Is COVID-19 infection also a silent killer?: A case of acute stroke

A 59-year-old male had multiple comorbidities such as diabetes, dilated cardiomyopathy, hypertension, ischemic heart disease, and chronic obstructive pulmonary disease. He presented with dyspnea and had ground-glass opacity in the lungs. It was during the pandemic of COVID-19 so repeated Reverse transcription polymerase chain reaction (RT-PCR) was done, but all were negative. He got stabilized within 5 days and we planned discharge. Suddenly, he had right hemiplegia and developed altered sensorium. He had NIH Stroke Scale/Score of 28 and computed tomography-Alberta Stroke Program Early Computed Tomography Score of 10. We used tenecteplase (0.25 mg/kg bodyweight) for thrombolysis within 20 min of onset and planned mechanical thrombectomy for the occlusion of internal carotid artery and beyond. However, in magnetic resonance imaging of the brain, he had an established infarct in the left middle cerebral artery (MCA) territory (within this short time) without significant DWI/FLAIR mismatch. Hence, we continued conservative management. We incidentally detected him to have COVID-19 infection positivity on that day, but all inflammatory and coagulation parameters were normal on that day and later. His monitor did not reveal arrhythmia (during the event and later) and echocardiography failed to reveal evidence of culprit lesion. He had a rapid clinical decline, required hemicraniectomy but expired within 2 days. COVID-19 infection may have negative reports initially, but malignant MCA infarct with normal inflammatory markers makes our case special. The rapidity with which stroke developed underscores the severe nature of the disease process, the absence of arrhythmias (in this in-house stroke), and normal coagulation parameters hints that the exact mechanism of stroke in this type of infection is still an enigma.