Case1. Post vaccination encephalopathy
The patient was a 56-year-old female laboratory technician with no remarkable medical history and drug consumption. She was admitted to the hospital with complaints of confusion, decreased level of consciousness, and some degree of disorientation. She had received the first shot of the AstraZeneca COVID-19 vaccine one week before the admission. Two days after vaccination, her symptoms initiated with general weakness, myalgia, headache, and low grade fever that gradually worsened. The symptoms continued with decrease in consciousness, disorientation, bizarre behaviors and agitation during 72 hours that, eventually led to hospital admission. At the time of hospital admission, the patient was confused, and her neurological examination demonstrated disorientation to time, place, and person. She also had impairment in gait and the finger-to-nose test. Glasgow coma scale revealed E3M5V3; (an eye (3), verbal (3), and motor (5) response). Other neurological examinations (i.e., sensory, cranial nerves, and speech) were normal. Her vital signs were stable except for fever (38.6 °C).
With clinical suspicious of viral encephalitis, lumbar puncture was done and intravenous acyclovir, 10mg/kg every 8 hours was started. The patient’s orientation and consciousness improved within less than two days. Cerebral spinal fluid (CSF) was clear and colorless with a total WBC count of <5 cells/mm3, a normal glucose level, and significantly raised protein concentration of 119mg/dl. However, CSF viral panels (HSV1, HSV2, CMV, EBV, VZV, HHV6, HHV7, and HHV8 polymerase chain reaction (PCR) were negative. Acyclovir was discontinued. Further laboratory studies including complete blood count (CBC), blood electrolytes (Na, K, P, Ca, and Mg), liver enzymes tests, urine analysis and culture, blood culture, blood and urine toxicology, blood gases test, coagulation tests, and SARS-COV-2 PCR were all unremarkable. She also underwent brain MRI (figure1) and abdominopelvic sonography that were normal. Rapidly, the patient’s general condition was ameliorated and she was discharged two days later and referred to the outpatient clinic for a follow-up visit. Clinical and neurological conditions were normal at the follow-up visit one month later.