# Hemorrhagic shock and encephalopathy syndrome with hyper-inflammation and elevation of IL-6 and GDF-15 following COVID-19: A case report

## TL;DR

A young woman developed a severe and fatal brain condition after a mild case of COVID-19, marked by extreme inflammation and high levels of specific proteins.

## Contribution

This is the first reported case of HSES following COVID-19, highlighting its rapid progression and extreme cytokine elevation.

## Key findings

- HSES occurred in a 21-year-old woman after a mild COVID-19 infection.
- IL-6 and GDF-15 levels were extremely high, exceeding those seen in other COVID-19 cases.
- The patient's condition rapidly deteriorated despite intensive care and treatment.

## Abstract

Hemorrhagic shock and encephalopathy syndrome (HSES) is a life-threatening condition predominantly reported in children and often associated with viral infections such as influenza. We describe a case of HSES in a 21-year-old woman following Coronavirus disease-2019 (COVID-19) infection. She presented with a sore throat, nocturnal chills, and arthralgia one day before admission. On the day of admission, she developed fever and dyspnea and contacted emergency services. Upon arrival, her Glasgow Coma Scale score was E1V1M1 with tachycardia and hypotension. Tachycardia, hypotension, and lactate elevation persisted throughout the early phase of hospitalization. Orotracheal intubation and mechanical ventilation were initiated. Computed tomography revealed no intracranial lesions or pneumonia. A COVID-19 antigen test was positive, and cerebrospinal fluid analysis showed no meningitis. Despite intensive care, shock persisted with critical coagulopathy. Hemodynamic stabilization was achieved with vasopressors and fresh frozen plasma. On day 2, mydriasis developed, and head computed tomography revealed severe cerebral edema and extensive low-density areas consistent with HSES. Despite the administration of steroids and supportive care, the patient died on day 17. The patient’s interleukin-6 (IL-6) and growth differentiation factor (GDF)-15 levels were markedly elevated, with IL-6 peaking at 37,489 ng/mL and GDF-15 at 19,936 pg/mL, exceeding levels observed in other COVID-19 cases at our institution. HSES following COVID-19 infection can progress rapidly, accompanied by marked inflammatory cytokine elevation. Rapid onset of consciousness disorder, coagulopathy, and IL-6 elevation in COVID-19 or other viral infections should raise suspicion for HSES. Early recognition may aid in understanding its pathogenesis and guiding clinical care.