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No commercial re-use. See rights and permissions. Published by BMJ.. This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.https://bmj.com/coronavirus/usage" /> <meta name="DC.AccessRights" content="restricted" /> <meta name="DC.Description" content="Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), millions have been diagnosed with COVID-19. The major clinical manifestations of SARS-CoV-2 infection are pulmonary, however reports of COVID-19-associated central nervous system complications emerged.1 2 We report a case of encephalitis in a pulmonologically asymptomatic patient with COVID-19. A 66-year-old female presented in mid-March 2020, with a few hours history of confusion. She was completely well until the day of admission. There was no medical, infectious or behavioural prodrome. There was no alcohol or nutritional history. She had travelled to Spain, the USA and Mexico in the 3 months prior, but had been home for 19 days. She suddenly complained that her head ‘felt funny’. She carried on normal tasks but, within an hour, became confused, amnestic and was unaware of why social distancing measures were being observed. On admission, her temperature was 37.9°C. Other observations were normal. She was lymphopaenic at 0.4×109/L (0.8–3.1). Full blood count was otherwise normal. C-reactive protein (CRP) was 14.5 mg/L (0–5). Routine blood tests, including renal function, liver function and clotting, were normal. A brain CT was unremarkable. Six hours after admission, she had a single, spontaneously resolving, generalised tonic-clonic seizure. Her postictal Glasgow Coma Scale (GCS) was 6/15 (E1/V1/M4). This remained unchanged for 48 hours. Postictal neurological examination showed equal, reactive pupils, no response to visual menace, no vestibulo-ocular reflex, normal tone bilaterally, symmetrical brisk reflexes and extensor plantars. She remained febrile (37.9°C) for 48 hours. Oxygen saturation dropped to 93% on air only once during her 4-week admission. She never developed breathlessness, cough or tachypnoea. An MRI of the brain on day 2 showed non-enhancing, symmetrical T2 and FLAIR …" /> <meta name="DC.Contributor" content="Laura Zambreanu" /> <meta name="DC.Contributor" content="Sophie Lightbody" /> <meta name="DC.Contributor" content="Mohit Bhandari" /> <meta name="DC.Contributor" content="Chandrashekar Hoskote" /> <meta name="DC.Contributor" content="Hala Kandil" /> <meta name="DC.Contributor" content="Catherine F Houlihan" /> <meta name="DC.Contributor" content="Michael P Lunn" /> <meta name="article:published_time" content="2020-11-01" /> <meta name="article:section" content="PostScript" /> <meta name="citation_title" content="A case of limbic encephalitis associated with asymptomatic COVID-19 infection" /> <meta name="citation_journal_title" content="Journal of Neurology, Neurosurgery & Psychiatry" /> <meta name="citation_publisher" content="BMJ Publishing Group Ltd" /> <meta name="citation_publication_date" content="2020/11/01" /> <meta name="citation_mjid" content="jnnp;91/11/1229" /> <meta name="citation_id" content="91/11/1229" /> <meta name="citation_public_url" content="https://jnnp.bmj.com/content/91/11/1229" /> <meta name="citation_abstract_html_url" content="https://jnnp.bmj.com/content/91/11/1229.abstract" /> <meta name="citation_full_html_url" content="https://jnnp.bmj.com/content/91/11/1229.full" /> <meta name="citation_pdf_url" content="https://jnnp.bmj.com/content/jnnp/91/11/1229.full.pdf" /> <meta name="citation_issn" content="0022-3050" /> <meta name="citation_issn" content="1468-330X" /> <meta name="citation_journal_abbrev" content="J Neurol Neurosurg Psychiatry" /> <meta name="citation_doi" content="10.1136/jnnp-2020-323839" /> <meta name="citation_pmid" content="32661082" /> <meta name="citation_volume" content="91" /> <meta name="citation_issue" content="11" /> <meta name="citation_article_type" content="Letter" /> <meta name="citation_section" content="PostScript" /> <meta name="citation_firstpage" content="1229" /> <meta name="citation_lastpage" content="1230" /> <meta name="citation_author" content="Laura Zambreanu" /> <meta name="citation_author_institution" content="MRC Centre for Neuromuscular Diseases" /> <meta name="citation_author_institution" content="University College London Hospitals NHS Foundation Trust" /> <meta name="citation_author_institution" content="Neurology Department" /> <meta name="citation_author_institution" content="West Hertfordshire Hospitals NHS Trust" /> <meta name="citation_author_orcid" content="http://orcid.org/0000-0002-0257-8362" /> <meta name="citation_author" content="Sophie Lightbody" /> <meta name="citation_author_institution" content="Stroke Unit" /> <meta name="citation_author_institution" content="West Hertfordshire Hospitals NHS Trust" /> <meta name="citation_author" content="Mohit Bhandari" /> <meta name="citation_author_institution" content="Stroke Unit" /> <meta name="citation_author_institution" content="West Hertfordshire Hospitals NHS Trust" /> <meta name="citation_author" content="Chandrashekar Hoskote" /> <meta name="citation_author_institution" content="Lysholm Department of Neuroradiology" /> <meta name="citation_author_institution" content="National Hospital for Neurology & Neurosurgery" /> <meta name="citation_author" content="Hala Kandil" /> <meta name="citation_author_institution" content="Microbiology Department" /> <meta name="citation_author_institution" content="West Hertfordshire Hospitals NHS Trust" /> <meta name="citation_author" content="Catherine F Houlihan" /> <meta name="citation_author_institution" content="Department of Virology" /> <meta name="citation_author_institution" content="University College London Hospitals NHS Foundation Trust" /> <meta name="citation_author_institution" content="Department of Infection and Immunity" /> <meta name="citation_author_institution" content="University College London" /> <meta name="citation_author" content="Michael P Lunn" /> <meta name="citation_author_institution" content="MRC Centre for Neuromuscular Disease and Department of Molecular Neuroscience" /> <meta name="citation_author_institution" content="University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery" /> <meta name="citation_author_institution" content="NIHR Biomedical Research Centre" /> <meta name="citation_author_institution" content="University College London Hospitals NHS Foundation Trust" /> <meta name="citation_author_orcid" content="http://orcid.org/0000-0003-3174-6027" /> <meta name="citation_reference" content="citation_journal_title=N Engl J Med;citation_title=Neurologic features in severe SARS-CoV-2 infection;citation_year=2020" /> <meta name="citation_reference" content="Evaluation of Roche Elecsys Anti-SARS-CoV-2 serology assay for the detection of anti-SARS-CoV-2 antibodies, 2020. 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Gao;citation_title=First case of 2019 novel coronavirus disease with encephalitis;citation_pages=00015;citation_volume=T202003;citation_year=2020" /> <meta name="citation_reference" content="citation_title=Guidance and standard operating procedure;citation_year=2020" /> <meta name="citation_reference" content="citation_title=Extraction-free COVID-19 (SARS-CoV-2) diagnosis by RT-PCR to increase capacity for national testing programmes during a pandemic;citation_year=2020" /> <meta name="citation_fulltext_world_readable" content="" /> <meta name="twitter:title" content="A case of limbic encephalitis associated with asymptomatic COVID-19 infection" /> <meta name="twitter:card" content="summary_large_image" /> <meta name="twitter:image" content="https://jnnp.bmj.com/sites/default/files/highwire/jnnp/91/11.cover-source.jpg" /> <meta name="twitter:description" content="Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), millions have been diagnosed with COVID-19. The major clinical manifestations of SARS-CoV-2 infection are pulmonary, however reports of COVID-19-associated central nervous system complications emerged.1 2 We report a case of encephalitis in a pulmonologically asymptomatic patient with COVID-19. A 66-year-old female presented in mid-March 2020, with a few hours history of confusion. She was completely well until the day of admission. There was no medical, infectious or behavioural prodrome. There was no alcohol or nutritional history. She had travelled to Spain, the USA and Mexico in the 3 months prior, but had been home for 19 days. She suddenly complained that her head ‘felt funny’. She carried on normal tasks but, within an hour, became confused, amnestic and was unaware of why social distancing measures were being observed. On admission, her temperature was 37.9°C. Other observations were normal. She was lymphopaenic at 0.4×109/L (0.8–3.1). Full blood count was otherwise normal. C-reactive protein (CRP) was 14.5 mg/L (0–5). Routine blood tests, including renal function, liver function and clotting, were normal. A brain CT was unremarkable. Six hours after admission, she had a single, spontaneously resolving, generalised tonic-clonic seizure. Her postictal Glasgow Coma Scale (GCS) was 6/15 (E1/V1/M4). This remained unchanged for 48 hours. Postictal neurological examination showed equal, reactive pupils, no response to visual menace, no vestibulo-ocular reflex, normal tone bilaterally, symmetrical brisk reflexes and extensor plantars. She remained febrile (37.9°C) for 48 hours. Oxygen saturation dropped to 93% on air only once during her 4-week admission. She never developed breathlessness, cough or tachypnoea. An MRI of the brain on day 2 showed non-enhancing, symmetrical T2 and FLAIR …" /> <meta name="og-title" property="og:title" content="A case of limbic encephalitis associated with asymptomatic COVID-19 infection" /> <meta name="og-url" property="og:url" content="https://jnnp.bmj.com/content/91/11/1229" /> <meta name="og-site-name" property="og:site_name" content="Journal of Neurology, Neurosurgery & Psychiatry" /> <meta name="og-description" property="og:description" content="Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), millions have been diagnosed with COVID-19. The major clinical manifestations of SARS-CoV-2 infection are pulmonary, however reports of COVID-19-associated central nervous system complications emerged.1 2 We report a case of encephalitis in a pulmonologically asymptomatic patient with COVID-19. A 66-year-old female presented in mid-March 2020, with a few hours history of confusion. She was completely well until the day of admission. There was no medical, infectious or behavioural prodrome. There was no alcohol or nutritional history. She had travelled to Spain, the USA and Mexico in the 3 months prior, but had been home for 19 days. She suddenly complained that her head ‘felt funny’. She carried on normal tasks but, within an hour, became confused, amnestic and was unaware of why social distancing measures were being observed. On admission, her temperature was 37.9°C. Other observations were normal. She was lymphopaenic at 0.4×109/L (0.8–3.1). Full blood count was otherwise normal. C-reactive protein (CRP) was 14.5 mg/L (0–5). Routine blood tests, including renal function, liver function and clotting, were normal. A brain CT was unremarkable. Six hours after admission, she had a single, spontaneously resolving, generalised tonic-clonic seizure. Her postictal Glasgow Coma Scale (GCS) was 6/15 (E1/V1/M4). This remained unchanged for 48 hours. Postictal neurological examination showed equal, reactive pupils, no response to visual menace, no vestibulo-ocular reflex, normal tone bilaterally, symmetrical brisk reflexes and extensor plantars. She remained febrile (37.9°C) for 48 hours. Oxygen saturation dropped to 93% on air only once during her 4-week admission. She never developed breathlessness, cough or tachypnoea. An MRI of the brain on day 2 showed non-enhancing, symmetrical T2 and FLAIR …" /> <meta name="og-type" property="og:type" content="article" /> <meta name="og-image" property="og:image" content="https://jnnp.bmj.com/sites/default/files/highwire/jnnp/91/11.cover-source.jpg" /> <link rel="alternate" type="application/vnd.ms-powerpoint" title="Powerpoint" href="/content/91/11/1229.ppt" /> <title>A case of limbic encephalitis associated with asymptomatic COVID-19 infection | Journal of Neurology, Neurosurgery & Psychiatry</title> <link type="text/css" rel="stylesheet" href="/sites/default/files/advagg_css/css__kE9tbX5lqjZTJ_7fT2iv7biJQT2HPRDK5XOS7VdfU28__UYiG8I7qza54fqIl3EgAUMhVJJpGJ_LcYYZYVTCB-7w__qw1DJnk-5gO1smAYQ6Cv-FvON600W_QtaIfAGcQ9MYA.css" media="all" />  <script src="https://cookie-cdn.cookiepro.com/scripttemplates/otSDKStub.js" type="text/javascript" charset="UTF-8" data-domain-script="565e50dd-f6e9-46d6-91cd-5c40a270264f"></script> <script type="text/javascript"> function OnetrustAdsConsent(){ if(googletag.apiReady){ //console.log("GoogleTag API ready") googletag.pubads().disableInitialLoad(); if(OptanonActiveGroups.match(/,4,/)){ googletag.pubads().setRequestNonPersonalizedAds(0); //googletag.pubads().refresh(); } else{ googletag.pubads().setRequestNonPersonalizedAds(1); googletag.pubads().refresh(); } } else{ OnetrustAdsConsent(); } } function OptanonWrapper() { OnetrustAdsConsent(); } </script>  <script type="text/javascript" src="/sites/default/files/advagg_js/js__DdxPgqGimsdUot2QWNz_pGsHzqNGpx6RMCWHpL8YWkg__c6zfK6oHHbLpTal5PdQxeQI3xGoCM8IXWtEHwIZr560__qw1DJnk-5gO1smAYQ6Cv-FvON600W_QtaIfAGcQ9MYA.js"></script> <script type="text/javascript" src="https://securepubads.g.doubleclick.net/tag/js/gpt.js"></script> <script type="text/javascript" src="/sites/default/files/advagg_js/js__RplUf5n1SHvT_MHHQProZaAaHxo7a_9YZuaKWYnqVeQ__t8vznsHJmtJcTuSP5JnWJ92mdmFUGaXxtxwBatvNwmc__qw1DJnk-5gO1smAYQ6Cv-FvON600W_QtaIfAGcQ9MYA.js"></script> <script type="text/javascript" src="https://d1bxh8uas1mnw7.cloudfront.net/assets/embed.js"></script> <script type="text/javascript" src="/sites/default/files/advagg_js/js__RxmsdK7-WlnwoO5NREEVy8MRi0OqO4ZhkOHaMokGNlw__IAyE4mioyYmepJfxC77gDsM0J1xDyesxXH7WjkUNmyc__qw1DJnk-5gO1smAYQ6Cv-FvON600W_QtaIfAGcQ9MYA.js"></script> <script type="text/javascript" defer="defer" async="async" src="//cdn.foxycart.com/bmjpg.ecommerce.highwire.org/loader.js"></script> <script type="text/javascript" async="async" src="https://scholar.google.com/scholar_js/casa.js"></script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script> <script type="text/javascript"> <![CDATA[//><!]]> </script>   <script> let cookies = parseCookies(); let bmj_uuid = cookies.bmj_uuid; let bmj_ppid = cookies.bmj_ppid; window.dataLayer = window.dataLayer || []; const anonMailId = 'e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855'; function checkUserLoginStatus(dataLayer) { const userMail = dataLayer.find((item) => item.user)?.user?.mail; if (!userMail) { return false; } return userMail !== anonMailId; } let nonAnonMailId = ((dataLayer.find(item => item.user)?.user)?.mail) === anonMailId ? null : (dataLayer.find(item => item.user)?.user)?.mail; let userId = ((dataLayer.find(item => item.user)?.user)?.['data-ics']) ?? 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id="node-209628--2561077597" data-pisa="jnnp;91/11/1229" data-pisa-master="jnnp;jnnp-2020-323839" data-apath="/jnnp/91/11/1229.atom"><cite class="highwire-cite highwire-cite-highwire-article highwire-citation-bmjj-title clearfix"> <div class="highwire-cite-title">A case of limbic encephalitis associated with asymptomatic COVID-19 infection</div> <span class="highwire-cite-access"><span class="highwire-citation-access highwire-citation-access-check" data-pisa-id="jnnp;jnnp-2020-323839" data-atom-uri="/jnnp/91/11/1229.atom" data-request-view="full"></span></span> </cite> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-panel-tabs-container col-narrow-12 clear" > <div class="pane-content"> <div data-panels-ajax-tab-preloaded="jnl_template_bmjj_tab_art" id="panels-ajax-tab-container-highwire_article_tabs" class="panels-ajax-tab-container"><div class="panels-ajax-tab-loading" style ="display:none"><img class="loading" src="https://jnnp.bmj.com/sites/all/modules/contrib/panels_ajax_tab/images/loading.gif" alt="Loading" title="Loading" /></div><div class="panels-ajax-tab-wrap-jnl_template_bmjj_tab_art"><div class="panel-display panel-1col clearfix" > <div class="panel-panel panel-col"> <div><div class="panel-pane pane-highwire-markup author-affiliates col-narrow-12 author-affiliates-corresp article" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div xmlns:xhtml="http://www.w3.org/1999/xhtml" class="contributors"><ol class="contributor-list" id="contrib-group-1"><li class="contributor" id="contrib-1"><a href="http://orcid.org/0000-0002-0257-8362" class="bmjj-markup-orcid-logo" target="_blank">http://orcid.org/0000-0002-0257-8362</a><span class="name">Laura Zambreanu</span><span class="xref-aff">1</span><span class="xref-sep">,</span><span class="xref-aff">2</span>, </li><li class="contributor" id="contrib-2"><span class="name">Sophie Lightbody</span><span class="xref-aff">3</span>, </li><li class="contributor" id="contrib-3"><span class="name">Mohit Bhandari</span><span class="xref-aff">3</span>, </li><li class="contributor" id="contrib-4"><span class="name">Chandrashekar Hoskote</span><span class="xref-aff">4</span>, </li><li class="contributor" id="contrib-5"><span class="name">Hala Kandil</span><span class="xref-aff">5</span>, </li><li class="contributor" id="contrib-6"><span class="name">Catherine F Houlihan</span><span class="xref-aff">6</span><span class="xref-sep">,</span><span class="xref-aff">7</span>, </li><li class="last" id="contrib-7"><a href="http://orcid.org/0000-0003-3174-6027" class="bmjj-markup-orcid-logo" target="_blank">http://orcid.org/0000-0003-3174-6027</a><span class="name">Michael P Lunn</span><span class="xref-aff">8</span><span class="xref-sep">,</span><span class="xref-aff">9</span></li></ol><ol class="affiliation-list"><li class="aff"><address> <sup>1</sup> <span class="institution">MRC Centre for Neuromuscular Diseases</span>, <span class="institution">University College London Hospitals NHS Foundation Trust</span>, <span class="addr-line">London</span>, UK </address></li><li class="aff"><address> <sup>2</sup> <span class="institution">Neurology Department</span>, <span class="institution">West Hertfordshire Hospitals NHS Trust</span>, <span class="addr-line">Watford</span>, UK </address></li><li class="aff"><address> <sup>3</sup> <span class="institution">Stroke Unit</span>, <span class="institution">West Hertfordshire Hospitals NHS Trust</span>, <span class="addr-line">Watford</span>, <span class="addr-line">Hertfordshire</span>, UK </address></li><li class="aff"><address> <sup>4</sup> <span class="institution">Lysholm Department of Neuroradiology</span>, <span class="institution">National Hospital for Neurology & Neurosurgery</span>, <span class="addr-line">London</span>, UK </address></li><li class="aff"><address> <sup>5</sup> <span class="institution">Microbiology Department</span>, <span class="institution">West Hertfordshire Hospitals NHS Trust</span>, <span class="addr-line">Watford</span>, <span class="addr-line">Hertfordshire</span>, UK </address></li><li class="aff"><address> <sup>6</sup> <span class="institution">Department of Virology</span>, <span class="institution">University College London Hospitals NHS Foundation Trust</span>, <span class="addr-line">London</span>, UK </address></li><li class="aff"><address> <sup>7</sup> <span class="institution">Department of Infection and Immunity</span>, <span class="institution">University College London</span>, <span class="addr-line">London</span>, United Kingdom </address></li><li class="aff"><address> <sup>8</sup> <span class="institution">MRC Centre for Neuromuscular Disease and Department of Molecular Neuroscience</span>, <span class="institution">University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery</span>, <span class="addr-line">London</span>, UK </address></li><li class="aff"><address> <sup>9</sup> <span class="institution">NIHR Biomedical Research Centre</span>, <span class="institution">University College London Hospitals NHS Foundation Trust</span>, <span class="addr-line">London</span>, <span class="addr-line">London</span>, UK </address></li></ol><ol class="corresp-list"><li class="corresp" id="corresp-1"><span class="corresp-label">Correspondence to</span> Dr Laura Zambreanu, Nuerology department, West Hertfordshire Hospitals NHS Trust, Watford WD18 0HB, UK; <span class="em-link"><span class="em-addr">l.zambreanu{at}nhs.net</span></span> </li></ol></div></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-markup abstract-with-bc" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" id="content-block" 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You will be able to get a quick price and instant permission to reuse the content in many different ways.</p> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-panels-ajax-pane-content permissions-box pane-highwire-permission-link" id="request-permissions"> <h2 class="pane-title"><span class='panels-ajax-pane-title' data-pid='new-70fd4c70-563e-4b94-ae3b-2a97f3980c13'></span></h2> <div class="pane-content"> <div class='panels-ajax-pane panels-ajax-pane-new-70fd4c70-563e-4b94-ae3b-2a97f3980c13' data-pid='new-70fd4c70-563e-4b94-ae3b-2a97f3980c13'></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-markup" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article extract-view"><span class="highwire-journal-article-marker-start"></span><ul class="kwd-group"><li class="kwd"><a href="/keyword/autoimmune-encephalitis" class="hw-term hw-article-keyword hw-article-keyword-autoimmune-encephalitis" rel="nofollow">autoimmune encephalitis</a></li><li class="kwd"><a href="/keyword/limbic-system" class="hw-term hw-article-keyword hw-article-keyword-limbic-system" rel="nofollow">limbic system</a></li><li class="kwd"><a href="/keyword/virology" class="hw-term hw-article-keyword hw-article-keyword-virology" rel="nofollow">virology</a></li></ul><p id="p-2">Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), millions have been diagnosed with COVID-19. The major clinical manifestations of SARS-CoV-2 infection are pulmonary, however reports of COVID-19-associated central nervous system complications emerged.<span class="xref-bibr">1 2</span> We report a case of encephalitis in a pulmonologically asymptomatic patient with COVID-19.</p><p id="p-3">A 66-year-old female presented in mid-March 2020, with a few hours history of confusion. She was completely well until the day of admission. There was no medical, infectious or behavioural prodrome. There was no alcohol or nutritional history. She had travelled to Spain, the USA and Mexico in the 3 months prior, but had been home for 19 days. She suddenly complained that her head ‘felt funny’. She carried on normal tasks but, within an hour, became confused, amnestic and was unaware of why social distancing measures were being observed.</p><p id="p-4">On admission, her temperature was 37.9°C. Other observations were normal. She was lymphopaenic at 0.4×10<sup>9</sup>/L (0.8–3.1). Full blood count was otherwise normal. C-reactive protein (CRP) was 14.5 mg/L (0–5). Routine blood tests, including renal function, liver function and clotting, were normal. A brain CT was unremarkable. Six hours after admission, she had a single, spontaneously resolving, generalised tonic-clonic seizure. Her postictal Glasgow Coma Scale (GCS) was 6/15 (E1/V1/M4). This remained unchanged for 48 hours. Postictal neurological examination showed equal, reactive pupils, no response to visual menace, no vestibulo-ocular reflex, normal tone bilaterally, symmetrical brisk reflexes and extensor plantars. She remained febrile (37.9°C) for 48 hours. Oxygen saturation dropped to 93% on air only once during her 4-week admission. She never developed breathlessness, cough or tachypnoea.</p><p id="p-5">An MRI of the brain on day 2 showed non-enhancing, symmetrical T2 and FLAIR … </p><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div><a href="https://jnnp.bmj.com/content/91/11/1229.full" class="hw-link hw-link-article-full-text" data-icon-position="" data-hide-link-title="0">View Full Text</a></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-markup footnotes" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-dfp-pane" > <div class="pane-content"> <div id="dfp-ad-mpu-wrapper" class="dfp-tag-wrapper"> <div id="dfp-ad-mpu" class="dfp-tag-wrapper"> <script type="text/javascript"> googletag.cmd.push(function() { 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