There has been an increasing number of reports of severe neurological manifestations in patients who have been infected with SARS-CoV-2 . Several mechanisms have been proposed for how the virus infects the Central Nervous System (CNS) including direct viral invasion of the nervous system, neurologic injury from systemic dysfunction, and parainfectious or postinfectious autoimmune attack leading to neurological manifestations.

31-year-old Caucasian male presented with right-sided weakness, right facial droop, slurred speech and altered mental status after 2 weeks of COVID-19 infection. The presentation was preceded by 5 days of severe headache, fever, and persistent hiccups. Later on the same day of presentation, he developed ophthalmoplegia of the left eye, numbness, and weakness in the right upper and lower extremities.

A repeated brain MRI showed an enhancing brainstem lesion in the left pons. Lumbar puncture indicated the presence of neutrophilic pleocytosis and mildly elevated protein levels in the cerebrospinal fluid (CSF). While waiting for the infectious and autoimmune workups, which were found to be negative later on, the patient was started on wide-spectrum antibiotics. Initially, Listeria infection was highly suspected, given the patient's occupation involving handling raw chickens in his work environment.

A few days later, as the patient kept worsening, respiratory failure developed, and the patient had to be intubated. IV methylprednisolone was started due to suspicion of a malignant or inflammatory process. Repeat tests showed improving pleocytosis in the CSF, while imaging revealed involvement of the right pons and cerebral peduncle. Antibiotic therapy was discontinued as most infectious workups were negative. The patient was ultimately diagnosed with post-infectious rhombencephalitis secondary to his recent COVID-19 infection, after excluding other potential causes. Treatment with high-dose corticosteroids with 4 weeks of taper resulted in excellent clinical recovery without any relapse.