A Relapsing Autoimmune CNS Disorder with Dynamic Pleocytosis Following COVID-19 Vaccination
Elif Dogan1, Gina Perez-Giraldo1
1Neurology, Medical University of South Carolina
Objective:
To describe a challenging case of a recurrent autoimmune CNS disorder following Ad26.COV2.S COVID-19 vaccination.
Background:
Post-vaccination inflammatory CNS syndromes are increasingly recognized but remain diagnostically challenging, particularly when clinical and laboratory findings are atypical or evolving. Disease course and optimal immunotherapy duration remain unclear.
Design/Methods:

NA

Results:

45-year-old woman presented with fever and new-onset intractable headache with meningismus within one week of receiving COVID-19 vaccine. Initial CSF analysis demonstrated leukocytosis with neutrophilic predominance. MRI brain showed mild diffuse leptomeningeal enhancement. 

She was empirically treated for bacterial meningitis. CSF cultures and viral studies, including HSV-1/HSV-2 PCR, was negative. During her course, she developed bilateral sensorineural hearing loss, raising concern for Cogan syndrome; however, other systemic findings including interstitial keratitis were negative. 

She was readmitted with recurrent fever, worsening headache. Serial lumbar punctures demonstrated dynamic CSF pleocytosis, with neutrophilic predominance during febrile episodes and lymphocytic predominance when afebrile.

Extensive evaluation, including CSF autoimmune encephalitis panel (including GFAP-IgG), MOG antibodies, CSF flow cytometry, PET imaging, and genetic testing for periodic fever syndromes, was unrevealing. Brain biopsy was unremarkable. Evaluation for systemic vasculitis, sarcoidosis, IgG4-related disease, and Behçet disease was negative. 

Over time, the patient developed persistent chronic cough of unclear etiology despite negative systemic and pulmonary evaluations, raising concern for neurogenic cough. 

The patient demonstrated partial clinical response to corticosteroids but experienced relapses during tapering. Mycophenolate mofetil provided limited benefit. Significant clinical and radiographic improvement was observed following initiation of rituximab. 

Conclusions:

This case highlights a relapsing autoimmune CNS disorder with CSF pleocytosis and leptomeningeal involvement following COVID-19 vaccination. The patient’s relapsing course over years and marked response to B-cell depletion support autoimmune mechanism. While autoimmune neurological events after Ad26.COV2.S vaccination have been reported, this case is notable for relapsing trajectory and highlights the diagnostic and therapeutic challenges, including uncertainty regarding optimal immunotherapy duration. 

Generative AI Usage
Yes, used generative AI in the drafting or editing in this abstract.

Tool, version, and prompt(s) used, as well as area of the abstract affected
ChatGPT use "the first draft, add J&J vaccine, emphasize patient also developed chronic cough later and this patient is unique because autoimmune cns conditions occured after the j&j vaccine but this patient had multiple recurrences years after and determining the duration of the therapy is challenging" for text generation for Results and conclusion
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