Saturday, April 11, 2020

JAMA: Neurologic Manifestations Of Patients With Severe Coronavirus Disease


Although COVID-19 is primarily thought of as a respiratory disease, we've seen evidence of a more systemic impact, including viremia (see Severe Acute Respiratory Syndrome Coronavirus 2 RNA Detected in Blood Donations), gastrointestinal involvement (see NEJM Journal Watch Gastrointestinal Aspects of COVID-19), and even cardiac problems (see COVID-19 linked to cardiac injury).
Anecdotally, the New York Fire Department has reported a 400% increase in sudden cardiac arrest death calls since late March (see NBC affiliate Massive Spike in NYC ‘Cardiac Arrest’ Deaths Seen as Sign of COVID-19 Undercounting).
How much of this increase can be directly attributed to COVID-19 infection is unknown, as most of these cases are never tested for the virus, but many local officials are blaming the pandemic virus. 

As we've seen with influenza and other respiratory infections, the risks for an adverse cardiac event go up markedly in the days and weeks following infection (see Int. Med. J.: Triggering Of Acute M.I. By Respiratory Infection and Eur. Resp.J.: Influenza & Pneumonia Infections Increase Risk Of Heart Attack and Stroke ).

We are also hearing of a range of neurological issues related to COVID-19 infection, and again, this is something we occasionally see with severe influenza (see Neuroinfluenza: A Review Of Recently Published Studies). 

Credit CDC 2018 COCA Call On Severe Influenza

A month ago, a paper published in ACS Chemical Neuroscience presented (mostly theoretical) evidence of how COVID-19 might attack the brain.
Evidence of the COVID-19 Virus Targeting the CNS: Tissue Distribution, Host–Virus Interaction, and Proposed Neurotropic Mechanisms
While there have been anecdotal reports of COVID-19 patients with neurological impacts, yesterday JAMA Neurology published the strongest evidence to date, finding more than 1/3rd of a study group of 214 patients hospitalized in Wuhan, China showed signs of neurological involvement.
Neurological manifestations ranged from relatively mild (headaches, dizziness, anosmia, mild confusion, etc.) to more profound (seizures, stupor, loss of consciousness, etc.) to potentially fatal (ischemic stroke, cerebral hemorrhage, muscle injury (rhabdomyolysis), etc.). 
The full open-access study is available without charge, so I've only lifted a few excerpts from the summary. Follow the link to read it in its entirety.  After the break, you'll find a link to a JAMA editorial (also open access) on this study.

Original Investigation
April 10, 2020
Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China
Ling Mao1; Huijuan Jin1; Mengdie Wang1; et alYu Hu2; Shengcai Chen1; Quanwei He1; Jiang Chang3; Candong Hong1; Yifan Zhou1; David Wang4; Xiaoping Miao3; Yanan Li, MD, PhD1; Bo Hu, MD, PhD1
Author Affiliations Article InformationJAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1127

Key Points
  • Question What are neurologic manifestations of patients with coronavirus disease 2019? 
  • Findings In a case series of 214 patients with coronavirus disease 2019, neurologic symptoms were seen in 36.4% of patients and were more common in patients with severe infection (45.5%) according to their respiratory status, which included acute cerebrovascular events, impaired consciousness, and muscle injury.
  • Meaning  Neurologic symptoms manifest in a notable proportion of patients with coronavirus disease 2019.
Conclusions and Relevance Patients with COVID-19 commonly have neurologic manifestations. During the epidemic period of COVID-19, when seeing patients with neurologic manifestations, clinicians should suspect severe acute respiratory syndrome coronavirus 2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.
(Continue . . . .)

April 10, 2020
The Spectrum of Neurologic Disease in the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic Infection
Neurologists Move to the Frontlines
Samuel J. Pleasure, MD, PhD1,2; Ari J. Green, MD1,2; S. Andrew Josephson, MD1,3Author Affiliations Article InformationJAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1065