert Mbeo, MD
Neuro Critical Care
AdventHealth Orlando, United States
Disclosure information not submitted.
Title: Post COVID-19 Super Refractory Status Epilepticus Successfully Treated with Intrathecal Rituximab
Case Report Body:
Introduction: COVID-19 is a respiratory infection recognized for its pulmonary complications, but literature later suggested neurologic complications such as the capability to trigger a neuroinflammatory cascade and affect the blood brain barrier. It became clear these neurologic sequala, especially seizures, were difficult to treat. We present a case of post COVID-19 super refractory status epilepticus that failed several therapies and was treated successfully with intrathecal rituximab, improving the neurologic outcome.
Description: A 31-year-old male with no medical history arrived for confusion and fever. Patient had 2 seizures and received lorazepam. Head CT, chest x-ray, lumbar puncture, and COVID-19 polymerase chain reaction (PCR) were unremarkable. He was intubated and started on antibiotics. Continuous electroencephalogram showed refractory status epilepticus for which a propofol infusion was started. He completed intravenous immunoglobulin and antiepileptic drugs were optimized. Seizures continued despite max doses of midazolam, propofol and ketamine infusions, which were then switched for pentobarbital. Brain MRI, cerebrospinal fluid (CSF) studies and additional workup were unremarkable. COVID-19 antibody test was sent and was positive, along with elevated interleukin levels. Attempts were made to wean the pentobarbital; however, status returned and he required pentobarbital infusion 3 additional times. CSF PCR COVID-19 was ordered; however, the test was prohibited. A diagnosis of post COVID-19 encephalitis leading to super refractory status epilepticus was made. Patient completed high-dose steroids, 5 doses of plasmapheresis, rituximab and anakinra without seizure resolution. Three doses of intrathecal rituximab were given which resolved seizures and leading to patient recovery.
Discussion: Status epilepticus is difficult to treat, especially with COVID-19 as the etiology. Intrathecal rituximab has been used to treat CNS lymphoma and non-teratoma anti N-methyl-D-Aspartate receptor encephalitis but there have been no reports on its use in COVID-19 status epilepticus. Our patient was discharged, decannulated and returned to work. We want to bring attention to this treatment modality that can help resolve seizures in post COVID-19 status epilepticus and contribute to a promising neurologic recovery.