Bilateral globus pallidus lesions associated with COVID-19: Mimicking acute carbon monoxide poisoning

Rationale: Bilateral symmetrical globus pallidus (GP) involvement associated with coronavirus disease 2019 (COVID-19) infection is an extremely rare finding among cases of COVID-19-related encephalopathy. Patient concerns: A 76-year-old man was diagnosed with pneumonia and subsequently tested positive for COVID-19. He was transferred to the hospital on day 9 after symptom onset due to worsening respiratory distress and hypotension. Despite improvement in his pneumonia following the transfer, his mental status remained altered throughout his hospital stay. Diagnoses: A neurologic work-up, including brain magnetic resonance imaging (MRI) performed 2 weeks after the onset of altered mental state, revealed symmetrical high signal intensity lesions in the bilateral GP on MRI. Interventions: The patient received high-flow nasal oxygen therapy with norepinephrine infusion for hemodynamic support, along with intravenous meropenem and remdesivir. Outcomes: The patient gradually recovered and was able to engage in simple communication by the 3rd week. Follow-up MRI at 5 weeks showed resolution of GP lesions. Lessons: Differentiating COVID-19-related encephalopathy from acute carbon monoxide poisoning is challenging in the presence when bilateral symmetrical GP lesions are present. However, coexisting multiple ischemic lesions – common in COVID-19-related encephalopathy but rare in carbon monoxide poisoning – may serve as a useful radiologic clue.