Neonates, infants, and young children with positive Coronavirus disease 2019 (COVID-19) infection are likely to remain asymptomatic or present with less severe disease compared to adults. However, some cases of severe neurological presentation of SARS-CoV-2 have been reported among young children. We report a case of extensive white matter injury and systemic disease associated with SARS-CoV-2 in a neonate.

A previously healthy 4-day-old neonate, born full-term by vacuum-assisted vaginal delivery, presented with afebrile status epilepticus in the setting of active COVID-19 infection. Initial examination revealed no acute distress or dysmorphic features but was notable for intermittent apnea with responsiveness to stimuli, intact reflexes, and mild hypotonia in the bilateral upper and lower extremities. Seizure semiology consisted of lip-smacking, nystagmus, and full-body tonic-clonic jerking. EEG demonstrated focal subclinical seizures emanating from the right central parietal lobe. Benzodiazepines and phenobarbital were administered, and no subsequent seizures were detected. MRI brain showed multifocal restricted diffusion and signal abnormalities within the bilateral white matter, corpus callosum, subcortical white matter, and brainstem. A nasopharyngeal swab was positive for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (rRT-PCR) assay otherwise CSF and serum studies were unremarkable. The patient developed acute respiratory distress syndrome, requiring extracorporeal membrane oxygenation (ECMO). After two-months of prolonged hospitalization, the patient was successfully weaned from oxygen, formula fed, and discharged to rehabilitation without any neurological deficits.