A 69-year-old Caucasian man presented fever (38°C) with abdominal pain, left posterior
chest pain without cough or dyspnea, and mild occipital headache that persisted in
the next few days. Eleven days later, he woke up with binocular diplopia and severe
stabbing occipital headache. There were no peripheral signs of systemic vasculitis.
The neurological evaluation identified bilateral paresis of the fourth cranial nerve.
He had well-controlled arterial hypertension and denied trauma or use of other medications.
COVID-19 infection was confirmed by the reverse transcription technique followed by
polymerase chain reaction (RT-PCR) in a nasopharyngeal swab. A brain magnetic resonance
imaging (MRI) with MRI angiography and vessel wall imaging showed signs of vasculitis
of the vertebrobasilar system[1], as well as inflammatory radiologic signs in the periaqueductal region, along the
topography of the trochlear nuclei ([Figure 1]). Chest computed tomography (CT) showed peripheral parenchymal ground-glass opacities,
suggesting viral pneumonia. Cerebrospinal fluid (CSF) revealed 2 cells/mm3 (69% lymphocytes, 29% monocytes, 2% macrophages) and proteins slightly increased
to 46 mg/dL (with 17.01% gamma globulin). CSF antibody testing was negative for syphilis
and other viruses. Rheumatological causes, hypovitaminosis, and thyroid dysfunction
were ruled out. Erythrocyte sedimentation rate (ESR) was 33 mm/h. He received IV methylprednisolone
for five days with complete improvement of pain and diplopia.
Figure 1 (A and B) axial MRI 3D-T1 FATSAT post-contrast vessel wall imaging at the level of
the vertebral arteries (A) and basilar artery (B) shows mild abnormal concentric enhancement
of the basilar artery wall (arrow) and intense abnormal concentric enhancement of
the vertebral artery wall, which are tortuous and lateralized to the left (arrow).
(C) Reformatted Coronal Oblique 3D-T1 FATSAT post-contrast vessel wall imaging shows
abnormal concentric enhancement of the basilar and vertebral artery walls (arrows).
This is the first case report of cerebral vasculitis related to COVID-19 infection
in an adult patient. We emphasize that headache[2] could be a warning sign of cerebral vasculitis in these individuals.
