Glial Fibrillary Acidic Protein (GFAP) antibody has been reported to cause an autoimmune meningoencephalomyelitis. It is associated with paraneoplastic and infectious processes. Flu, dengue and herpes have previously been reported as triggers. 

We describe a case of a 23 year old male who developed upper respiratory tract symptoms and tested positive for COVID-19 at an outside clinic. Patient developed sudden onset headache, confusion, weakness and ataxia over the next few days which prompted his admission to an outside hospital. Cerebrospinal fluid (CSF) analysis revealed leukocyte count of 336cells/mm³, RBC count of 40cells/mm³ and protein of 236mg/dl. MRI Brain showed leptomeningeal enhancement. COVID-19 PCR remained negative throughout admission. On transfer to our facility, he was intubated, quadriplegic and could only communicate with eye movements. Second MRI Brain at our facility showed bilateral diffusion restricting lesions in paramedian pons along with abnormal T2 signal in midbrain, basal ganglia and thalamus. Repeat CSF analysis showed lymphocytic pleocytosis and positive PCR for enterovirus (negative for EV-D68). CSF encephalopathy panel was positive for GFAP antibodies (titer 1:64). Cerebral angiogram and malignancy screen was negative. He was treated with high dose methyl-prednisone and intravenous immunoglobulin. Patient responded well to the treatments and regained some motor function of his extremities. Repeat MRI Brain after 4 weeks showed interval worsening with new lesions in the bilateral middle cerebellar peduncles, pons and white matter involving the fourth ventricle and periventricular areas. Despite worsening imaging, patient continues to improve and was weaned off the ventilator. He is now on a prednisone taper with plans to transition to inpatient rehabilitation. 

This is the first reported case of GFAP astropathy associated with enterovirus encephalitis and COVID-19. We hypothesize that these infectious pathogens likely triggered the GFAP astropathy. Patient’s imaging findings and response to therapy supported the diagnosis of GFAP astropathy.