52-year-old healthy white female with insignificant past medical history presented to emergency department with one day history of intractable holocephalic headache, nausea and vomiting. In the emergency department, patient experienced witnessed generalized tonic-clonic seizure. Patient denied loss of taste, smell or respiratory symptoms. Blood pressure on presentation was 165/85. Neurological examination unremarkable except for memory compromise. CT head reported normal. Lumbar puncture (LP) attempted without success and given presentation, empiric meningitis coverage was initiaited. LP re-attempted and was unremarkable. MRI brain with and without contrast showed increased T2 signal abnormality symmetrically in subgyral distribution affecting bilateral occipital more than frontal and parietal lobes without any associated enhancement. Radiological picture consistent with PRES. No evidence of vasculitis found. Electroencephalogram normal. Given the intractable nature of headache and new onset seizure in absence of CSF abnormalities, SARS-CoV-2 test was obtained which resulted positive. Patient did not have typical respiratory symptoms of SARS-CoV-2 and presentation was limited to neurological manifestation. Patient was treated symptomatically for headache and control of blood pressure and discharged the next day. Repeat MRI brain three months later showed resolution of radiological findings.

Anosmia, ageusia and headache are known neurologic symptoms of SARS-CoV-2 infection. The majority of SARS-CoV-2 cases have respiratory symptoms. This case highlights the importance of testing for SARS-CoV-2 in a patient with new onset intractable headache, seizure and brain MRI finding of PRES with normal CSF analysis.