A 23-Year-Old Man with SARS-CoV-2 Infection Who Presented with Auditory Hallucinations and Imaging Findings of Cytotoxic Lesions of the Corpus Callosum (CLOCC).

BACKGROUND Cytotoxic lesions of the corpus callosum (CLOCC) is a rare clinical and radiological syndrome that has been associated with various infectious etiologies. CLOCC are among the recently described neurological associations with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with coronavirus disease 2019 (COVID-19). We report a case of CLOCC in a man with SARS-CoV-2 infection who presented with auditory hallucinations and rapidly developed systemic inflammatory response syndrome (SIRS). CASE REPORT A 23-year-old man with no past medical and psychiatric history presented with auditory hallucinations, restlessness, and suicidal ideations. A nasopharyngeal swab specimen tested using real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay was positive for SARS-CoV-2. A brain MRI revealed an isolated oval-shaped lesion in the splenium of the corpus callosum, with hyperintense signal on diffusion-weighted imaging (DWI) and hypointense on apparent diffusion coefficient (ADC) maps, suggestive of CLOCC. After a dramatic hospital course associated with multiple organ dysfunction syndrome (MODS) and severe intra-abdominal and cerebral bleeding, he developed cardiac arrest and died on hospital day 15. CONCLUSIONS This case highlights the need for increased vigilance for the atypical manifestations of SARS-CoV-2 infection. In addition, it suggests that CLOCC can be considered as a differential diagnosis by clinicians in patients with SARS-CoV-2 infection who present with unexplained neurological and neuropsychiatric symptoms, leading to poor outcome.

Influence of efavirenz pharmacokinetics and pharmacogenetics on neuropsychological disorders in Ugandan HIV-positive patients with or without tuberculosis: a prospective cohort study.

BACKGROUND: HIV infection, anti-tuberculosis and efavirenz therapy are associated with neuropsychological effects. We evaluated the influence of rifampicin cotreatment, efavirenz pharmacokinetics and pharmacogenetics on neuropsychiatric disorders in Ugandan HIV patients with or without tuberculosis coinfection. METHODS: 197 treatment naïve Ugandan HIV patients, of whom 138 were TB co-infected, enrolled prospectively and received efavirenz based HAART. TB-HIV confected patients received concomitant rifampicin based anti-TB therapy. Genotypes for CYP2B6 (*6, *11), CYP3A5 (*3, *6, *7), ABCB1 (c.3435C>T and c.4036 A/G rs3842), CYP2A6 (*9, *17) and NR1I3 rs3003596 T/C were determined. Efavirenz plasma concentrations were serially quantified at 3rd day, 1st, 2nd, 4th, 6th, 8th and 12th weeks during therapy. Efavirenz neuropsychiatric symptoms were evaluated in terms of sleep disorders, hallucinations and cognitive effects at baseline, at two and twelve weeks of efavirenz treatment using a modified Mini Mental State Examination (MMSE) score. RESULTS: During the first twelve weeks of ART, 73.6% of the patients experienced at least one efavirenz related neuropsychiatric symptom. Commonest symptoms experienced were sleep disorders 60.5% (n=124) and hallucination 30.7% (n=63). Neuropsychiatric symptoms during HAART were significantly predicted by efavirenz plasma concentrations consistently. Rifampicin cotreatment reduced plasma efavirenz concentrations significantly only during the first week but not afterwards. There was no significant difference in the incidence of neuropsychiatric symptoms between patients receiving efavirenz with or without rifampicin cotreatment. CYP2B6*6 and ABCB1 c.4036 A/G genotype significantly predicted efavirenz concentrations. The tendency of CYP2B6*6 genotype association with higher incidence of having vivid dream (p=0.05), insomnia (p=0.19) and tactile hallucination (p=0.09) was observed mainly at week-2. CONCLUSIONS: Efavirenz related neuropsychiatric symptoms are common among Ugandan HIV patients receiving ART and is mainly predicted by higher efavirenz plasma concentrations and CYP2B6 genotype but not by rifampicin based anti-TB co-treatment.

Cerebral perfusion in children with Alice in Wonderland syndrome.

Alice in Wonderland syndrome (AIWS) is characterized by visual hallucinations and bizarre perceptual distortions. Technetium-99m hexamethylpropyleneamine tomography (SPECT) brain scans were performed in four patients during the acute stage of AIWS. Two patients were demonstrated to have Epstein-Barr virus infections. One had abnormal (EEG) findings. The visual-evoked potential, cranial CT, and MRI findings were negative. The decreased cerebral perfusion areas in all patients were near the visual tract and visual cortex. All involved some regions of the temporal lobe. In most patients with AIWS, the EEG, CT, and MRI are unable to determine the precise pathologic areas. However, a SPECT brain scan may demonstrate abnormal perfusion areas and explain the clinical presentations.