Seizures occur when there is an uncontrollable electrical activity in the neurons, leading to changes in muscle activity, behavior, sensation, and level of consciousness. A myriad of different etiologies could trigger a seizure such as alcohol withdrawal, substance abuse, high fever, electrolyte abnormalities, infections, and other causes. It is crucial to identify the source of the seizure so it can be treated before it can cause permanent neural damage to the patient. However, there has been an increase in the incidence of possible covid induced seizures.

Although the mechanism is not fully understood, there are cases of covid induced seizures reported [1-4]. A few proposed models of the pathophysiology of SARS-CoV-2 induced seizures have been proposed. A proposed mechanism states that the virus invasion triggers the microglial inflammatory cascade that will release cytokines such as IL-Ib, Il-6, TNFa among others that could propagate inflammation and then seizure [5].  Another working hypothesis is that the SARS-CoV-2 virus can disrupt the blood-brain barrier, thereby affecting homeostasis in the CNS which could also result in the peripheral cytokines entering the brain thereby causing febrile seizures [5]. The SARS-CoV-2 virus has an affinity for cells that express ACE2 receptors such as glial cells and neurons [2].

Further, vaccines have been linked to the onset of seizures [6]. In this case, the patient had recently received his SARS-CoV-2 vaccine. The lack of literature available on the association between the SARS-CoV-2 vaccine and seizure made it difficult to associate the onset of the seizure to the vaccine. However, there have been cases reported where patients suffered from a seizure after receiving the SARS-CoV-2 vaccine [7].

Given the history of alcohol abuse, alcohol withdrawal is a well-known trigger of seizures. Likewise, when a person consumes alcohol the seizure threshold is increased and it declines about 6-8 hours after the patient has his last alcoholic drink [8]. In the toxicology report, it was also noted that the patient tested positive for cocaine which can also be an independent trigger for seizures, and a few different biochemical mechanisms have been established.  Cocaine acts to promote a catecholaminergic state by blocking enzymes that remove these substances from neurons and increases serotonin content in nerve synapses [9].  Furthermore, cocaine has membrane-stabilizing properties which synergistically act with endogenous substances responsible for convulsions [9].  One study, in particular, suggested that cocaine consumption could lead to focal cerebral ischemia, culminating in seizures [10]. The constellation of these biochemical effects renders cocaine and its ability to cause seizures, many of which have been noted to be tonic-clonic [9]. Majlesi et al pointed out that while single substantial cocaine infusions can induce status epilepticus, most seizures associated with cocaine follow a “kindling” model, wherein multiple sub-convulsive infusions of cocaine eventually reach a seizure threshold [11]. Koppel and colleagues conducted a retrospective study, concluding that cocaine exacerbated convulsion thresholds in patients who were seemingly predisposed to have seizures, secondary to certain comorbidities [12].

While it is still difficult to pinpoint a definite source of seizure to be the covid-19 virus, it is still one of the important differentials as SARS-CoV-2 is not fully understood. It is known that the SARS-CoV-2 virus affects multiple organs [13,14]. The Angiotensin-converting-enzyme 2 receptors are expressed on many cells across the human body. Therefore, extrapulmonary symptoms and associations such as dysfunctions in the myocardium, gastrointestinal tract, renal system, hepatic and neurological systems must be considered [14].

Our case conveys a 61-year-old male experiencing his first seizure. Although he has a history of alcohol abuse and his urine tested positive for cocaine, the patient was actively drinking when he experienced his first seizure. The only potential causes of his seizure may be due to him being positive for the SARS-CoV-2 virus. Although further investigation is warranted, we find it very plausible that the reason for our patient’s seizure was due to his underlying infection with the SARS-CoV-2 virus.