NeuroCOVID: neurological manifestations an emerging challenge

By Mardi Chapman

20 Apr 2020

Neurologists will be increasingly on the front lines of the COVID-19 pandemic as the neurological manifestations in early and late stages of the disease become more apparent, researchers say.

Amid the plethora of reports on the spectrum of neuroCOVID, one study of over 200 COVID-19 patients from Wuhan in China, found more than a third of patients (36.4%) had symptoms mostly of the CNS but also peripheral nervous system involvement and skeletal muscle injury.

The study, published in JAMA Neurology, reported symptoms ranging from dizziness, headache, nerve pain, smell, taste and vision disturbances to impaired consciousness, ataxia, seizures and acute cerebrovascular events.

Patients with neurologic manifestations had more severe COVID-19 disease, were older and had more hypertension but fewer typical symptoms such as fever and cough.

The study found most neurologic symptoms were obvious early in the disease with a median time of 1-2 days from onset to hospital admission.

“Some patients without typical symptoms (fever, cough, anorexia, and diarrhoea) of COVID-19 came to the hospital with only neurologic manifestation as their presenting symptoms,” the authors said.

“It is especially meaningful to learn that for those with severe COVID-19, rapid clinical deterioration or worsening could be associated with a neurologic event such as stroke, which would contribute to its high mortality rate.”

“Moreover, during the epidemic period of COVID-19, when seeing patients with these neurologic manifestations, clinicians should consider SARS-CoV-2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and prevention of transmission.”

An accompanying editorial said neurological manifestations were also seen in the earlier SARS-CoV-1 epidemic.

“At the time, it was unclear whether some of these manifestations might be owing to critical illness–related effects, but pathology subsequently showed that patients with SARS had widespread vasculitis seen in many organs, including striated muscle, suggesting that the clinical features in these neuromuscular patients might be more than just nonspecific complications of severe illness,” the editorial said.

The authors added that neurologists can expect to be confronted with COVID-19 patients commonly in the coming months and years.

“As the means for reliably assessing infection and prior exposure become available, less common neurologic complications should be anticipated; however, this glimpse into neurologic manifestations opens a window into neurologists’ role and places them on the front lines of the pandemic.”

There have also been cases of Guillain-Barre syndrome (GBS) in COVID-19 patients, according to a report from Italy published in the NEJM.

It noted the interval between the onset of symptoms of COVID-19 and the first symptoms of GBS ranged from 5 to 10 days – consistent with the interval seen with GBS that occurs during or after other infections.

The authors said GBS with COVID-19 should be distinguished from critical illness neuropathy and myopathy which tends to appear later in the course of critical illness than GBS.

Encephalopathy, prominent agitation and confusion, and corticospinal tract signs were also reported in another series of patients from France.

Published as Correspondence in the NEJM, it said, “Data are lacking to determine which of these features were due to critical illness–related encephalopathy, cytokines, or the effect or withdrawal of medication, and which features were specific to SARS-CoV-2 infection.”

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