Credit NIAID
#15,488
Not quite six months ago, in JAMA: Neurologic Manifestations Of Patients With Severe Coronavirus Disease, we looked at the first major report on the neurological impact of COVID-19, one which found more than 1/3rd of a study group (n=214) 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.).
While this early report from Wuhan indicated an unusually high percentage of patients with neurological symptoms, it isn't unheard of that a severe respiratory infection can cause neurological complications.
Two years previously, in Neuroinfluenza: A Review Of Recently Published Studies, we had looked at rare instances of neurological manifestations associated with with seasonal (and avian) influenza infection.
 |
| Credit CDC 2018 COCA Call On Severe Influenza |
Over the summer additional studies have appeared in the medical literature describing neurological manifestations in COVID patients - with some warning of potential long-term sequelae - including an enhanced risk of Parkinson's disease.
- In mid-June, in The Lancet: COVID-19: Can We Learn From Encephalitis Lethargica?, we revisited the mysterious neurological epidemic that began around the time of the 1918 pandemic, and continued on for a decade.
- A couple of weeks later, in The Lancet: Yet Another Study On Neurological Manifestations In Severe COVID-19 Patients, we looked at report published in The Lancet Psychiatry, that described 153 COVID-19 cases treated in UK hospitals which found a wide range of neurological and psychiatric complications affecting both younger and elderly patients.
- In July I blogged on a 63-page report from the Journal Brain called The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings.
- In August, in J. Neurology: COVID-19 As A Potential Risk Factor For Chronic Neurological. Disorders, we revisited the growing concerns over the long-term neurological impacts of COVID-19 infection.
- And late last month (see Parkinsonism as a Third Wave of the COVID-19 Pandemic?) we looked at a Review Article, published in the Journal of Parkinson's Disease, that examined the parallels between COVID-19 and epidemics of the past, and the potential for seeing a new wave of neurological disorders.
- While the long-term neurological impact of COVID-19 remains unknown, we are seeing a lot of warning signs, much as we have with other organ systems (see JASN: Acute Kidney Injury In Hospitalized Patients With COVID-19 and JAMA: Two Studies Linking SARS-CoV-2 Infection To Cardiac Injury).
All of which brings us to today's study - published yesterday in the Annals of Clinical and Translational Neurology - which presents the first detailed study of neurological manifestations in hospitalized COVID patients in the United States.
Their results are similar to what we've seen previously reported out of China and Europe, with a high percentage of patients (8 out of 10) - sometime during the course of their illness - presenting at least one of broad range of neurological symptoms, and roughly 1/3rd (31.8%) showing signs of altered mental status suggestive of encephalopathy.
First a link, and the abstract from the study, followed by excerpts from a press release from Northwestern Memorial Hospital, where the study was conducted.
Follow the links to read both in their entirety.
Frequent neurologic manifestations and encephalopathy‐associated morbidity in Covid‐19 patients
Eric M. Liotta, Ayush Batra ,Jeffrey R. Clark , Nathan A. Shlobin ,Steven C. Hoffman ,Zachary S. Orban ,Igor J. Koralnik
First published: 05 October 2020
Abstract
Objective
Covid‐19 can involve multiple organs including the nervous system. We sought to characterize the neurologic manifestations, their risk factors, and associated outcomes in hospitalized patients with Covid‐19.Methods
We examined neurologic manifestations in 509 consecutive patients admitted with confirmed Covid‐19 within a hospital network in Chicago, Illinois. We compared the severity of Covid‐19 and outcomes in patients with and without neurologic manifestations. We also identified independent predictors of any neurologic manifestations, encephalopathy, and functional outcome using binary logistic regression.
Results
Neurologic manifestations were present at Covid‐19 onset in 215 (42.2%), at hospitalization in 319 (62.7%), and at any time during the disease course in 419 patients (82.3%). The most frequent neurologic manifestations were myalgias (44.8%), headaches (37.7%), encephalopathy (31.8%), dizziness (29.7%), dysgeusia (15.9%), and anosmia (11.4%). Strokes, movement disorders, motor and sensory deficits, ataxia, and seizures were uncommon (0.2 to 1.4% of patients each). Severe respiratory disease requiring mechanical ventilation occurred in 134 patients (26.3%).
Independent risk factors for developing any neurologic manifestation were severe Covid‐19 (OR 4.02; 95% CI 2.04–8.89; P < 0.001) and younger age (OR 0.982; 95% CI 0.968–0.996; P = 0.014). Of all patients, 362 (71.1%) had a favorable functional outcome at discharge (modified Rankin Scale 0–2). However, encephalopathy was independently associated with worse functional outcome (OR 0.22; 95% CI 0.11–0.42; P < 0.001) and higher mortality within 30 days of hospitalization (35 [21.7%] vs. 11 [3.2%] patients; P < 0.001).
Interpretation
Neurologic manifestations occur in most hospitalized Covid‐19 patients. Encephalopathy was associated with increased morbidity and mortality, independent of respiratory disease severity.
First-of-its-kind Study Examines the Frequency and Severity of Neurologic Manifestations in Patients Hospitalized with COVID-19 in the United States
NORTHWESTERN MEMORIAL HOSPITAL OCTOBER 05, 2020
Of the 509 patients who were studied, 82% had neurological manifestations during the course of COVID-19, such as muscle pain, headaches, dizziness, alteration of mental function and disorder of taste and smell
Chicago, IL – A new Northwestern Medicine study published in the Annals of Clinical and Translational Neurology* analyzed 509 COVID-19 hospitalized patients and discovered neurologic manifestations happened 82% at any time during the course of the disease. The study conducted by the Northwestern Medicine Neuro COVID-19 research group outlined the frequency and severity of neurologic signs and symptoms in patients hospitalized throughout the Chicago-based health system.
“This is the first study of its kind in the United States,” says Igor Koralnik, MD, chief of neuro-infectious diseases and global neurology in the Ken & Ruth Davee Department of Neurology at Northwestern Medicine, who also oversees the Neuro COVID-19 Clinic at Northwestern Memorial Hospital. “There are only two other published papers describing the prevalence of neurological manifestations in hospitalized COVID-19 patients in China and Europe. Our research group spent the summer performing chart reviews on the first 509 patients hospitalized for COVID-19 within the Northwestern Medicine health system, and our findings show neurological manifestations are very common in these patients.”
Of the 509 hospitalized patients with COVID-19:
- 42% had neurological manifestations at the time of initial symptom onset
- 63% at time of hospitalization
- 82% at any time during the course of the disease
Dr. Koralnik says, the most frequent neurological symptoms were:
- Muscle pain (44.8%)
- Headaches (37.7%)
- Encephalopathy (31.8%)
- Dizziness (29.7%)
- Disorder of taste (15.9%)
- Disorder of smell (11.4%)
“Encephalopathy, which is characterized by altered mental function ranging from mild confusion to coma, is the most severe neurologic manifestation of COVID-19,” explains Dr. Koralnik.
Upon discharge from the hospital, only 32.1% of patients with encephalopathy were able to care for their own affairs, compared to 89.3% of those who did not develop encephalopathy. There was also higher mortality in patients with encephalopathy (21.7%) compared to 3.2% of those without.
“We are now looking to characterize the long-term neurologic effects of COVID-19 and the cognitive outcomes in patients with COVID-19-associated encephalopathy,” says Dr. Koralnik. “We’re studying this in patients who are discharged from the hospital, as well as in COVID-19 ‘long-haulers,’ who have never been hospitalized but also suffer from a similar range of neurological problems, including brain fog.”
Long-haulers from all over the United States have scheduled appointments with Dr. Koralnik and the Neuro COVID-19 Clinic team at Northwestern Memorial Hospital. The team’s extensive knowledge of infectious diseases that affect the nervous system helps them determine what is causing a patient’s symptoms. Dr. Koralnik says, the use of telehealth technology makes it easier and safer for patients who are recovering from COVID-19 to receive care.
“The Neuro COVID-19 Clinic’s unique approach, along with this new study, will help shape long-term care for people who suffer from neurological complications of COVID-19,” adds Dr. Koralnik. “Patients and clinicians need to be aware of the high frequency of neurologic manifestations of COVID-19 and the severity of altered mental function associated with this disease.”
The study was published on Monday, Oct. 5, in Annals of Clinical and Translational Neurology*.
Not quite 2 months ago, in PAHO Epi Alert: Complications & Sequelae Of COVID-19, we looked at some of the suspected - but not yet quantified - lingering impacts of COVID-19 among `recovered' cases. In Nature Med. Review: Extrapulmonary manifestations of COVID-19, you'll find an excellent review of COVID-19's impact outside the lungs.
As we've seen with Agent Orange exposure in Vietnam and toxic dust exposure of ground zero first responders in NYC nearly 2 decades ago, it may be years before we can fully appreciate the impact of COVID-19 on individual and public health.
All reasons why - even for young and healthy individuals - COVID-19 is a non-trivial illness and is best avoided if possible.
