Gretchen Santana Cepero, MD
Resident
Cleveland Clinic Foundation
Disclosure information not submitted.
Marina Boushra Freiberg, MD
Physician
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Simon Mucha, MD, FACP
Physician
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Title: Encephalopathy after COVID-19 Infection and Vaccine in Patient with Underlying Autoimmune Disease
Introduction: Although usually safe and effective, COVID-19 vaccines can precipitate severe inflammatory responses, particularly in patients with prior SARS-CoV-2 infection. There are two documented cases of encephalopathy following the COVID-19 vaccine in patients without prior infection. We present a case of encephalopathy following the first and second dose of the mRNA-1273-SARS-CoV-2 vaccine in a patient with prior COVID-19 that resolved with immunosuppression.
Description: A 67-year-old female with a history of rheumatoid arthritis, Sjogren’s syndrome, chronic obstructive pulmonary disease, and prior COVID-19 presented for encephalopathy the day following her first COVID-19 vaccine. Cerebrospinal fluid analysis, MRI, and electroencephalogram were negative, and the encephalopathy resolved with levetiracetam. Six weeks later, she presented again the day after receiving her second vaccine dose for similarly progressive encephalopathy complicated by respiratory failure, acute respiratory distress syndrome, and septic shock secondary to aspiration pneumonia. She was liberated from the ventilator after four days of antibiotics but remained encephalopathic with a Glasgow Coma Scale (GCS) of 3. Her course was characterized by recurrent fevers of unknown etiology with elevated inflammatory markers, despite negative findings on repeat infectious, autoimmune, and paraneoplastic testing. The patient was unresponsive for 32 days and family desired a transition to hospice. A dose of one gram of methylprednisolone was trialed prior to transition to hospice. The patient had a dramatic improvement in her mental status within 24 hours and was subsequently discharged to an acute rehabilitation facility with resolution of encephalopathy.
Discussion: Despite broad workup without a definitive diagnosis, the striking association of symptom onset following both vaccine doses and the response to steroids suggest a potential inflammatory encephalopathy in response to mRNA-1273-SARS-CoV-2 vaccine in this patient with underlying autoimmune disease. This case describes the first documented response to immunosuppression in encephalopathy after COVID-19 vaccination and is the first such case of vaccine-related encephalopathy in a patient with prior infection.