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One day later, he passed away due to multi-organ failure. His laboratory work up showed respiratory acidosis and a picture of disseminated intravascular coagulation (DIC) ( Table 3). His chest X-ray showed diffuse multi-lobar infiltrates consistent with acute respiratory distress syndrome ( Figure 1). On that same day, he developed tachycardia, tachypnea, and hypotension his oxygen saturation started to drop progressively and was put on a ventilator. Based on these X-ray findings, testing for COVID-19 was done and a reverse transcriptase polymerase chain reaction for SARS-CoV-2 on nasopharyngeal swab was positive on day 5 of hospitalization.

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Even though he had no respiratory symptoms of cough and shortness of breath, a chest x-ray was ordered due to the ongoing COVID-19 pandemic and it showed a patch of consolidation. On day 2 of hospitalization (day 4 of initial symptoms), he had swelling of his left eye, and a computed tomography (CT) head was ordered on neurologist recommendation which showed no significant findings. He had a fever of 101 F and neck rigidity with absent Babinski sign and 2+ deep tendon reflexes. On physical examination, he was alert, oriented, and awake with a Glasgow coma scale score of 15/15. He denied any cough, shortness of breath, body aches, and diarrhea ( Table 1). Case ReportДЄ 21-years-old male medical student with no known co-morbidities was presented to an emergency department with a 2-days history of frontal headache and fever, and 1-day history of neck stiffness. It is important to diagnose and manage these patients at the earliest possible stage of treatment to prevent the horizontal spread of COVID-19. In this article, we present a case discussion of instances in which the initial presenting symptoms were exclusive to meningitis and later diagnosed as COVID-19, to make physicians and healthcare workers cognizant of such rare presentations. Although very rare, these neurological manifestations sometimes are the sole initial presenting complaint of COVID-19. Since then, two or three more cases of meningoencephalitis have also been reported in the United States ( 6вЂ“ 8). The first case of meningitis associated with COVID-19 was reported in Japan in February 2020 ( 5). In addition to the common presenting symptoms of fever, fatigue, and mild respiratory symptoms like dry cough, patients with COVID-19 can also develop neurological manifestations like headache, anosmia, hyposmia, dysgeusia, meningitis, encephalitis, and acute cerebrovascular accidents during the course of the disease ( 3, 4). It is important to increase awareness of these rare presentations in physicians and healthcare workers and facilitate early diagnosis and management to prevent the horizontal spread of the disease.ДЇollowing its emergence in Wuhan, China in December 2019, the Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory coronavirus-2 (SARS-CoV-2), has become a pandemic ( 1) and been declared a global health emergency ( 2). This case report discusses patients where the initial presenting symptoms seemed to be exclusive to meningitis but the later diagnosis was COVID-19.

Although very rare, these neurological manifestations are sometimes the sole initial presenting complaint of COVID-19. The common presenting symptoms of fever, fatigue, and mild respiratory symptoms like dry cough, are associated with COVID-19, however, patients can also develop neurological manifestations like headache, anosmia, hyposmia, dysgeusia, meningitis, encephalitis, and acute cerebrovascular accidents during the disease. 5Ziauddin University and Hospital, Ziauddin Medical College, Karachi, Pakistan.4Department of Internal Medicine, King Edward Medical University Lahore, Lahore, Pakistan.

3Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan.2Khyber Medical College Peshawar, Hayatabad Medical Complex, Peshawar, Pakistan.1Department of Internal Medicine, University of Health Sciences, Lahore, Pakistan.Sidra Naz 1 вЂ , Muhammad Hanif 2 * вЂ , Muhammad Adnan Haider 3 вЂ , Mukarram Jamat Ali 4 вЂ , Muhammad Umer Ahmed 5 вЂ and Sana Saleem 1 вЂ