Fatal Case of COVID-19-Associated Acute Hemorrhagic Leukoencephalitis Without Respiratory Involvement: A Diagnostic and Therapeutic Challenge

We report a rare and fatal case of acute hemorrhagic leukoencephalitis (AHLE) as the sole manifestation of COVID-19 in a 76-year-old woman who presented without respiratory symptoms. The patient was admitted with an acute altered mental status following a recent fall and a positive SARS-CoV-2 test. Initial imaging showed a small subdural hematoma; however, further evaluation revealed widespread white matter changes and petechial hemorrhages on MRI, consistent with AHLE. Despite aggressive treatment, including intravenous immunoglobulin (IVIG) and high-dose corticosteroids, the patient showed minimal neurological recovery. Cerebrospinal fluid (CSF) studies revealed elevated protein with no infectious or autoimmune markers, and the brain biopsy was non-contributory. She was ultimately transitioned to hospice care. This case underscores the importance of considering AHLE in COVID-19 patients presenting with isolated neurological deterioration, even in the absence of pulmonary involvement. Prompt recognition and escalation of care are crucial, although the prognosis remains poor.