Self-limited focal epilepsy in a young child with SARS-CoV-2: serendipity or causal association?

Neurological manifestations have been reported in adults with COVID-19. In children with COVID-19, data on neurological symptoms are scarce. A 4-year-old girl was assisted at home for prolonged afebrile seizures. She was unresponsive, with a conjugate eye right deviation lasting > 20 minutes. Intravenous midazolam was administered. Before arrival in our Emergency Department, EMS providers excluded risk factors for COVID-19, such as fever, respiratory symptoms, other signs of viral infections, or recent contacts with suspected COVID-19 cases. Upon her arrival, seizures had resolved, GCS was 12. Temperature was 36,6°C. Chest was clear (SatO2 100%). Blood tests did not show signs of infection. We collected a nasopharyngeal swab, which tested positive for SARS-CoV-2. The patient rapidly recovered her neurological function. A pediatric neurological examination and video-EEG recording produced a possible diagnosis of self-limited focal epilepsy, with temporo-occipital spikes. Family history revealed her father had occasional seizures during fever episodes, at 14 and 21 years. The child was discharged home, scheduling further neurological investigations once the swab was negative. Our case emphasizes that keeping a high suspicion for SARS-CoV-2 infection is pivotal in hot spots, regardless of the absence of typical COVID-19 symptoms. As for the seizures episode, we know infections and fever are leading seizure precipitating factors in children. To our knowledge, this is the first case of focal status epilepticus in new onset focal self-limited epilepsy in an afebrile child with SARS-CoV-2. We speculate that SARS-CoV-2 infection may have triggered the onset of self-limited focal epilepsy in our patient.