Reactivation of COVID-19 in a neurosurgical patient with early neuropsychiatric presentation. Does seroconversion mean immunity?
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Italy.
- Neuroanaesthesia and Intensive Care, Fondazione IRCCS Istituto Neurologico C. Besta, University of Milan, Milan, Italy.
- Experimental Neurology Unit, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Department of Neurosurgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
Department of Neurosurgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
DOI:10.25259/SNI_831_2020Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Giulio Bonomo1, Dario Caldiroli2, Roberta Bonomo3, Raffaelino Pugliese4, Francesco DiMeco1, Cesare Zoia4. Reactivation of COVID-19 in a neurosurgical patient with early neuropsychiatric presentation. Does seroconversion mean immunity?. 19-Apr-2021;12:166
How to cite this URL: Giulio Bonomo1, Dario Caldiroli2, Roberta Bonomo3, Raffaelino Pugliese4, Francesco DiMeco1, Cesare Zoia4. Reactivation of COVID-19 in a neurosurgical patient with early neuropsychiatric presentation. Does seroconversion mean immunity?. 19-Apr-2021;12:166. Available from: https://surgicalneurologyint.com/surgicalint-articles/10741/
Background: In the aftermath of COVID-19 outbreak, there is a strong need to find strategies to monitor SARSCoV-2 transmission. While the application of screening techniques plays a major role to this end, there is evidence challenging the real significance of seroconversion. We reported a case of COVID-19 reactivation associated with a neurosurgical operation with early neuropsychiatric involvement presumably promoted by olfactory and gustatory impairment in the first infection.
Case Descriptio: A 57-year-old man was referred for a 2-month history of progressive development of imbalance, dizziness, and vomiting. Magnetic resonance imaging showed two bilateral hemispheric cerebellar lesions. In line with our triage protocol, the patient underwent a nasopharyngeal swab for RNA of SARS-CoV-2 detection, which resulted positive. Of note, the patient had reported in the previous month hyposmia and hypogeusia. After a period of 14 days, three new swabs were performed with negative results, leading the way to surgery. In the early post-operative period, the patient manifested acute onset of psychotic symptoms with hyperactive delirium, followed by fever and acute respiratory failure. A chest computed tomography revealed a specific pattern of ground-glass opacities in the lower lobes bilaterally, suggesting a viral pneumonia. Serological tests demonstrated the seroconversion and a new nasopharyngeal swab confirmed SARS-CoV-2 infection.
Conclusion: Our report highlights the importance of comprehensive screening assessments in sensitive cases highly susceptible to COVID-19 recurrence.
Keywords: COVID-19, Neuropsychiatric presentation, Neurosurgery, Reactivation, SARS-CoV-2, Seroconversion
In the aftermath of COVID-19 outbreak, there is a strong need to find strategies to monitor SARS-CoV-2 transmission. While the application of screening techniques plays a major role to this end, there is evidence challenging the real significance of seroconversion.[
We report a case of COVID-19 reactivation in a seroconverted patient following a neurosurgical intervention and manifesting early neuropsychiatric symptoms. The possible underlying mechanisms are further discussed.
This 57-year-old man was referred for a 2-month history of progressive development of imbalance, dizziness, and vomiting. On examination, he presented with wide-based gait, uncoordinated limb movements, and nystagmus on extreme gaze. Radiological investigations disclosed two bilateral hemispheric cerebellar lesions, suggestive of metastases [
Recent studies have suggested that SARS-CoV-2 can spread in the brain through the olfactory nerve and bulb and reach a latency state by eluding the immune response.[
It has been documented that up to one-third of patients with COVID-19 develop neuropsychiatric symptoms, including delirium, and these manifestations tend to occur early in the disease (mean period: 1–2 days). However, these patients may be associated with a more severe evolution of the disease.[
In accordance with these observations, we hypothesize that olfactory and gustatory dysfunction in the first infection may have been the predisposing cause of neuropsychiatric involvement in early post-operative reactivation of the virus. Thereafter, the spread of the virus provoked pneumonia with characteristic chest CT findings of ground-glass opacities in the lower lobes bilaterally.
Ai et al. recommend that a chest CT scan with typical features may be useful in early detection of suspected COVID-19 cases, despite an initial negative RT-PCR test.[
Another study by Ye et al. reported 5 patients with reactivation of 55 patients (9%) after discharge. All 5 patients had typical chest CT findings with clinical features similar to the other non-recurrent patients. Their reactivation time range was 4–17 days. The authors assumed that immunosuppressive therapies may be the main factor causing reactivation.[
Hoang et al. in a recent letter to the editor discuss possible scenarios of the recurrence of a positive RT-PCR after discharge with a negative test, considering false negatives, reactivation, and reinfection.[
Serological tests on our patient, performed in parallel with pneumonia and post-operative positive RT-PCR, demonstrated seroconversion with high levels of IgG (133 kAU/L). These neutralizing antibodies could be the product of the first infection, since recent publications indicate a mean time of seroconversion between 9 and 14 days after the onset of the disease, and we place the reactivation of the infection in the immediate postoperative period when neuropsychiatric symptoms occurred [
In this view, we can infer that the antibodies, presumably produced by the first infection, were not protective against the virus, raising the suspect that under particular stress conditions weakening the immune defense system, seroconverted patients may still be at risk of reactivation and spread of the virus.
In agreement with Hoang et al., we believe that the problem of SARS-CoV-2 reactivation is of crucial importance in the global public health emergency management, warranting further thorough investigation of its underlying mechanisms and prevalence.[
We reported a case of COVID-19 reactivation associated with a neurosurgical operation with early neuropsychiatric involvement presumably promoted by olfactory and gustatory impairment in the first infection. Our report highlights the importance of comprehensive screening assessments in sensitive cases highly susceptible to COVID-19 recurrence.
Ethical compliance statement
We confirm that we have read the journal’s position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Consent to publish
Patient signed informed consent regarding publishing his data and photographs.
Data availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
1. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W. Correlation of chest CT and RT-PCR testing for Coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology. 2020. 296: E32-40
2. Baig AM, Khaleeq A, Ali U, Syeda H. Evidence of the COVID-19 virus targeting the CNS: Tissue distribution, host-virus interaction, and proposed neurotropic mechanisms. ACS Chem Neurosci. 2020. 11: 995-8
3. Beach SR, Praschan NC, Hogan C, Dotson S, Merideth F, Kontos N. Delirium in COVID-19: A case series and exploration of potential mechanisms for central nervous system involvement. Gen Hosp Psychiatry. 2020. 65: 47-53
4. Butowt R, Bilinska K. SARS-CoV-2: Olfaction, brain infection, and the urgent need for clinical samples allowing earlier virus detection. ACS Chem Neurosci. 2020. 11: 1200-3
5. Cenzato M, DiMeco F, Fontanella M, Locatelli D, Servadei F.editors. Editorial Neurosurgery in the storm of COVID-19: Suggestions from the Lombardy region, Italy (ex malo bonum). J Neurosurg 2020. 2020. p. 1-2
6. Hoang VT, Dao TL, Gautret P. Recurrence of positive SARSCoV-2 in patients recovered from COVID-19. J Med Virol. 2020. 92: 2366-7
7. Mao L, Jin H, Wang M, Hu Y, Chen S, He Q. Neurologic manifestations of hospitalized patients with Coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020. 77: 683-90
8. Netland J, Meyerholz DK, Moore S, Cassell M, Perlman S. Severe acute respiratory syndrome Coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ACE2. J Virol. 2008. 82: 7264-75
9. Politi LS, Salsano E, Grimaldi M. Magnetic resonance imaging alteration of the brain in a patient with Coronavirus disease 2019 (COVID-19) and anosmia. JAMA Neurol. 2020. 77: 1028-19
10. Roe K. Explanation for COVID-19 infection neurological damage and reactivations. Transbound Emerg Dis. 2020. 67: 1414-5
11. Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, FusarPoli P. Psychiatric and neuropsychiatric presentations associated with severe Coronavirus infections: A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020. 7: 611-27
12. Weinstein MC, Freedberg KA, Hyle EP, Paltiel AD. Waiting for certainty on COVID-19 antibody tests-at what cost?. N Engl J Med. 2020. 383: e37
13. Ye G, Pan Z, Pan Y, Deng Q, Chen L, Li J. Clinical characteristics of severe acute respiratory syndrome Coronavirus 2 reactivation. J Infect. 2020. 80: e14-7
14. Zhao J, Yuan Q, Wang H, Liu W, Liao X, Su Y. Antibody responses to SARS-CoV-2 in patients with novel Coronavirus disease 2019. Clin Infect Dis. 2020. 71: 2027-34