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Rhally A, Bommarito G, Uginet M, Breville G, Stancu P, Accorroni A, Assal F, Lalive PH, Lövblad KO, Allali G. High-dose glucocorticoids in COVID-19 patients with acute encephalopathy: clinical and imaging findings in a retrospective cohort study. J Neural Transm (Vienna) 2024; 131:377-384. [PMID: 38363389 PMCID: PMC11016005 DOI: 10.1007/s00702-024-02751-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/25/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Acute encephalopathy (AE) has been described as a severe complication of COVID-19. Inflammation has been suggested as a pathogenic mechanism, with high-dose glucocorticoids (GC) showing a beneficial effect. Here, we retrospectively analyzed the clinical and radiological features in a group of COVID-19 AE patients who received GC treatment (GT) and in a non-treated (NT) group. METHOD Thirty-six patients with COVID-19 AE (mean age 72.6 ± 11 years; 86.11% men) were evaluated for GC treatment. Twelve patients (mean age 73.6 ± 4.5 years; 66.67% men) received GC, whereas 24 patients who showed signs of spontaneous remission were not treated with GC (mean age 70.1 ± 8.6 years; 95.83% men). Differences in clinical characteristics and correlations with imaging features were explored. RESULTS The GT group showed signs of vulnerability, with a longer hospitalization (p = 0.009) and AE duration (p = 0.012) and a higher hypertensive arteriopathy (HTNA) score (p = 0.022), when compared to NT group. At hospital discharge, the two groups were comparable in terms of clinical outcome (modified Rankin scale; p = 0.666) or mortality (p = 0.607). In our whole group analyses, AE severity was positively correlated with periventricular white matter hyperintensities (p = 0.011), deep enlarged perivascular spaces (p = 0.039) and HTNA score (p = 0.014). CONCLUSION This study suggests that, despite signs of radiological vulnerability and AE severity, patients treated by high-dose GC showed similar outcome at discharge, with respect to NT patients. Imaging features of cerebral small vessel disease correlated with AE severity, supporting the hypothesis that brain structural vulnerability can impact AE in COVID-19.
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Affiliation(s)
- Alexandra Rhally
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Division of Neurology, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.
| | - Giulia Bommarito
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marjolaine Uginet
- Division of Neurology, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Gautier Breville
- Division of Neurology, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Patrick Stancu
- Division of Neurology, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Alice Accorroni
- Division of Neurology, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Frédéric Assal
- Division of Neurology, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Patrice H Lalive
- Division of Neurology, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Karl-Olof Lövblad
- Division of Neuroradiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Gilles Allali
- Division of Cognitive and Motor Aging, Department of Neurology, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
- Leenaards Memory Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Maliha ST, Fatemi R, Araf Y. COVID-19 and the brain: understanding the pathogenesis and consequences of neurological damage. Mol Biol Rep 2024; 51:318. [PMID: 38386201 DOI: 10.1007/s11033-024-09279-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/22/2024] [Indexed: 02/23/2024]
Abstract
SARS-CoV-2 has been known remarkably since December 2019 as a strain of pathogenic coronavirus. Starting from the earlier stages of the COVID-19 pandemic until now, we have witnessed many cases of neurological damage caused by SARS-CoV-2. There are many studies and research conducted on COVID-19-positive-patients that have found brain-related abnormalities with clear neurological symptoms, ranging from simple headaches to life-threatening strokes. For treating neurological damage, knowing the actual pathway or mechanism of causing brain damage via SARS-CoV-2 is very important. For this reason, we have tried to explain the possible pathways of brain damage due to SARS-CoV-2 with mechanisms and illustrations. The SARS-CoV-2 virus enters the human body by binding to specific ACE2 receptors in the targeted cells, which are present in the glial cells and CNS neurons of the human brain. It is found that direct and indirect infections with SARS-CoV-2 in the brain result in endothelial cell death, which alters the BBB tight junctions. These probable alterations can be the reason for the excessive transmission and pathogenicity of SARS-CoV-2 in the human brain. In this precise review, we have tried to demonstrate the neurological symptoms in the case of COVID-19-positive-patients and the possible mechanisms of neurological damage, along with the treatment options for brain-related abnormalities. Knowing the transmission mechanism of SARS-CoV-2 in the human brain can assist us in generating novel treatments associated with neuroinflammation in other brain diseases.
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Affiliation(s)
- Sumaiya Tasnim Maliha
- Biotechnology Program, Department of Mathematics and Natural Sciences, School of Data and Sciences, BRAC University, Dhaka, Bangladesh
| | - Rabeya Fatemi
- Department of Genetic Engineering and Biotechnology, East West University, Dhaka, 1212, Bangladesh
| | - Yusha Araf
- Department of Biotechnology, Bangladesh Agricultural University, Mymensingh, Bangladesh.
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Breville G, Herrmann F, Adler D, Deffert C, Bommarito G, Stancu P, Accorroni A, Uginet M, Assal F, Tamisier R, Lalive PH, Pepin JL, Lövblad KO, Allali G. Obstructive sleep apnea: a major risk factor for COVID-19 encephalopathy? BMC Neurol 2023; 23:340. [PMID: 37752429 PMCID: PMC10523731 DOI: 10.1186/s12883-023-03393-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND This study evaluates the impact of high risk of obstructive sleep apnea (OSA) on coronavirus disease 2019 (COVID-19) acute encephalopathy (AE). METHODS Between 3/1/2020 and 11/1/2021, 97 consecutive patients were evaluated at the Geneva University Hospitals with a neurological diagnosis of COVID-19 AE. They were divided in two groups depending on the presence or absence of high risk for OSA based on the modified NOSAS score (mNOSAS, respectively ≥ 8 and < 8). We compared patients' characteristics (clinical, biological, brain MRI, EEG, pulmonary CT). The severity of COVID-19 AE relied on the RASS and CAM scores. RESULTS Most COVID-19 AE patients presented with a high mNOSAS, suggesting high risk of OSA (> 80%). Patients with a high mNOSAS had a more severe form of COVID-19 AE (84.8% versus 27.8%), longer mean duration of COVID-19 AE (27.9 versus 16.9 days), higher mRS at discharge (≥ 3 in 58.2% versus 16.7%), and increased prevalence of brain vessels enhancement (98.1% versus 20.0%). High risk of OSA was associated with a 14 fold increased risk of developing a severe COVID-19 AE (OR = 14.52). DISCUSSION These observations suggest an association between high risk of OSA and COVID-19 AE severity. High risk of OSA could be a predisposing factor leading to severe COVID-19 AE and consecutive long-term sequalae.
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Affiliation(s)
- Gautier Breville
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland.
| | - François Herrmann
- Department of Rehabilitation and Geriatrics, Division of Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Dan Adler
- Division of Pneumology, La Tour Hospital, Geneva, Switzerland
| | - Christine Deffert
- Laboratory of Biological Fluids, Laboratory Medicine Division, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
- Laboratory Medicine Division, Department of Medical Specialties, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Giulia Bommarito
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrick Stancu
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Alice Accorroni
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Marjolaine Uginet
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Frederic Assal
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Renaud Tamisier
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Patrice H Lalive
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Diagnostic Department, Division of Laboratory Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Louis Pepin
- Division of Pneumology, La Tour Hospital, Geneva, Switzerland
- Univ. Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2, 38000, Grenoble, France
| | - Karl-Olof Lövblad
- Division of Neuroradiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Gilles Allali
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
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Bommarito G, Garibotto V, Frisoni GB, Assal F, Lalive PH, Allali G. The Two-Way Route between Delirium Disorder and Dementia: Insights from COVID-19. NEURODEGENER DIS 2023; 22:91-103. [PMID: 37054684 DOI: 10.1159/000530566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/23/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Delirium disorder is a frequent neurological complication of SARS-CoV-2 infection and associated with increased disease severity and mortality. Cognitive impairment is a major risk factor for developing delirium disorder during COVID-19, which, in turn, increases the risk of subsequent neurological complications and cognitive decline. SUMMARY The bidirectional connection between delirium disorder and dementia likely resides at multiple levels, and its pathophysiological mechanisms during COVID-19 include endothelial damage, blood-brain barrier dysfunction, and local inflammation, with activation of microglia and astrocytes. Here, we describe the putative pathogenic pathways underlying delirium disorder during COVID-19 and highlight how they cross with the ones leading to neurodegenerative dementia. KEY MESSAGES The analysis of the two-sided link can offer useful insights for confronting with long-term neurological consequences of COVID-19 and framing future prevention and early treatment strategies.
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Affiliation(s)
- Giulia Bommarito
- Department of Clinical Neurosciences, Lausanne University Hospitals and University of Lausanne, Lausanne, Switzerland
| | - Valentina Garibotto
- Division of Nuclear Medicine and Molecular Imaging, Geneva University Hospitals and NIMTlab, University of Geneva, Geneva, Switzerland
| | - Giovanni B Frisoni
- Memory Center and LANVIE-Laboratory of Neuroimaging of Aging, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Frédéric Assal
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Patrice H Lalive
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Gilles Allali
- Department of Clinical Neurosciences, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- Division of Cognitive and Motor Aging, Department of Neurology, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York, USA
- Leenaards Memory Center, Lausanne University Hospitals and University of Lausanne, Lausanne, Switzerland
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Sehgal V, Kapila S, Taneja R, Mehmi P, Gulati N. Review of Neurological Manifestations of SARS-CoV-2. Cureus 2023; 15:e38194. [PMID: 37257164 PMCID: PMC10223874 DOI: 10.7759/cureus.38194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can affect any part of the neuraxis. Many neurological conditions have been attributed to be caused by SARS-CoV-2, namely encephalopathy (acute necrotizing encephalopathy and encephalopathy with reversible splenial lesions), seizures, stroke, cranial nerve palsies, meningoencephalitis, acute disseminated encephalomyelitis (ADEM), transverse myelitis (long and short segment), Guillain-Barré syndrome (GBS) and its variants, polyneuritis cranialis, optic neuritis (ON), plexopathy, myasthenia gravis (MG), and myositis. The pathophysiology differs depending on the time frame of presentation. In patients with concomitant pulmonary disease, for instance, acute neurological illness appears to be caused by endotheliopathy and cytokine storm. Autoimmunity and molecular mimicry are causative for post-coronavirus disease 2019 (COVID-19)-sequelae. It has not yet been shown that the virus can penetrate the central nervous system (CNS) directly. This review aims to describe the disease and root pathogenic cause of the various neurological manifestations of COVID-19. We searched Pubmed/Medline and Google Scholar using the keywords "SARS-CoV-2" and "neurological illness" for articles published between January 2020 and November 2022. Then, we used the SWIFT-Review (Sciome LLC, North Carolina, United States), a text-mining workbench for systematic review, to classify the 1383 articles into MeSH hierarchical tree codes for articles on various parts of the nervous system, such as the CNS, peripheral nervous system, autonomic nervous system, neuromuscular junction, sensory system, and musculoskeletal system. Finally, we reviewed 152 articles in full text. SARS-CoV-2 RNA has been found in multiple brain areas without any histopathological changes. Despite the absence of in vivo virions or virus-infected cells, CNS inflammation has been reported, especially in the olfactory bulb and brain stem. SARS-CoV-2 genomes and proteins have been found in affected individuals' brain tissues, but corresponding neuropathologic changes are seldom found in these cases. Additionally, viral RNA can rarely be identified in neurological patients' CSF post hoc SARS-CoV-2 infection. Most patients with neurological symptoms do not have active viral replication in the nervous system and infrequently have typical clinical and laboratory characteristics of viral CNS infections. Endotheliopathy and the systemic inflammatory response to SARS-CoV-2 infection play a crucial role in developing neuro-COVID-19, with proinflammatory cytokine release mediating both pathological pathways. The systemic inflammatory mediators likely activate astrocytes and microglia across the blood-brain barrier, indirectly affecting CNS-specific immune activation and tissue injury. The management differs according to co-morbidities and the neurological disorder.
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Affiliation(s)
- Vineet Sehgal
- Neurology, Sehgal's Neuro & Child Care Center, Amritsar, IND
| | - Saniya Kapila
- General Practice, Fortis Escorts Hospital, Amritsar, IND
| | - Rishabh Taneja
- Medicine, Government Multi-Specialty Hospital, Chandigarh, IND
- Graduate Medical Education, Adesh Institute of Medical Sciences & Research, Bathinda, IND
| | - Prachi Mehmi
- Neurology, Adesh Institute of Medical Sciences & Research, Bathinda, IND
| | - Nihal Gulati
- General Practice, Navpreet Hospital, Amritsar, IND
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Bernard-Valnet R, Favre E, Bernini A, Oddo M, Chiche JD, Du Pasquier RA, Rossetti AO. Delirium in Adults With COVID-19-Related Acute Respiratory Distress Syndrome: Comparison With Other Etiologies. Neurology 2022; 99:e2326-e2335. [PMID: 36376086 PMCID: PMC9695422 DOI: 10.1212/wnl.0000000000201162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Neurologic complications have been associated with COVID-19, including delirium. Such complications have been reported to be frequent among intensive care unit (ICU)-admitted patients. We hypothesized that the rate of neurologic complications would be higher in COVID-19 associated acute respiratory distress syndrome (ARDS) than those who develop ARDS from a different cause. METHODS We conducted a retrospective cohort study in the adult ICU of Lausanne University Hospital, including all consecutive patients fulfilling the Berlin criteria for ARDS hospitalized between December 2017 and June 2021, stratifying exposure between COVID-19 or not. The primary outcome was delirium onset during ICU stay, defined by the confusion assessment method (CAM-ICU). Exploratory outcomes included development of neurologic complications of the central nervous system (stroke, hemorrhage, and vasculitis), critical illness weakness, and 30- and 180-day all-cause mortality. RESULTS Three hundred eleven patients were included in the study (253 with COVID-19 and 58 with other causes) and CAM-ICU could be assessed in 231 (74.3% in COVID-19 vs 74.1% in non-COVID-19). The proportion of patients developing delirium was similar in patients with COVID-19 and controls in univariate comparison (69.1% vs 60.5%, p = 0.246). Yet, patients with COVID-19 had a higher body mass index, lower ICU severity, longer mechanical ventilation, and higher sedation doses (propofol and dexmedetomidine). After adjusting for these factors in a multivariable analysis, the risk of delirium remained comparable across groups (adjusted OR [95% CI]: 0.86 [0.35-2.1]). Similarly, COVID-19-related ARDS had no effect on all-cause mortality at 30 days (adjusted OR: 0.87 [0.39-1.92]) and 180 days (adjusted OR: 0.67 [0.33-1.35]). Finally, neurologic complications affecting the CNS (adjusted OR: 1.15 [0.25-5.29]) and critical illness weakness (adjusted OR: 2.99 [0.97-9.1]) were not higher in the COVID-19 group. DISCUSSION Compared with other etiologies, patients with COVID-19 did not have higher incidence of delirium and other neurologic complications, after accounting for underlying disease severity in patients with ARDS. Management of COVID-19-associated ARDS needed longer invasive ventilation and higher sedation, which could explain higher rates of delirium in uncontrolled studies.
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Affiliation(s)
- Raphael Bernard-Valnet
- From the Neurology Service (R.B.-V., R.A.D.P., A.O.R.), Department of Clinical Neurosciences; Department of Intensive Care Medicine (E.F., J.-D.C.); Neuroscience Critical Care Research Group (A.B.), Department of Intensive Care Medicine; and Medical Direction (M.O.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne, Switzerland.
| | - Eva Favre
- From the Neurology Service (R.B.-V., R.A.D.P., A.O.R.), Department of Clinical Neurosciences; Department of Intensive Care Medicine (E.F., J.-D.C.); Neuroscience Critical Care Research Group (A.B.), Department of Intensive Care Medicine; and Medical Direction (M.O.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne, Switzerland
| | - Adriano Bernini
- From the Neurology Service (R.B.-V., R.A.D.P., A.O.R.), Department of Clinical Neurosciences; Department of Intensive Care Medicine (E.F., J.-D.C.); Neuroscience Critical Care Research Group (A.B.), Department of Intensive Care Medicine; and Medical Direction (M.O.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne, Switzerland
| | - Mauro Oddo
- From the Neurology Service (R.B.-V., R.A.D.P., A.O.R.), Department of Clinical Neurosciences; Department of Intensive Care Medicine (E.F., J.-D.C.); Neuroscience Critical Care Research Group (A.B.), Department of Intensive Care Medicine; and Medical Direction (M.O.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne, Switzerland
| | - Jean-Daniel Chiche
- From the Neurology Service (R.B.-V., R.A.D.P., A.O.R.), Department of Clinical Neurosciences; Department of Intensive Care Medicine (E.F., J.-D.C.); Neuroscience Critical Care Research Group (A.B.), Department of Intensive Care Medicine; and Medical Direction (M.O.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne, Switzerland
| | - Renaud A Du Pasquier
- From the Neurology Service (R.B.-V., R.A.D.P., A.O.R.), Department of Clinical Neurosciences; Department of Intensive Care Medicine (E.F., J.-D.C.); Neuroscience Critical Care Research Group (A.B.), Department of Intensive Care Medicine; and Medical Direction (M.O.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne, Switzerland
| | - Andrea O Rossetti
- From the Neurology Service (R.B.-V., R.A.D.P., A.O.R.), Department of Clinical Neurosciences; Department of Intensive Care Medicine (E.F., J.-D.C.); Neuroscience Critical Care Research Group (A.B.), Department of Intensive Care Medicine; and Medical Direction (M.O.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne, Switzerland
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Rossi E, Mutti L, Morrione A, Giordano A. Neuro–Immune Interactions in Severe COVID-19 Infection. Pathogens 2022; 11:1256. [PMID: 36365007 PMCID: PMC9699641 DOI: 10.3390/pathogens11111256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 12/15/2022] Open
Abstract
SARS-CoV-2 is a new coronavirus that has affected the world since 2019. Interstitial pneumonia is the most common clinical presentation, but additional symptoms have been reported, including neurological manifestations. Severe forms of infection, especially in elderly patients, present as an excessive inflammatory response called “cytokine storm”, which can lead to acute respiratory distress syndrome (ARDS), multiorgan failure and death. Little is known about the relationship between symptoms and clinical outcomes or the characteristics of virus–host interactions. The aim of this narrative review is to highlight possible links between neurological involvement and respiratory damage mediated by pathological inflammatory pathways in SARS-CoV-2 infection. We will focus on neuro–immune interactions and age-related immunity decline and discuss some pathological mechanisms that contribute to negative outcomes in COVID-19 patients. Furthermore, we will describe available therapeutic strategies and their effects on COVID-19 neurological symptoms.
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Vecchio D, Moretto F, Padelli S, Grossi F, Cantello R, Vaschetto R. Isolated Central Nervous System Vasculitides in COVID-19: A Systematic Review of Case Reports and Series. Reports 2022; 5:36. [DOI: 10.3390/reports5030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cerebral vasculitides, both isolated or in systemic disorders, could be triggered by infections, and few cases have been associated to coronavirus disease 2019 (COVID-19). This study searched for publications in Pubmed, EMBASE, and Cochrane library databases for case reports and series of isolated central nervous system (CNS) vasculitides triggered by severe acute respiratory syndrome coronavirus-2. We included 12 studies (published from June 2020 to July 2022) and collected 39 adult patients (5/39 pathologically or radiologically proven, 34/39 suggestive for primary CNS vasculitis or PCNSV). All cases had a positive real-time polymerase chain reaction on a nasopharyngeal swab or a respiratory tract specimen. About the 85% of the included cases were males, and disease onset occurred later than 50 years old in all but three subjects. In total, 33/39 patients presented severe COVID-19 pneumonia, frequently requiring intensive care unit care. The most common neurological features were headache, obnubilation, and coma. PCNSV was suspected mainly on radiological findings, whereas the cerebrospinal fluid analysis was minimally altered. Magnetic resonance imaging showed vessel wall enhancement in 32/39 cases, generally with the concomitant presence of microbleeds, subarachnoid haemorrhages, and/or multiple ischemic lesions. Despite the severe respiratory and neurological disease course, most cases (93%) improved spontaneously or after a course of high-dose intravenous steroids with no need for immunosuppression. In conclusion, PCNSV could rarely relate to COVID-19 and independently from pulmonary disease severity. Adults with COVID-19-related PCNSV could have a favourable prognosis.
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Abstract
As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.
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Affiliation(s)
- Edith L Graham
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Igor J Koralnik
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Eric M Liotta
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA.
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Baksh A, Hadid A, Jaiganesh T. COVID-19 Encephalopathy Presenting As New-Onset Seizure: A Case Report. Cureus 2022; 14:e28204. [PMID: 36158377 PMCID: PMC9484586 DOI: 10.7759/cureus.28204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2022] [Indexed: 01/08/2023] Open
Abstract
Since its outbreak, it's been well-documented that coronavirus disease 2019 (COVID-19) can present with wide variety of neurological manifestations in absence of the usual respiratory symptoms. We report one such severe neurological manifestation of SARS-CoV-2 infection. To our knowledge, this is the first reported case of COVID-19 encephalopathy with CSF and MRI findings in the United Arab Emirates. We present a case of a 52-year-old female who presented with complaints of altered mentation, anosmia, headache, dizziness, weakness, lethargy, and vomiting. While in the emergency department she developed two generalized tonic-clonic seizure episodes, a more pronounced delirium, and tachypnea which required intubation. She was then admitted to the intensive care unit (ICU). She was COVID-19 positive and subsequent MRI revealed encephalopathy. She was discharged from ICU and was under long-term care at the time of case documentation.
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Di Gregorio F, La Porta F, Petrone V, Battaglia S, Orlandi S, Ippolito G, Romei V, Piperno R, Lullini G. Accuracy of EEG Biomarkers in the Detection of Clinical Outcome in Disorders of Consciousness after Severe Acquired Brain Injury: Preliminary Results of a Pilot Study Using a Machine Learning Approach. Biomedicines 2022; 10:biomedicines10081897. [PMID: 36009445 PMCID: PMC9405912 DOI: 10.3390/biomedicines10081897] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/04/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022] Open
Abstract
Accurate outcome detection in neuro-rehabilitative settings is crucial for appropriate long-term rehabilitative decisions in patients with disorders of consciousness (DoC). EEG measures derived from high-density EEG can provide helpful information regarding diagnosis and recovery in DoC patients. However, the accuracy rate of EEG biomarkers to predict the clinical outcome in DoC patients is largely unknown. This study investigated the accuracy of psychophysiological biomarkers based on clinical EEG in predicting clinical outcomes in DoC patients. To this aim, we extracted a set of EEG biomarkers in 33 DoC patients with traumatic and nontraumatic etiologies and estimated their accuracy to discriminate patients’ etiologies and predict clinical outcomes 6 months after the injury. Machine learning reached an accuracy of 83.3% (sensitivity = 92.3%, specificity = 60%) with EEG-based functional connectivity predicting clinical outcome in nontraumatic patients. Furthermore, the combination of functional connectivity and dominant frequency in EEG activity best predicted clinical outcomes in traumatic patients with an accuracy of 80% (sensitivity = 85.7%, specificity = 71.4%). These results highlight the importance of functional connectivity in predicting recovery in DoC patients. Moreover, this study shows the high translational value of EEG biomarkers both in terms of feasibility and accuracy for the assessment of DoC.
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Affiliation(s)
- Francesco Di Gregorio
- UO Medicina Riabilitativa e Neuroriabilitazione, Azienda Unità Sanitaria Locale, 40133 Bologna, Italy
| | - Fabio La Porta
- IRCCS Istituto delle Scienze Neurologiche di Bologna
- Correspondence:
| | | | - Simone Battaglia
- Centro Studi e Ricerche in Neuroscienze Cognitive, Dipartimento di Psicologia, Alma Mater Studiorum—Università di Bologna, Campus di Cesena, 47521 Cesena, Italy
- Dipartimento di Psicologia, Università di Torino, 10124 Torino, Italy
| | - Silvia Orlandi
- Department of Electrical, Electronic and Information Engineering “Guglielmo Marconi”, University of Bologna, Viale Risorgimento, 2, 40136 Bologna, Italy
| | - Giuseppe Ippolito
- Centro Studi e Ricerche in Neuroscienze Cognitive, Dipartimento di Psicologia, Alma Mater Studiorum—Università di Bologna, Campus di Cesena, 47521 Cesena, Italy
| | - Vincenzo Romei
- Centro Studi e Ricerche in Neuroscienze Cognitive, Dipartimento di Psicologia, Alma Mater Studiorum—Università di Bologna, Campus di Cesena, 47521 Cesena, Italy
| | | | - Giada Lullini
- IRCCS Istituto delle Scienze Neurologiche di Bologna
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12
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Ariño H, Heartshorne R, Michael BD, Nicholson TR, Vincent A, Pollak TA, Vogrig A. Neuroimmune disorders in COVID-19. J Neurol 2022; 269:2827-2839. [PMID: 35353232 PMCID: PMC9120100 DOI: 10.1007/s00415-022-11050-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 12/15/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the aetiologic agent of the coronavirus disease 2019 (COVID-19), is now rapidly disseminating throughout the world with 147,443,848 cases reported so far. Around 30-80% of cases (depending on COVID-19 severity) are reported to have neurological manifestations including anosmia, stroke, and encephalopathy. In addition, some patients have recognised autoimmune neurological disorders, including both central (limbic and brainstem encephalitis, acute disseminated encephalomyelitis [ADEM], and myelitis) and peripheral diseases (Guillain-Barré and Miller Fisher syndrome). We systematically describe data from 133 reported series on the Neurology and Neuropsychiatry of COVID-19 blog ( https://blogs.bmj.com/jnnp/2020/05/01/the-neurology-and-neuropsychiatry-of-covid-19/ ) providing a comprehensive overview concerning the diagnosis, and treatment of patients with neurological immune-mediated complications of SARS-CoV-2. In most cases the latency to neurological disorder was highly variable and the immunological or other mechanisms involved were unclear. Despite specific neuronal or ganglioside antibodies only being identified in 10, many had apparent responses to immunotherapies. Although the proportion of patients experiencing immune-mediated neurological disorders is small, the total number is likely to be underestimated. The early recognition and improvement seen with use of immunomodulatory treatment, even in those without identified autoantibodies, makes delayed or missed diagnoses risk the potential for long-term disability, including the emerging challenge of post-acute COVID-19 sequelae (PACS). Finally, potential issues regarding the use of immunotherapies in patients with pre-existent neuro-immunological disorders are also discussed.
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Affiliation(s)
- Helena Ariño
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rosie Heartshorne
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Benedict D Michael
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Timothy R Nicholson
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Alberto Vogrig
- Centre de Référence National pour les Syndromes Neurologiques Paranéoplasique, Hôpital Neurologique, Hospices Civils de Lyon, Lyon, France
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Santa Maria Della Misericordia, Udine, Italy
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13
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Huo S, Ferse C, Bösl F, Reincke SM, Enghard P, Hinrichs C, Treskatsch S, Angermair S, Eckardt KU, Audebert HJ, Ploner CJ, Endres M, Prüss H, Franke C, Scheibe F. Intravenous immunoglobulins for treatment of severe COVID-19-related acute encephalopathy. J Neurol 2022. [PMID: 35538168 DOI: 10.1007/s00415-022-11152-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022]
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Abstract
Entering the third year into the pandemic, overwhelming evidence demonstrates that Coronavirus disease 2019 (COVID-19) infection is a systemic illness, often with involvement of the central nervous system. Multiple mechanisms may underlie the development of neurologic manifestations of illness, including hypoxia, systemic illness, hypercoagulability, endothelial dysfunction, general critical illness, inflammatory response, and neurotropism of the severe acute respiratory syndrome coronavirus 2 (SARS-Co-V2) virus. COVID-19 infection is associated with neurologic involvement in all stages; acute infection, subacute/post-infection, and growing evidence also suggests during a chronic phase, the post-acute sequalae of COVID-19 (PASC). With over 20,000 published articles on COVID and the brain at the time of writing, it is virtually impossible to present an unbiased comprehensive review of how SARS-Co-V2 impacts the nervous system. In this review, we will present an overview of common neurologic manifestations, in particular focusing on the cerebrovascular complications, and proposed pathophysiology.
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15
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Domingues RB, Leite FBVDM, Senne C. Cerebrospinal fluid analysis in patients with COVID-19-associated central nervous system manifestations: a systematic review. Arq Neuro-Psiquiatr 2022; 80:296-305. [DOI: 10.1590/0004-282x-anp-2021-0117] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/22/2021] [Indexed: 12/14/2022]
Abstract
ABSTRACT Background: Central nervous system (CNS) symptoms may occur in patients with acute COVID-19. The role of CSF examination in these patients remains to be established. Objective: A systematic review of CSF findings relating to COVID-19 was carried out. Methods: CSF parameters, including cytological and biochemical analyses, SARS-CoV-2 RT-PCR and other CSF markers, were recorded and analyzed among patients with acute COVID-19 and one of the following CNS syndromes: stroke, encephalopathy, encephalitis, inflammatory syndromes, seizure, headache and meningitis. Results: Increased white blood cells and/or increased protein concentration were found in 52.7% of the patients with encephalitis, 29.4% of the patients with encephalopathy and 46.7% of the patients with inflammatory syndromes (P < 0.05). CSF RT-PCR for SARS-CoV-2 was positive in 17.35% of the patients with encephalitis and less than 3.5% of the patients with encephalopathy or inflammatory syndromes (P < 0.05). Intrathecal production of immunoglobulins was found in only 8% of the cases. More than 85% of the patients had increased CSF cytokines and chemokines. Increased CSF neurofilament light chain (NfL) and CSF Tau were found in 71% and 36% of the cases, respectively. Conclusion: Non-specific inflammatory CSF abnormalities were frequently found in patients with COVID-19 CNS syndromes. The increase in neurodegeneration biomarkers suggests that neuronal damage occurs, with long-term consequences that are still unknown.
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16
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Abstract
In humans, several respiratory viruses can have neurologic implications affecting both central and peripheral nervous system. Neurologic manifestations can be linked to viral neurotropism and/or indirect effects of the infection due to endothelitis with vascular damage and ischemia, hypercoagulation state with thrombosis and hemorrhages, systemic inflammatory response, autoimmune reactions, and other damages. Among these respiratory viruses, recent and huge attention has been given to the coronaviruses, especially the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic started in 2020. Besides the common respiratory symptoms and the lung tropism of SARS-CoV-2 (COVID-19), neurologic manifestations are not rare and often present in the severe forms of the infection. The most common acute and subacute symptoms and signs include headache, fatigue, myalgia, anosmia, ageusia, sleep disturbances, whereas clinical syndromes include mainly encephalopathy, ischemic stroke, seizures, and autoimmune peripheral neuropathies. Although the pathogenetic mechanisms of COVID-19 in the various acute neurologic manifestations are partially understood, little is known about long-term consequences of the infection. These consequences concern both the so-called long-COVID (characterized by the persistence of neurological manifestations after the resolution of the acute viral phase), and the onset of new neurological symptoms that may be linked to the previous infection.
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Affiliation(s)
- Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria,Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Marialuisa Zedde
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elena Moro
- Division of Neurology, CHU of Grenoble, Grenoble Alpes University, Grenoble Institute of Neurosciences, Grenoble, France,Correspondence to: Elena Moro, Service de neurologie, CHU de Grenoble (Hôpital Nord), Boulevard de la Chantourne, 38043 La Tronche, France. Tel: + 33-4-76-76-94-52, Fax: +33-4-76-76-56-31
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17
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Jozuka R, Kimura H, Uematsu T, Fujigaki H, Yamamoto Y, Kobayashi M, Kawabata K, Koike H, Inada T, Saito K, Katsuno M, Ozaki N. Severe and long-lasting neuropsychiatric symptoms after mild respiratory symptoms caused by COVID-19: A case report. Neuropsychopharmacol Rep 2021; 42:114-119. [PMID: 34889531 PMCID: PMC8919122 DOI: 10.1002/npr2.12222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 12/25/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID‐19) is known to cause not only respiratory but also neuropsychiatric symptoms, which are assumed to be derived from a cytokine storm and its effects on the central nervous systems. Patients with COVID‐19 who develop severe respiratory symptoms are known to show severe neuropsychiatric symptoms such as cerebrovascular disease and encephalopathy. However, the detailed clinical courses of patients with neuropsychiatric symptoms caused by mild or asymptomatic COVID‐19 remain poorly understood. Here, we present a case of COVID‐19 who presented with severe and prolonged neuropsychiatric symptoms subsequent to mild respiratory symptoms. Case presentation A 55‐year‐old female with COVID‐19 accompanied by mild respiratory symptoms showed delusion, psychomotor excitement, and poor communication ability during quarantine outside the hospital. Considering her diminished respiratory symptoms, her neuropsychiatric symptoms were initially regarded as psychogenic reactions. However, as she showed progressive disturbance of consciousness accompanied by an abnormal electroencephalogram, she was diagnosed with post‐COVID‐19 encephalopathy. Although her impaired consciousness and elevated cytokine level improved after steroid pulse therapy, several neuropsychiatric symptoms, including a loss of concentration, unsteadiness while walking, and fatigue, remained. Conclusions This case suggests the importance of both recognizing that even apparently mild COVID‐19‐related respiratory symptoms can lead to severe and persistent neuropsychiatric symptoms, and elucidating the mechanisms, treatment, and long‐term course of COVID‐19‐related neuropsychiatric symptoms in the future. A 55‐year‐old female with COVID‐19 accompanied by mild respiratory symptoms was diagnosed with post‐COVID‐19 encephalopathy. Although her impaired consciousness and elevated cytokine level improved after steroid pulse therapy, several neuropsychiatric symptoms remained. This case suggests the importance of both recognizing that even apparently mild COVID‐19‐related respiratory symptoms can lead to severe and persistent neuropsychiatric symptoms.![]()
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Affiliation(s)
- Ryosuke Jozuka
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kimura
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Uematsu
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetsugu Fujigaki
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Science, Toyoake, Japan
| | - Yasuko Yamamoto
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Science, Toyoake, Japan
| | - Masato Kobayashi
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuya Kawabata
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiya Inada
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kuniaki Saito
- Department of Advanced Diagnostic System Development, Fujita Health University Graduate School of Health Science, Toyoake, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norio Ozaki
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
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18
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To KKW, Sridhar S, Chiu KHY, Hung DLL, Li X, Hung IFN, Tam AR, Chung TWH, Chan JFW, Zhang AJX, Cheng VCC, Yuen KY. Lessons learned 1 year after SARS-CoV-2 emergence leading to COVID-19 pandemic. Emerg Microbes Infect 2021; 10:507-535. [PMID: 33666147 PMCID: PMC8006950 DOI: 10.1080/22221751.2021.1898291] [Citation(s) in RCA: 149] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/26/2021] [Accepted: 02/28/2021] [Indexed: 02/06/2023]
Abstract
Without modern medical management and vaccines, the severity of the Coronavirus Disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2) might approach the magnitude of 1894-plague (12 million deaths) and 1918-A(H1N1) influenza (50 million deaths) pandemics. The COVID-19 pandemic was heralded by the 2003 SARS epidemic which led to the discovery of human and civet SARS-CoV-1, bat SARS-related-CoVs, Middle East respiratory syndrome (MERS)-related bat CoV HKU4 and HKU5, and other novel animal coronaviruses. The suspected animal-to-human jumping of 4 betacoronaviruses including the human coronaviruses OC43(1890), SARS-CoV-1(2003), MERS-CoV(2012), and SARS-CoV-2(2019) indicates their significant pandemic potential. The presence of a large reservoir of coronaviruses in bats and other wild mammals, culture of mixing and selling them in urban markets with suboptimal hygiene, habit of eating exotic mammals in highly populated areas, and the rapid and frequent air travels from these areas are perfect ingredients for brewing rapidly exploding epidemics. The possibility of emergence of a hypothetical SARS-CoV-3 or other novel viruses from animals or laboratories, and therefore needs for global preparedness should not be ignored. We reviewed representative publications on the epidemiology, virology, clinical manifestations, pathology, laboratory diagnostics, treatment, vaccination, and infection control of COVID-19 as of 20 January 2021, which is 1 year after person-to-person transmission of SARS-CoV-2 was announced. The difficulties of mass testing, labour-intensive contact tracing, importance of compliance to universal masking, low efficacy of antiviral treatment for severe disease, possibilities of vaccine or antiviral-resistant virus variants and SARS-CoV-2 becoming another common cold coronavirus are discussed.
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Affiliation(s)
- Kelvin Kai-Wang To
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Carol Yu Centre for Infection, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Siddharth Sridhar
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Carol Yu Centre for Infection, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Kelvin Hei-Yeung Chiu
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Derek Ling-Lung Hung
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Xin Li
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Ivan Fan-Ngai Hung
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Anthony Raymond Tam
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Tom Wai-Hin Chung
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Jasper Fuk-Woo Chan
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Carol Yu Centre for Infection, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Anna Jian-Xia Zhang
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Carol Yu Centre for Infection, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Vincent Chi-Chung Cheng
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
| | - Kwok-Yung Yuen
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Carol Yu Centre for Infection, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China
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19
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Saenz Lafourcade C, Pinel González A, Martin Ávila G. Disimmune encephalopathy with onconeuronal antibodies in SARS-CoV-2 infected patients. Medicina Clínica (English Edition) 2021; 157:e357-e358. [PMID: 34786483 PMCID: PMC8585633 DOI: 10.1016/j.medcle.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Ana Pinel González
- Servicio de Neurología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
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20
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Pizzato Tondo L, Beck Paglioli Neto E, Arpini S, Passos G, Becker J. Encephalopathy Due to COVID-19 With Great Response to Glucocorticoids. Cureus 2021; 13:e17845. [PMID: 34660051 PMCID: PMC8501896 DOI: 10.7759/cureus.17845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2021] [Indexed: 11/15/2022] Open
Abstract
Minor neurological symptoms such as anosmia are relatively common manifestations of coronavirus disease 2019 (COVID-19). However, severe affection of the central nervous system (CNS) occurs in a minority of cases and its treatment and pathophysiology is not yet well understood. It has been described that encephalitis due to COVID-19 may be caused by the proinflammatory state due to the cytokine storm or direct invasion of the virus in the CNS. Here we present a case of a 66-year-old man with bipolar disorder and moderate respiratory COVID-19 symptoms who presented to the emergency department with a decreased level of consciousness. Brain computerized tomography (CT) showed no acute pathology. A thorough investigation of other possible causes of CNS affection was negative. The patient was treated with pulse therapy with methylprednisolone and presented a significant improvement of his neurological condition, being discharged with a complete neurological recovery five days after the start of the treatment. This case illustrates the importance of a high index of suspicion in diagnosing severe CNS impairment in mild respiratory COVID-19 cases. Also, this case corroborates with previous reports of glucocorticoid response in CNS impairment associated with COVID-19, although more robust studies are required to confirm this relation.
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Affiliation(s)
- Lucca Pizzato Tondo
- Neurology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, BRA
| | | | - Soel Arpini
- Neurology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, BRA
| | - Giordani Passos
- Neurology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, BRA
| | - Jefferson Becker
- Neurology, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, BRA
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21
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Arandela K, Samudrala S, Abdalkader M, Anand P, Daneshmand A, Dasenbrock H, Nguyen T, Ong C, Takahashi C, Shulman J, Babi MA, Sivakumar S, Shah N, Jain S, Anand S, Nobleza COS, Shekhar S, Venkatasubramanian C, Salahuddin H, Taqi MA, Nour HA, Nofar JB, Cervantes-Arslanian AM. Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series. J Stroke Cerebrovasc Dis 2021; 30:106118. [PMID: 34560378 PMCID: PMC8445803 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19. MATERIALS AND METHODS Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site. RESULTS Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1). CONCLUSIONS Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.
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Affiliation(s)
- Kristine Arandela
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Shilpa Samudrala
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Mohamad Abdalkader
- Departments of Radiology, Boston University School of Medicine and Boston Medical Center, United States
| | - Pria Anand
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Ali Daneshmand
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Hormuzdiyar Dasenbrock
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Thanh Nguyen
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Radiology, Boston University School of Medicine and Boston Medical Center, United States
| | - Charlene Ong
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Courtney Takahashi
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States
| | - Julie Shulman
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States
| | - Marc Alain Babi
- Departments of Neurology and Neurosurgery, University of Florida, United States
| | - Sanjeev Sivakumar
- Department of Neurology, University of South Carolina Greenville School of Medicine, United States
| | - Neel Shah
- Department of Neurology, University of South Carolina Greenville School of Medicine, United States
| | - Sandip Jain
- Department of Neurology, University of South Carolina Greenville School of Medicine, United States
| | - Samyuktha Anand
- Department of Neurology, Prisma Health-Upstate, United States
| | | | - Shashank Shekhar
- Departments Neurology and Neurosurgery, University of Mississippi Medical Center, United States
| | | | | | - Muhammad A Taqi
- Department of Neurology, Los Robles Medical Center, United States
| | | | - Justin B Nofar
- Department of Neurology, Henry Ford Health System, United States
| | - Anna M Cervantes-Arslanian
- Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States; Departments of Medicine Infectious Diseases, Boston University School of Medicine and Boston Medical Center, United States.
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22
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Sullivan BN, Fischer T. Age-Associated Neurological Complications of COVID-19: A Systematic Review and Meta-Analysis. Front Aging Neurosci 2021; 13:653694. [PMID: 34408638 PMCID: PMC8366271 DOI: 10.3389/fnagi.2021.653694] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/08/2021] [Indexed: 12/15/2022] Open
Abstract
The outbreak of the novel and highly infectious severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in hundreds of millions of infections and millions of deaths globally. Infected individuals that progress to coronavirus disease-19 (COVID-19) experience upper and lower respiratory complications that range in severity and may lead to wide-spread inflammation and generalized hypoxia or hypoxemia that impacts multiple organ systems, including the central and peripheral nervous systems. Since the SARS-CoV-2 outbreak, multiple reports continue to emerge that detail neurological symptoms, ranging from relatively mild (e.g., impaired taste and/or smell) to severe (e.g., stroke), suggesting SARS-CoV-2 may be neurotropic and/or contribute to nervous system injury through direct and/or indirect mechanisms. To gain insight into the types of neurological complications associated with SARS-CoV-2 infection and their possible relationship with age, sex, COVID-19 severity, and comorbidities, we performed a systematic review of case reports and series published in 2020 - April 4, 2021 of infected patients with neurological manifestations. Meta-analyses were conducted using individual patient data from reports where these data could be extracted. Here, we report neurological injury occurs across the lifespan in the context of infection, with and without known comorbidities, and with all disease severities, including asymptomatic patients. Older individuals, however, are more susceptible to developing life-threatening COVID-19 and cerebrovascular disease (CVD), such as stroke. A mild but inverse correlation with age was seen with CNS inflammatory diseases, such as encephalitis, as well as taste and/or smell disorders. When reported, increased age was also associated with comorbid cardiovascular risk factors, including hypertension, diabetes mellitus, and lipid disorders, but not with obesity. Obesity did correlate with development of critical COVID-19. Discussion into potential pathophysiological mechanisms by which neurological symptoms arise and long-term consequences of infection to the nervous system is also provided.
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Affiliation(s)
- Brianne N. Sullivan
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, United States
- Neuroscience Program, Tulane Brain Institute, School of Science and Engineering, Tulane University, New Orleans, LA, United States
| | - Tracy Fischer
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, United States
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, LA, United States
- Tulane Brain Institute, Tulane University School of Medicine, New Orleans, LA, United States
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23
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Hentsch L, Cocetta S, Allali G, Santana I, Eason R, Adam E, Janssens JP. Breathlessness and COVID-19: A Call for Research. Respiration 2021; 100:1016-1026. [PMID: 34333497 PMCID: PMC8450822 DOI: 10.1159/000517400] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/19/2021] [Indexed: 01/08/2023] Open
Abstract
Breathlessness, also known as dyspnoea, is a debilitating and frequent symptom. Several reports have highlighted the lack of dyspnoea in a subgroup of patients suffering from COVID-19, sometimes referred to as “silent” or “happy hypoxaemia.” Reports have also mentioned the absence of a clear relationship between the clinical severity of the disease and levels of breathlessness reported by patients. The cerebral complications of COVID-19 have been largely demonstrated with a high prevalence of an acute encephalopathy that could possibly affect the processing of afferent signals or top-down modulation of breathlessness signals. In this review, we aim to highlight the mechanisms involved in breathlessness and summarize the pathophysiology of COVID-19 and its known effects on the brain-lung interaction. We then offer hypotheses for the alteration of breathlessness perception in COVID-19 patients and suggest ways of further researching this phenomenon.
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Affiliation(s)
- Lisa Hentsch
- Division of Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Gilles Allali
- Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Cognitive and Motor Aging, Department of Neurology, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York, USA
| | | | - Rowena Eason
- Phyllis Tuckwell Hospice Care, Surrey, United Kingdom
| | - Emily Adam
- Independent Researcher, London, United Kingdom
| | - Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospital, Geneva, Switzerland
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24
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Bitirgen G, Korkmaz C, Zamani A, Ozkagnici A, Zengin N, Ponirakis G, Malik RA. Corneal confocal microscopy identifies corneal nerve fibre loss and increased dendritic cells in patients with long COVID. Br J Ophthalmol 2021; 106:1635-1641. [PMID: 34312122 PMCID: PMC8359871 DOI: 10.1136/bjophthalmol-2021-319450] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/24/2021] [Indexed: 12/14/2022]
Abstract
Background/Aims Long COVID is characterised by a range of potentially debilitating symptoms which develop in at least 10% of people who have recovered from acute SARS-CoV-2 infection. This study has quantified corneal sub-basal nerve plexus morphology and dendritic cell (DC) density in patients with and without long COVID. Methods Forty subjects who had recovered from COVID-19 and 30 control participants were included in this cross-sectional comparative study undertaken at a university hospital. All patients underwent assessment with the National Institute for Health and Care Excellence (NICE) long COVID, Douleur Neuropathique 4 (DN4) and Fibromyalgia questionnaires, and corneal confocal microscopy (CCM) to quantify corneal nerve fibre density (CNFD), corneal nerve branch density (CNBD), corneal nerve fibre length (CNFL), and total, mature and immature DC density. Results The mean time after the diagnosis of COVID-19 was 3.7±1.5 months. Patients with neurological symptoms 4 weeks after acute COVID-19 had a lower CNFD (p=0.032), CNBD (p=0.020), and CNFL (p=0.012), and increased DC density (p=0.046) compared with controls, while patients without neurological symptoms had comparable corneal nerve parameters, but increased DC density (p=0.003). There were significant correlations between the total score on the NICE long COVID questionnaire at 4 and 12 weeks with CNFD (ρ=−0.436; p=0.005, ρ=−0.387; p=0.038, respectively) and CNFL (ρ=−0.404; p=0.010, ρ=−0.412; p=0.026, respectively). Conclusion Corneal confocal microscopy identifies corneal small nerve fibre loss and increased DCs in patients with long COVID, especially those with neurological symptoms. CCM could be used to objectively identify patients with long COVID.
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Affiliation(s)
- Gulfidan Bitirgen
- Department of Ophthalmology, Necmettin Erbakan University Meram Medical Faculty Hospital, Konya, Turkey
| | - Celalettin Korkmaz
- Department of Pulmonary Medicine, Necmettin Erbakan University Meram Medical Faculty Hospital, Konya, Turkey
| | - Adil Zamani
- Department of Pulmonary Medicine, Necmettin Erbakan University Meram Medical Faculty Hospital, Konya, Turkey
| | - Ahmet Ozkagnici
- Department of Ophthalmology, Necmettin Erbakan University Meram Medical Faculty Hospital, Konya, Turkey
| | - Nazmi Zengin
- Department of Ophthalmology, Necmettin Erbakan University Meram Medical Faculty Hospital, Konya, Turkey
| | | | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.,Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR Clinical Research Facility, Manchester, UK
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25
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Barbosa-Silva MC, Lima MN, Battaglini D, Robba C, Pelosi P, Rocco PRM, Maron-Gutierrez T. Infectious disease-associated encephalopathies. Crit Care 2021; 25:236. [PMID: 34229735 PMCID: PMC8259088 DOI: 10.1186/s13054-021-03659-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Infectious diseases may affect brain function and cause encephalopathy even when the pathogen does not directly infect the central nervous system, known as infectious disease-associated encephalopathy. The systemic inflammatory process may result in neuroinflammation, with glial cell activation and increased levels of cytokines, reduced neurotrophic factors, blood-brain barrier dysfunction, neurotransmitter metabolism imbalances, and neurotoxicity, and behavioral and cognitive impairments often occur in the late course. Even though infectious disease-associated encephalopathies may cause devastating neurologic and cognitive deficits, the concept of infectious disease-associated encephalopathies is still under-investigated; knowledge of the underlying mechanisms, which may be distinct from those of encephalopathies of non-infectious cause, is still limited. In this review, we focus on the pathophysiology of encephalopathies associated with peripheral (sepsis, malaria, influenza, and COVID-19), emerging therapeutic strategies, and the role of neuroinflammation.
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Affiliation(s)
- Maria C Barbosa-Silva
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Maiara N Lima
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Tatiana Maron-Gutierrez
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil.
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil.
- National Institute of Science and Technology on Neuroimmunomodulation, Rio de Janeiro, Rio de Janeiro, Brazil.
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26
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Spagnolo-Allende A, Gutierrez J. Role of Brain Arterial Remodeling in HIV-Associated Cerebrovascular Outcomes. Front Neurol 2021; 12:593605. [PMID: 34239489 PMCID: PMC8258100 DOI: 10.3389/fneur.2021.593605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 05/07/2021] [Indexed: 01/11/2023] Open
Abstract
As the life expectancy of people living with HIV (PLWH) on combination antiretroviral therapy (cART) increases, so does morbidity from cerebrovascular disease and neurocognitive disorders. Brain arterial remodeling stands out as a novel investigational target to understand the role of HIV in cerebrovascular and neurocognitive outcomes. We therefore conducted a review of publications in PubMed, EMBASE, Web of Science and Wiley Online Library, from inception to April 2021. We included search terms such as HIV, cART, brain, neuroimmunity, arterial remodeling, cerebrovascular disease, and neurocognitive disorders. The literature shows that, in the post-cART era, PLWH continue to experience an increased risk of stroke and neurocognitive disorders (albeit milder forms) compared to uninfected populations. PLWH who are immunosuppressed have a higher proportion of hemorrhagic strokes and strokes caused by opportunistic infection and HIV vasculopathy, while PLWH on long-term cART have higher rates of ischemic strokes, compared to HIV-seronegative controls. Brain large artery atherosclerosis in PLWH is associated with lower CD4 nadir and higher CD4 count during the stroke event. HIV vasculopathy, a form of non-atherosclerotic outward remodeling, on the other hand, is associated with protracted immunosuppression. HIV vasculopathy was also linked to a thinner media layer and increased adventitial macrophages, suggestive of non-atherosclerotic degeneration of the brain arterial wall in the setting of chronic central nervous system inflammation. Cerebrovascular architecture seems to be differentially affected by HIV infection in successfully treated versus immunosuppressed PLWH. Brain large artery atherosclerosis is prevalent even with long-term immune reconstitution post-cART. HIV-associated changes in brain arterial walls may also relate to higher rates of HIV-associated neurocognitive disorders, although milder forms are more prevalent in the post-cART era. The underlying mechanisms of HIV-associated pathological arterial remodeling remain poorly understood, but a role has been proposed for chronic HIV-associated inflammation with increased burden on the vasculature. Neuroimaging may come to play a role in assessing brain arterial remodeling and stratifying cerebrovascular risk, but the data remains inconclusive. An improved understanding of the different phenotypes of brain arterial remodeling associated with HIV may reveal opportunities to reduce rates of cerebrovascular disease in the aging population of PLWH on cART.
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Affiliation(s)
| | - Jose Gutierrez
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
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27
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Bernard-Valnet R, Perriot S, Canales M, Pizzarotti B, Caranzano L, Castro-Jiménez M, Epiney JB, Vijiala S, Salvioni-Chiabotti P, Anichini A, Salerno A, Jaton K, Vaucher J, Perreau M, Greub G, Pantaleo G, Du Pasquier RA. Encephalopathies Associated With Severe COVID-19 Present Neurovascular Unit Alterations Without Evidence for Strong Neuroinflammation. Neurol Neuroimmunol Neuroinflamm 2021; 8:8/5/e1029. [PMID: 34135107 PMCID: PMC8210172 DOI: 10.1212/nxi.0000000000001029] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/04/2021] [Indexed: 12/29/2022]
Abstract
Objective Coronavirus disease (COVID-19) has been associated with a large variety of neurologic disorders. However, the mechanisms underlying these neurologic complications remain elusive. In this study, we aimed at determining whether neurologic symptoms were caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) direct infection or by either systemic or local proinflammatory mediators. Methods In this cross-sectional study, we checked for SARS-CoV-2 RNA by quantitative reverse transcription PCR, SARS-CoV-2–specific antibodies, and 49 cytokines/chemokines/growth factors (by Luminex) in the CSF +/− sera of a cohort of 22 COVID-19 patients with neurologic presentation and 55 neurologic control patients (inflammatory neurologic disorder [IND], noninflammatory neurologic disorder, and MS). Results We detected anti–SARS-CoV-2 immunoglobulin G in patients with severe COVID-19 with signs of intrathecal synthesis for some of them. Of the 4 categories of tested patients, the CSF of IND exhibited the highest level of cytokines, chemokines, and growth factors. By contrast, patients with COVID-19 did not present overall upregulation of inflammatory mediators in the CSF. However, patients with severe COVID-19 (intensive care unit patients) exhibited higher concentrations of CCL2, CXCL8, and vascular endothelium growth factor A (VEGF-A) in the CSF than patients with a milder form of COVID-19. In addition, we could show that intrathecal CXCL8 synthesis was linked to an elevated albumin ratio and correlated with the increase of peripheral inflammation (serum hepatocyte growth factor [HGF] and CXCL10). Conclusions Our results do not indicate active replication of SARS-CoV-2 in the CSF or signs of massive inflammation in the CSF compartment but highlight a specific impairment of the neurovascular unit linked to intrathecal production of CXCL8.
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Affiliation(s)
- Raphael Bernard-Valnet
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland.
| | - Sylvain Perriot
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Mathieu Canales
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Beatrice Pizzarotti
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Leonardo Caranzano
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Mayté Castro-Jiménez
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Jean-Benoit Epiney
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Sergiu Vijiala
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Paolo Salvioni-Chiabotti
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Angelica Anichini
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Alexander Salerno
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Katia Jaton
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Julien Vaucher
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Matthieu Perreau
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Gilbert Greub
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Giuseppe Pantaleo
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Renaud A Du Pasquier
- From the Service of Neurology and Laboratory of Neuroimmunology (R.B.-V., S.P., M.C., B.P., L.C., M.C.-J., J.-B.E., S.V., P.S.-C., A.A., A.S., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; Institute of Microbiology (K.J., G.G.), University of Lausanne and University Hospital of Lausanne; Service of Internal Medicine (J.V.), Department of Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and University of Lausanne; and Service of Immunology and Allergy (M.P., G.P.), Department of Medicine, Lausanne University Hospital and University of Lausanne, Switzerland
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Manca R, De Marco M, Ince PG, Venneri A. Heterogeneity in Regional Damage Detected by Neuroimaging and Neuropathological Studies in Older Adults With COVID-19: A Cognitive-Neuroscience Systematic Review to Inform the Long-Term Impact of the Virus on Neurocognitive Trajectories. Front Aging Neurosci 2021; 13:646908. [PMID: 34149394 PMCID: PMC8209297 DOI: 10.3389/fnagi.2021.646908] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/28/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Other than its direct impact on cardiopulmonary health, Coronavirus Disease 2019 (COVID-19) infection affects additional body systems, especially in older adults. Several studies have reported acute neurological symptoms that present at onset or develop during hospitalisation, with associated neural injuries. Whilst the acute neurological phase is widely documented, the long-term consequences of COVID-19 infection on neurocognitive functioning remain unknown. Although an evidence-based framework describing the disease chronic phase is premature, it is important to lay the foundations for future data-driven models. This systematic review aimed at summarising the literature on neuroimaging and neuropathological findings in older over-60 patients with COVID-19 following a cognitive neuroscientific perspective, to clarify the most vulnerable brain areas and speculate on the possible cognitive consequences. Methods: PubMed and Web of Science databases were searched to identify relevant manuscripts published between 1st March 2020 and 31th December 2020. Outputs were screened and selected by two assessors. Relevant studies not detected by literature search were added manually. Results: Ninety studies, mainly single cases and case series, were included. Several neuroimaging and neuropathological findings in older patients with COVID-19 emerged from these studies, with cerebrovascular damage having a prominent role. Abnormalities (hyperintensities, hypoperfusion, inflammation, and cellular damage) were reported in most brain areas. The most consistent cross-aetiology findings were in white matter, brainstem and fronto-temporal areas. Viral DNA was detected mainly in olfactory, orbitofrontal and brainstem areas. Conclusion: Studies on COVID-19 related neural damage are rich and diverse, but limited to description of hospitalised patients with fatal outcome (i.e., in neuropathological studies) or severe symptoms (i.e., in neuroimaging studies). The damage seen in this population indicates acute and largely irreversible dysfunction to neural regions involved in major functional networks that support normal cognitive and behavioural functioning. It is still unknown whether the long-term impact of the virus will be limited to chronic evolution of acute events, whether sub-clinical pathological processes will be exacerbated or whether novel mechanisms will emerge. Based on current literature, future theoretical frameworks describing the long-term impact of COVID-19 infection on mental abilities will have to factor in major trends of aetiological and topographic heterogeneity.
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Affiliation(s)
- Riccardo Manca
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Matteo De Marco
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Paul G Ince
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Annalena Venneri
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom
- Department of Life Sciences, Brunel University London, Uxbridge, United Kingdom
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29
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Saenz Lafourcade C, Pinel González A, Martin Ávila G. Disimmune encephalopathy with onconeuronal antibodies in SARS-CoV-2 infected patients. Med Clin (Barc) 2021; 157:e357-e358. [PMID: 34140164 PMCID: PMC8162706 DOI: 10.1016/j.medcli.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 12/03/2022]
Affiliation(s)
| | - Ana Pinel González
- Servicio de Neurología, Hospital Universitario de Getafe, Getafe, Madrid, España
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30
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Berlit P, Frölich L, Förstl H. [The "Fourth Wave"? COVID-19 and consecutive cognitive impairment]. Dtsch Med Wochenschr 2021; 146:671-676. [PMID: 33957689 DOI: 10.1055/a-1468-1529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The COVID-19 pandemic poses new challenges for the healthcare systems world-wide which will go beyond prevention, acute and intensive care treatment of patients with severe illness. A large proportion of "COVID-survivors" - and not only elderly patients - suffers from "post-COVID-syndrome". Risk factors are preexisting somatic multimorbidity, cognitive and cerebral changes together with pneumonia and hypoxemia, intensive care treatment and confusional states during the acute phase of illness. Post-COVID cognitive deficits usually manifest as a frontal dysexecutive syndrome combined with fatigue and dysphoria and/or with attentional and memory deficits. Several pathogenetic mechanisms of COVID encephalopathy are understood, but no specific treatment strategies have been established so far. We assume that general practitioners, psychiatrists, neurologists and social workers will need to take care of the activation, reintegration and expert appraisals of patients with post-COVID fatigue and cognitive deficits during the years to come.
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Affiliation(s)
| | - Lutz Frölich
- Abteilung Gerontopsychiatrie, Zentralinstitut für Seelische Gesundheit, Mannheim
| | - Hans Förstl
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München
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31
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Giannantoni NM, Rigamonti E, Rampolli FI, Grazioli-Gauthier L, Allali G, Vanini G. Myoclonus and Cerebellar Ataxia Associated with SARS-CoV-2 Infection: Case Report and Review of the Literature. Eur J Case Rep Intern Med 2021; 8:002531. [PMID: 34123943 DOI: 10.12890/2021_002531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/16/2021] [Indexed: 12/26/2022] Open
Abstract
The current SARS-CoV-2/COVID-19 pandemic has led to a global health crisis. The clinical spectrum of SARS-CoV-2 infection ranges from asymptomatic infection to critical illness affecting almost every organ including the central and peripheral nervous systems. Myoclonus, a less expected and relatively unusual neurological complication, together with ataxia, has lately been associated with SARS-CoV-2 infection. We describe the case of a 67-year-old male patient, admitted to our hospital for interstitial bilateral pneumonia due to SARS-CoV-2 infection, who progressively developed general myoclonus and later cerebellar ataxia and gait disturbance. Given the timeline from COVID-19 systemic symptoms to neurological manifestations and the normal results of extensive and non-conclusive diagnostic work-up (blood test, lumbar puncture, EEG, cerebral MRI), a para-infectious encephalopathy related to SARS-CoV-2 was contemplated and a high dose of methylprednisolone was started with prompt symptom improvement. Further investigation and neuroepidemiological studies are needed to help define the mechanism of neuroinvasion and the entire spectrum of neurological manifestations of SARS-CoV-2 infection, even in mildly affected patients, in terms of prevention, treatment and possible neurological sequelae. LEARNING POINTS SARS-CoV-2 infection can be related to neurological symptoms and sequelae.Myoclonus, specifically when associated with ataxia, might represent the expression of COVID-19-related encephalopathy.Myoclonus associated with SARS-CoV-2 infection mostly responds to treatment with steroids.
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Affiliation(s)
| | - Elia Rigamonti
- Department of Internal Medicine, Ospedale Regionale di Lugano, Switzerland
| | | | | | - Gilles Allali
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland.,Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Gianluca Vanini
- Department of Internal Medicine, Ospedale Regionale di Lugano, Switzerland
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32
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Breville G, Adler D, Uginet M, Assal F, Tamisier R, Lalive PH, Pepin JL, Allali G. Does Endothelial Vulnerability in OSA Syndrome Promote COVID-19 Encephalopathy? Chest 2021; 160:e161-e164. [PMID: 33930384 PMCID: PMC8076771 DOI: 10.1016/j.chest.2021.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Gautier Breville
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland.
| | - Dan Adler
- Division of Pneumology, Geneva University Hospitals, Geneva, Switzerland
| | - Marjolaine Uginet
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Frederic Assal
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Renaud Tamisier
- University of Grenoble Alpes, INSERM, Genoble, France; EFCR Laboratory, Pole Thorax et Vaisseaux, Grenoble Alpes University Hospital, Genoble, France
| | - Patrice H Lalive
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland; Diagnostic Department, Division of Laboratory Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean-Louis Pepin
- Division of Pneumology, Geneva University Hospitals, Geneva, Switzerland; University of Grenoble Alpes, INSERM, Genoble, France; EFCR Laboratory, Pole Thorax et Vaisseaux, Grenoble Alpes University Hospital, Genoble, France
| | - Gilles Allali
- Department of Neurosciences, Division of Neurology, Geneva University Hospitals, Geneva, Switzerland; Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY
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33
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Uginet M, Breville G, Assal F, Lövblad KO, Vargas MI, Pugin J, Serratrice J, Herrmann FR, Lalive PH, Allali G. COVID-19 encephalopathy: Clinical and neurobiological features. J Med Virol 2021; 93:4374-4381. [PMID: 33782993 PMCID: PMC8251282 DOI: 10.1002/jmv.26973] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/13/2022]
Abstract
Severe acute respiratory coronavirus 2 (SARS-CoV-2) has been associated with neurological complications, including acute encephalopathy. To better understand the neuropathogenesis of this acute encephalopathy, we describe a series of patients with coronavirus disease 2019 (COVID-19) encephalopathy, highlighting its phenomenology and its neurobiological features. On May 10, 2020, 707 patients infected by SARS-CoV-2 were hospitalized at the Geneva University Hospitals; 31 (4.4%) consecutive patients with an acute encephalopathy (64.6 ± 12.1 years; 6.5% female) were included in this series, after exclusion of comorbid neurological conditions, such as stroke or meningitis. The severity of the COVID-19 encephalopathy was divided into severe and mild based on the Richmond Agitation Sedation Scale (RASS): severe cases (n = 14, 45.2%) were defined on a RASS < -3 at worst presentation. The severe form of this so-called COVID-19 encephalopathy presented more often a headache. The severity of the pneumonia was not associated with the severity of the COVID-19 encephalopathy: 28 of 31 (90%) patients did develop an acute respiratory distress syndrome, without any difference between groups (p = .665). Magnetic resonance imaging abnormalities were found in 92.0% (23 of 25 patients) with an intracranial vessel gadolinium enhancement in 85.0% (17 of 20 patients), while an increased cerebrospinal fluid/serum quotient of albumin suggestive of blood-brain barrier disruption was reported in 85.7% (6 of 7 patients). Reverse transcription-polymerase chain reaction for SARS-CoV-2 was negative for all patients in the cerebrospinal fluid. Although different pathophysiological mechanisms may contribute to this acute encephalopathy, our findings suggest the hypothesis of disturbed brain homeostasis and vascular dysfunction consistent with a SARS-CoV-2-induced endotheliitis.
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Affiliation(s)
- Marjolaine Uginet
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Gautier Breville
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Frédéric Assal
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Karl-Olof Lövblad
- Division of Neuroradiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Neuroradiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jérôme Pugin
- Division of Intensive Care, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jacques Serratrice
- Division of General Internal Medicine, Geneva University Hospital and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Francois R Herrmann
- Department of Rehabilitation and Geriatrics, Division of Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Patrice H Lalive
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Diagnostic Department, Division of Laboratory Medicine, Geneva University Hospital, Geneva, Switzerland.,Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Gilles Allali
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Internal Medicine, Geneva University Hospital and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York, USA
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34
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Pacheco-Herrero M, Soto-Rojas LO, Harrington CR, Flores-Martinez YM, Villegas-Rojas MM, León-Aguilar AM, Martínez-Gómez PA, Campa-Córdoba BB, Apátiga-Pérez R, Corniel-Taveras CN, Dominguez-García JDJ, Blanco-Alvarez VM, Luna-Muñoz J. Elucidating the Neuropathologic Mechanisms of SARS-CoV-2 Infection. Front Neurol 2021; 12:660087. [PMID: 33912129 PMCID: PMC8072392 DOI: 10.3389/fneur.2021.660087] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/09/2021] [Indexed: 01/08/2023] Open
Abstract
The current pandemic caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a public health emergency. To date, March 1, 2021, coronavirus disease 2019 (COVID-19) has caused about 114 million accumulated cases and 2.53 million deaths worldwide. Previous pieces of evidence suggest that SARS-CoV-2 may affect the central nervous system (CNS) and cause neurological symptoms in COVID-19 patients. It is also known that angiotensin-converting enzyme-2 (ACE2), the primary receptor for SARS-CoV-2 infection, is expressed in different brain areas and cell types. Thus, it is hypothesized that infection by this virus could generate or exacerbate neuropathological alterations. However, the molecular mechanisms that link COVID-19 disease and nerve damage are unclear. In this review, we describe the routes of SARS-CoV-2 invasion into the central nervous system. We also analyze the neuropathologic mechanisms underlying this viral infection, and their potential relationship with the neurological manifestations described in patients with COVID-19, and the appearance or exacerbation of some neurodegenerative diseases.
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Affiliation(s)
- Mar Pacheco-Herrero
- Neuroscience Research Laboratory, Faculty of Health Sciences, Pontificia Universidad Católica Madre y Maestra, Santiago de los Caballeros, Dominican Republic
| | - Luis O Soto-Rojas
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Charles R Harrington
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Yazmin M Flores-Martinez
- Programa Institucional de Biomedicina Molecular, Escuela Nacional de Medicina y Homeopatía, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Marcos M Villegas-Rojas
- Unidad Profesional Interdisciplinaria de Biotecnología del Instituto Politécnico Nacional (UPIBI- IPN), Mexico City, Mexico
| | - Alfredo M León-Aguilar
- Unidad Profesional Interdisciplinaria de Biotecnología del Instituto Politécnico Nacional (UPIBI- IPN), Mexico City, Mexico
| | - Paola A Martínez-Gómez
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - B Berenice Campa-Córdoba
- Departamento de Fisiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico.,National Dementia BioBank, Ciencias Biológicas, Facultad de Estudios Superiores, Cuautitlán, Mexico
| | - Ricardo Apátiga-Pérez
- Departamento de Fisiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico.,National Dementia BioBank, Ciencias Biológicas, Facultad de Estudios Superiores, Cuautitlán, Mexico
| | - Carolin N Corniel-Taveras
- Neuroscience Research Laboratory, Faculty of Health Sciences, Pontificia Universidad Católica Madre y Maestra, Santiago de los Caballeros, Dominican Republic
| | - Jesabelle de J Dominguez-García
- Neuroscience Research Laboratory, Faculty of Health Sciences, Pontificia Universidad Católica Madre y Maestra, Santiago de los Caballeros, Dominican Republic
| | | | - José Luna-Muñoz
- National Dementia BioBank, Ciencias Biológicas, Facultad de Estudios Superiores, Cuautitlán, Mexico.,Banco Estado de Cerebros-UNPHU, Universidad Nacional Pedro Henriquez Ureña, Santo Domingo, Dominican Republic
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35
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Stracciari A, Bottini G, Guarino M, Magni E, Pantoni L. Cognitive and behavioral manifestations in SARS-CoV-2 infection: not specific or distinctive features? Neurol Sci 2021; 42:2273-2281. [PMID: 33846880 PMCID: PMC8040761 DOI: 10.1007/s10072-021-05231-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/06/2021] [Indexed: 01/08/2023]
Abstract
Patients with COVID-19 are increasingly reported to suffer from a wide range of neurological complications, affecting both the central and peripheral nervous system. Among central manifestations, cognitive and behavioral symptoms are to date not exhaustively detailed. Furthermore, it is not clear whether these represent a combination of non-specific complications of a severe systemic disease, not differing from those usually seen in patients suffering from heterogenous pathological conditions affecting the central nervous system, or instead, they are a peculiar expression of COVID-19 neurotropism; in other words, if the infection has a coincidental or causal role in such patients. We examined both hypotheses, reporting opposite points of view, with the aim to stimulate discussion and raise awareness of the topic.
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Affiliation(s)
- Andrea Stracciari
- University of Bologna, Bologna, Italy. .,Chair of the "Cognitive and Behavioral Neurology" Study Group of the Italian Neurological Society, Bologna, Italy.
| | - Gabriella Bottini
- Neuroscience and Society Lab, Brain and Behavioral Sciences Department, University of Pavia, Pavia, Italy.,Cognitive Neuropsychology Center, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Eugenio Magni
- Department of Neuroscience, "Poliambulanza" Foundation, Brescia, Italy
| | - Leonardo Pantoni
- Stroke and Dementia Lab, "Luigi Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Milano, Italy
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36
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Pensato U, Muccioli L, Cani I, Janigro D, Zinzani PL, Guarino M, Cortelli P, Bisulli F. Brain dysfunction in COVID-19 and CAR-T therapy: cytokine storm-associated encephalopathy. Ann Clin Transl Neurol 2021; 8:968-979. [PMID: 33780166 PMCID: PMC8045903 DOI: 10.1002/acn3.51348] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Many neurological manifestations are associated with COVID-19, including a distinct form of encephalopathy related to cytokine storm, the acute systemic inflammatory syndrome present in a subgroup of COVID-19 patients. Cytokine storm is also associated with immune effector cell-associated neurotoxicity syndrome (ICANS), a complication of chimeric antigen receptor T-cell (CAR-T) therapy, a highly effective treatment for refractory hematological malignancies. We investigated whether COVID-19-related encephalopathy, ICANS, and other encephalopathies associated with cytokine storm, share clinical and investigative findings. METHODS Narrative literature review. RESULTS Comparisons between COVID-19-related encephalopathy and ICANS revealed several overlapping features. Clinically, these included dysexecutive syndrome, language disturbances, akinetic mutism and delirium. EEG showed a prevalence of frontal abnormalities. Brain MRI was often unrevealing. CSF elevated cytokine levels have been reported. A direct correlation between cytokine storm intensity and severity of neurological manifestations has been shown for both conditions. Clinical recovery occurred spontaneously or following immunotherapies in most of the patients. Similar clinical and investigative features were also reported in other encephalopathies associated with cytokine storm, such as hemophagocytic lymphohistiocytosis, sepsis, and febrile infection-associated encephalopathies. INTERPRETATION COVID-19-related encephalopathy and ICANS are characterized by a predominant electro-clinical frontal lobe dysfunction and share several features with other encephalopathies associated with cytokine storm, which may represent the common denominator of a clinical spectrum of neurological disorders. Therefore, we propose a unifying definition of cytokine storm-associated encephalopathy (CySE), and its diagnostic criteria.
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Affiliation(s)
- Umberto Pensato
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Lorenzo Muccioli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Ilaria Cani
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Damir Janigro
- Department of Physiology, Case Western Reserve University, Cleveland, OH, USA
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Istituto di Ematologia "Seragnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Pietro Cortelli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesca Bisulli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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37
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Uginet M, Breville G, Hofmeister J, Machi P, Lalive PH, Rosi A, Fitsiori A, Vargas MI, Assal F, Allali G, Lovblad KO. Cerebrovascular Complications and Vessel Wall Imaging in COVID-19 Encephalopathy-A Pilot Study. Clin Neuroradiol 2021; 32:287-293. [PMID: 33770199 PMCID: PMC7995679 DOI: 10.1007/s00062-021-01008-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/26/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with several complications of the central nervous system (CNS), including acute encephalopathy. METHODS In this pilot study, we report a series of 39 patients (66.5 ± 9.2 years; 10.3% female) with acute encephalopathy, who underwent a standard brain magnetic resonance imaging (MRI) at 1.5 T during the acute symptomatic phase. In addition to diffusion-weighted imaging, MR angiography and susceptibility-weighted images, high-resolution vascular black blood sequences (in 34 cases) were used to investigate the vasculature of the brain. RESULTS In 29 out of 34 patients with COVID-19 encephalopathy (85%) with high-resolution vessel wall imaging, we found a circular enhancement and thickening of the basilar and vertebral arteries, without any correlation with ischemia or microbleeds (reported in 21% and 59%, respectively). CONCLUSION We report a high prevalence of vascular changes suggestive of endotheliitis as reported in other organs. This could suggest an inflammatory mechanism underlying this encephalopathy.
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Affiliation(s)
- Marjolaine Uginet
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland
| | - Gautier Breville
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland
| | - Jérémy Hofmeister
- Division of Neuroradiology, Diagnostic Department, Geneva University Hospitals, 1211, Geneva, Switzerland
| | - Paolo Machi
- Division of Neuroradiology, Diagnostic Department, Geneva University Hospitals, 1211, Geneva, Switzerland
| | - Patrice H Lalive
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland
| | - Andrea Rosi
- Division of Neuroradiology, Diagnostic Department, Geneva University Hospitals, 1211, Geneva, Switzerland
| | - Aikaterini Fitsiori
- Division of Neuroradiology, Diagnostic Department, Geneva University Hospitals, 1211, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Neuroradiology, Diagnostic Department, Geneva University Hospitals, 1211, Geneva, Switzerland
| | - Frederic Assal
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland
| | - Gilles Allali
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland.,Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Karl-Olof Lovblad
- Division of Neuroradiology, Diagnostic Department, Geneva University Hospitals, 1211, Geneva, Switzerland.
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Affiliation(s)
- Julie G Shulman
- Department of Neurology, Boston University School of Medicine, 72 East Concord Street, Suite C3, Boston, MA 02118, USA.
| | - Thomas Ford
- Department of Neurology, Boston University School of Medicine, 72 East Concord Street, Suite C3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Department of Neurology, Boston University School of Medicine, 72 East Concord Street, Suite C3, Boston, MA 02118, USA; Department of Neurosurgery, Boston University School of Medicine, 725 Albany St, Suite 7C, Boston, MA 02118, USA; Department of Medicine (Infectious Diseases), Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown, 2nd floor, Boston MA 02118, USA
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Tandon M, Kataria S, Patel J, Mehta TR, Daimee M, Patel V, Prasad A, Chowdhary AA, Jaiswal S, Sriwastava S. A Comprehensive Systematic Review of CSF analysis that defines Neurological Manifestations of COVID-19. Int J Infect Dis 2021; 104:390-397. [PMID: 33434662 PMCID: PMC7837002 DOI: 10.1016/j.ijid.2021.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/28/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Limited literature exists on Cerebrospinal fluid (CSF) findings in COVID-19 patients with neurological symptoms. In this review, we conducted a descriptive analysis of CSF findings in patients with COVID-19 to understand prognosis and explore therapeutic options. METHODS We searched PubMed, Google Scholar, and Scopus databases using the keywords "SARS-CoV-2 in cerebrospinal fluid" and "SARS-CoV-2 and CNS Complications"" for reports of CSF findings in COVID-19 related neurological manifestations. Descriptive analyses were conducted to observe the CSF protein and cell counts based on age, gender, severity, fatality of COVID-19, and whether central (CNS) or peripheral nervous system (PNS) was associated. RESULTS A total of 113 patients were identified from 67 studies. Of these, 7 patients (6.2%) were fatal COVID-19 cases and 35 patients (31%) were considered severe COVID-19 cases. CSF protein was elevated in 100% (7/7) of the fatal cases with an average of 61.28 mg/dl and in 65.0% (52/80) in non-fatal cases with an average 56.73 mg/dl. CSF protein levels were elevated in 74.5% (38/51) patients with non-severe COVID-19 and 68.6% (24/35) in those with a severe COVID-19 infection. CSF cell count was increased in 43% of fatal cases, 25.7% severe cases, and 29.4% of non-severe cases. CONCLUSION Our analysis showed that the most common CSF findings situation in COVID-19 infection is elevated protein with, very occasionally, mild lymphocyte predominant pleocytosis. Further studies to elucidate the pathophysiology of neurological complications in COVID-19 are recommended.
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Affiliation(s)
| | - Saurabh Kataria
- Department of Neurology, University of Missouri Healthcare at Columbia, MO, United States
| | - Jenil Patel
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas Medical Sciences at Little Rock, AR, United States
| | - Tejas R Mehta
- Department of Neurology, University of Missouri Healthcare at Columbia, MO, United States
| | - Maha Daimee
- Department of Neurology, MedStar Georgetown University, Washington, DC, United States
| | - Viral Patel
- Jefferson Medical Center, West Virginia University, United States
| | - Apoorv Prasad
- Berkley Medical Center, West Virginia University, School of Medicine, Morgantown, WV, United States
| | | | - Shruti Jaiswal
- West Virginia Clinical and Translational Science Institute, United States
| | - Shitiz Sriwastava
- West Virginia Clinical and Translational Science Institute, United States; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States; Department of Neurology, Wayne State University, Detroit, MI, United States.
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Vellieux G, Sonneville R, Vledouts S, Jaquet P, Rouvel-Tallec A, d’Ortho MP. COVID-19-Associated Neurological Manifestations: An Emerging Electroencephalographic Literature. Front Physiol 2021; 11:622466. [PMID: 33679425 PMCID: PMC7933549 DOI: 10.3389/fphys.2020.622466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/29/2020] [Indexed: 02/02/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide since the end of year 2019 and is currently responsive for coronavirus infectious disease 2019 (COVID-19). The first reports considered COVID-19 as a respiratory tract disease responsible for pneumonia, but numerous studies rapidly emerged to warn the medical community of COVID-19-associated neurological manifestations, including encephalopathy at the acute phase and other postinfectious manifestations. Using standard visual analysis or spectral analysis, recent studies reported electroencephalographic (EEG) findings of COVID-19 patients with various neurological symptoms. Most EEG recordings were normal or revealed non-specific abnormalities, such as focal or generalized slowing, interictal epileptic figures, seizures, or status epilepticus. Interestingly, novel EEG abnormalities over frontal areas were also described at the acute phase. Underlying mechanisms leading to brain injury in COVID-19 are still unknown and matters of debate. These frontal EEG abnormalities could emphasize the hypothesis whereby SARS-CoV-2 enters the central nervous system (CNS) through olfactory structures and then spreads in CNS via frontal lobes. This hypothesis is reinforced by the presence of anosmia in a significant proportion of COVID-19 patients and by neuroimaging studies confirming orbitofrontal abnormalities. COVID-19 represents a new viral disease characterized by not only respiratory symptoms but also a systemic invasion associated with extra-respiratory signs. Neurological symptoms must be the focus of our attention, and functional brain evaluation with EEG is crucial, in combination with anatomical and functional brain imaging, to better understand its pathophysiology. Evolution of symptoms together with EEG patterns at the distance of the acute episode should also be scrutinized.
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Affiliation(s)
- Geoffroy Vellieux
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Romain Sonneville
- Médecine Intensive-Réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, UMR 1148, LVTS, Paris, France
| | - Sérafima Vledouts
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Pierre Jaquet
- Médecine Intensive-Réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, UMR 1148, LVTS, Paris, France
| | - Anny Rouvel-Tallec
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Marie-Pia d’Ortho
- Université de Paris, NeuroDiderot, Inserm, Paris, France
- Neurophysiologie clinique, Service de Physiologie – Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
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Abstract
Anosmia, encephalopathy and stroke are the most common neurological syndromes associated with SARS-CoV-2 infection1, though many others have been reported. Analysis of human biopsy samples suggests that anosmia results predominantly from SARS-CoV-2 infection of non-neuronal cells in the olfactory epithelium and olfactory bulb2, leading to local inflammation and neuronal malfunction. A high proportion of patients admitted to intensive care units with COVID-19 develop delirium, and evidence suggests that this is caused by microvascular and inflammatory mechanisms3. Autopsy data show activation of astrocytes and microglia in COVID-19, particularly in the brainstem, where there is also infiltration of cytotoxic T cells7,9. SARS-CoV-2 can be detected in the brain with PCR and immunohistochemistry, but the evidence to date suggests it is mostly in vascular and immune cells rather than directly infecting neurons7,9.
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Affiliation(s)
- Tom Solomon
- Health Protection Research Unit in Emerging and Zoonotic Infections, National Institute for Health Research, Institute of Infection Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK. .,The Walton Centre NHS Foundation Trust, Liverpool, UK.
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Stancu P, Uginet M, Assal F, Allali G, Lovblad KO. COVID-19 associated stroke and cerebral endotheliitis. J Neuroradiol 2021; 48:291-292. [PMID: 33549612 PMCID: PMC7860935 DOI: 10.1016/j.neurad.2021.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Patrick Stancu
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland
| | - Marjolaine Uginet
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland
| | - Frederic Assal
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland
| | - Gilles Allali
- Division of Neurology, Clinical Neurosciences Department, Geneva University Hospitals, Geneva, Switzerland; Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Karl-Olof Lovblad
- Division of Neuroradiology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland.
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Abstract
In global term, as of November 30, 2020, over 30 million people has been infected by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and more than 10,000,000 of them died of acute organ failure. Our reviews have shown that coronavirus disease 2019 (COVID-19) patients with pneumonia and acute respiratory distress syndrome (ARDS) have life-threatening acute brain dysfunction (ABD), ranging from altered mental status/delirium to stupor/coma. Altered mental status/delirium was the most common manifestation of ABD caused by severe COVID-19. The prevalence of altered mental status and/or delirium was up to 66-79.5%, and prevalence of coma was 10%. The most common clinical type of COVID-19-associated ABD was COVID-19-associated acute stroke including ischemic and hemorrhagic stroke (n > 350 cases), followed by COVID-19-associated encephalopathy (n > 200 cases), and COVID-19-associated central nervous system (CNS) infection (n > 70 cases). According to the Sepsis-3 criteria, we confess that severe COVID-19-associated ABD with ARDS and altered mental status is related to sepsis. Moreover, we also review the diagnosis and treatment of COVID-19-associated ABD with sepsis. In view of the fact that COVID-19 is at the peak of epidemic worldwide, we hope that this review will provide evidence of COVID-19 sepsis threating to the brain dysunction. Thus, recognizing the COVID-19-associated ABD related to sepsis is very important for early empirical combination therapy to survive severe COVID-19.
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Affiliation(s)
- Dao Ming Tong
- Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Ye Ting Zhou
- Department of Surgery, Affiliated Shuyang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Yuan Wei Wang
- Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Jiangsu, China
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Bodro M, Compta Y, Sánchez-Valle R. Presentations and mechanisms of CNS disorders related to COVID-19. Neurol Neuroimmunol Neuroinflamm 2021; 8:e923. [PMID: 33310765 PMCID: PMC7808129 DOI: 10.1212/nxi.0000000000000923] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/29/2020] [Indexed: 12/24/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of the coronavirus disease 2019 (COVID-19) pandemic. In addition to severe respiratory symptoms, there are a growing number of reports showing a wide range of CNS complications in patients with COVID-19. Here, we review the literature on these complications, ranging from nonspecific symptoms to necrotizing encephalopathies, encephalitis, myelitis, encephalomyelitis, endotheliitis, and stroke. We postulate that there are several different mechanisms involved in COVID-19-associated CNS dysfunction, particularly activation of inflammatory and thrombotic pathways and, in a few patients, a direct viral effect on the endothelium and the parenchyma. Last, critically ill patients frequently present with protracted cognitive dysfunction in the setting of septic encephalopathy likely due to multifactorial mechanisms. Further studies are needed to clarify the relative contribution of each of these mechanisms, but available data suggest that CNS complications in COVID-19 are rare and probably not directly caused by the virus.
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Affiliation(s)
- Marta Bodro
- From the Infectious Diseases Department (M.B.), Hospital Clínic de Barcelona, Catalonia; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.B., Y.C., R.S.-V.), Barcelona; Department of Medicine (M.B., Y.C., R.S.-V.), Universitat de Barcelona; Neurology Department (Y.C., R.S.-V.), Hospital Clínic de Barcelona; and Institut de Neurociències (Y.C., R.S.-V.), Maria de Maeztu Excellence Center, Universitat de Barcelona, Catalonia, Spain
| | - Yaroslau Compta
- From the Infectious Diseases Department (M.B.), Hospital Clínic de Barcelona, Catalonia; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.B., Y.C., R.S.-V.), Barcelona; Department of Medicine (M.B., Y.C., R.S.-V.), Universitat de Barcelona; Neurology Department (Y.C., R.S.-V.), Hospital Clínic de Barcelona; and Institut de Neurociències (Y.C., R.S.-V.), Maria de Maeztu Excellence Center, Universitat de Barcelona, Catalonia, Spain.
| | - Raquel Sánchez-Valle
- From the Infectious Diseases Department (M.B.), Hospital Clínic de Barcelona, Catalonia; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (M.B., Y.C., R.S.-V.), Barcelona; Department of Medicine (M.B., Y.C., R.S.-V.), Universitat de Barcelona; Neurology Department (Y.C., R.S.-V.), Hospital Clínic de Barcelona; and Institut de Neurociències (Y.C., R.S.-V.), Maria de Maeztu Excellence Center, Universitat de Barcelona, Catalonia, Spain
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Maury A, Lyoubi A, Peiffer-Smadja N, de Broucker T, Meppiel E. Neurological manifestations associated with SARS-CoV-2 and other coronaviruses: A narrative review for clinicians. Rev Neurol (Paris) 2021; 177:51-64. [PMID: 33446327 PMCID: PMC7832485 DOI: 10.1016/j.neurol.2020.10.001] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The past two decades have been marked by three epidemics linked to emerging coronaviruses. The COVID-19 pandemic highlighted the existence of neurological manifestations associated with SARS-CoV-2 infection and raised the question of the neuropathogenicity of coronaviruses. The aim of this review was to summarize the current data about neurological manifestations and diseases linked to human coronaviruses. MATERIAL AND METHODS Articles have been identified by searches of PubMed and Google scholar up to September 25, 2020, using a combination of coronavirus and neurology search terms and adding relevant references in the articles. RESULTS We found five cohorts providing prevalence data of neurological symptoms among a total of 2533 hospitalized COVID-19 patients, and articles focusing on COVID-19 patients with neurological manifestations including a total of 580 patients. Neurological symptoms involved up to 73% of COVID-19 hospitalized patients, and were mostly headache, myalgias and impaired consciousness. Central nervous system (CNS) manifestations reported in COVID-19 were mostly non-specific encephalopathies that represented between 13% and 40% of all neurological manifestations; post-infectious syndromes including acute demyelinating encephalomyelitis (ADEM, n=13), acute necrotizing encephalopathy (ANE, n=4), Bickerstaff's encephalitis (n=5), generalized myoclonus (n=3) and acute transverse myelitis (n=7); other encephalitis including limbic encephalitis (n=9) and miscellaneous encephalitis with variable radiologic findings (n=26); acute cerebrovascular diseases including ischemic strokes (between 1.3% and 4.7% of COVID-19 patients), hemorrhagic strokes (n=17), cerebral venous thrombosis (n=8) and posterior reversible encephalopathy (n=5). Peripheral nervous system (PNS) manifestations reported in COVID-19 were the following: Guillain-Barré syndrome (n=31) and variants including Miller Fisher syndrome (n=3), polyneuritis cranialis (n=2) and facial diplegia (n=2); isolated oculomotor neuropathy (n=6); critical illness myopathy (n=6). Neuropathological studies in COVID-19 patients demonstrated different patterns of CNS damage, mostly ischemic and hemorrhagic changes with few cases of inflammatory injuries. Only one case suggested SARS-CoV-2 infiltration in endothelial and neural cells. We found 10 case reports or case series describing 22 patients with neurological manifestations associated with other human coronaviruses. Among them we found four MERS patients with ADEM or Bickerstaff's encephalitis, two SARS patients with encephalitis who had a positive SARS-CoV PCR in cerebrospinal fluid, five patients with ischemic strokes associated with SARS, eight MERS patients with critical illness neuromyopathy and one MERS patient with Guillain-Barré Syndrome. An autopsy study on SARS-CoV patients demonstrated the presence of the virus in the brain of eight patients. CONCLUSION The wide range of neurological manifestations and diseases associated with SARS-CoV-2 is consistent with multiple pathogenic pathways including post-infectious mechanisms, septic-associated encephalopathies, coagulopathy or endothelitis. There was no definite evidence to support direct neuropathogenicity of SARS-CoV-2.
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Affiliation(s)
- A Maury
- Department of Neurology, centre hospitalier de Saint-Denis, hôpital Delafontaine, 93200 Saint-Denis, France
| | - A Lyoubi
- Department of Neurology, centre hospitalier de Saint-Denis, hôpital Delafontaine, 93200 Saint-Denis, France
| | - N Peiffer-Smadja
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK; Inserm, IAME, Université de Paris, 75018 Paris, France; Infectious and Tropical Diseases Department, Bichat-Claude-Bernard Hospital, AP-HP, 75018 Paris, France
| | - T de Broucker
- Department of Neurology, centre hospitalier de Saint-Denis, hôpital Delafontaine, 93200 Saint-Denis, France
| | - E Meppiel
- Department of Neurology, centre hospitalier de Saint-Denis, hôpital Delafontaine, 93200 Saint-Denis, France.
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Anand P, Zhou L, Bhadelia N, Hamer DH, Greer DM, Cervantes-Arslanian AM. Neurologic Findings Among Inpatients With COVID-19 at a Safety-net US Hospital. Neurol Clin Pract 2020; 11:e83-e91. [PMID: 33842075 DOI: 10.1212/cpj.0000000000001031] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/02/2020] [Indexed: 12/18/2022]
Abstract
Objective To characterize the breadth of neurologic findings associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a diverse group of inpatients at an urban, safety-net US medical center. Methods Patients were identified through an electronic medical record review from April 15, 2020, until July 1, 2020, at a large safety-net hospital in Boston, MA, caring primarily for underserved, low-income, and elderly patients. All hospitalized adult patients with positive nasopharyngeal swab or respiratory PCR testing for SARS-CoV-2 during their hospitalization or in the 30 days before admission who received an inpatient neurologic or neurocritical care consultation or admission during the study period were enrolled. Results Seventy-four patients were identified (42/57% male, median age 64 years). The majority of patients self-identified as Black or African American (38, 51%). The most common neurologic symptoms at presentation to the hospital included altered mental status (39, 53%), fatigue (18, 24%), and headache (18, 18%). Fifteen patients had ischemic strokes (20%). There were 10 in-hospital mortalities, with moderately severe disability among survivors at discharge (14%, median modified Rankin Scale score of 4). Conclusions Neurologic findings spanned inflammatory, vascular pathologies, sequelae of critical illness and metabolic derangements, possible direct involvement of the nervous system by SARS-CoV-2, and exacerbation of underlying neurologic conditions, highlighting a broad range of possible etiologies of neurologic complications in patients with coronavirus disease 2019 (COVID-19). Further studies are needed to characterize the infectious and postinfectious neurologic complications of COVID-19 in diverse patient populations.
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Affiliation(s)
- Pria Anand
- Boston University Medical Center (PA); and Boston University School of Medicine (LZ, NB, DHH, DMG, AMC-A), MA
| | - Lan Zhou
- Boston University Medical Center (PA); and Boston University School of Medicine (LZ, NB, DHH, DMG, AMC-A), MA
| | - Nahid Bhadelia
- Boston University Medical Center (PA); and Boston University School of Medicine (LZ, NB, DHH, DMG, AMC-A), MA
| | - Davidson H Hamer
- Boston University Medical Center (PA); and Boston University School of Medicine (LZ, NB, DHH, DMG, AMC-A), MA
| | - David M Greer
- Boston University Medical Center (PA); and Boston University School of Medicine (LZ, NB, DHH, DMG, AMC-A), MA
| | - Anna M Cervantes-Arslanian
- Boston University Medical Center (PA); and Boston University School of Medicine (LZ, NB, DHH, DMG, AMC-A), MA
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Abstract
The main objective of this study was to evaluate the retinas of severely or critically ill COVID-19 patients during their hospital stay, at varying time points after symptoms onset. This was a case series observed during May 2020 in two referral centers for COVID-19 treatment in Rio de Janeiro, Brazil. 47 eyes from 25 hospitalized patients with severe or critical confirmed illness were evaluated. A handheld retinal camera was used to acquire bilateral fundus images at several time points after symptoms onset. Electronic health records were retrospectively analyzed and clinical data collected. Severe and critical diseases were noticed in 52% (13/25) and 48% (12/25) of enrolled patients, respectively. Retinal changes were present in 12% (3/25) of patients: a 35 year-old male demonstrated bilateral nerve fiber layer infarcts and microhemorrhages in the papillomacular bundle, but required mechanical ventilation and developed severe anemia and systemic hypotension, acute kidney injury and neurologic symptoms during the course of the disease (critical illness); a 56 year-old male, who required full enoxaparin anticoagulation due to particularly elevated D-dimer (>5.0 mcg/mL), demonstrated unilateral and isolated flame-shaped hemorrhages; and a 49 year-old hypertensive male showed bilateral and discrete retinal dot and blot microhemorrhages. The other 22 patients evaluated did not demonstrate convincing retinal changes upon examination. There was no correlation between disease severity and admission serum levels of CRP, D-dimer and ferritin. This was the first study to show that vascular retinal changes may be present in not insignificant numbers of severe or critical COVID-19 inpatients. These retinal changes, only seen after morbid developments, were likely secondary to clinical intercurrences or comorbidities instead of a direct damage by SARS-CoV-2, and may be important and easily accessible outcome measures of therapeutic interventions and sentinels of neurologic and systemic diseases during COVID-19 pandemic.
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Affiliation(s)
- Rafael Lani-Louzada
- Hospital Nossa Senhora da Saúde, Santa Casa da Misericórdia do Rio de Janeiro (Hospital da Gamboa), Instituto de Oftalmologia do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Ricardo Mello Cordeiro
- Departamento de Clínica Médica, Hospital de Clínicas de Jacarepaguá, Rio de Janeiro, Rio de Janeiro, Brazil
- Departamento de Clínica Médica, Hospital de Clínicas Mário Lioni, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alfredo A. Sadun
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Doheny Eye Institute, Los Angeles, California, United States of America
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Pensato U, Muccioli L, Pasini E, Tappatà M, Ferri L, Volpi L, Licchetta L, Battaglia S, Rossini G, Bon I, Re MC, Cirillo L, Simonetti L, Gramegna LL, Michelucci R, Cortelli P, Zini A, Bisulli F. Encephalopathy in COVID-19 Presenting With Acute Aphasia Mimicking Stroke. Front Neurol 2020; 11:587226. [PMID: 33193051 PMCID: PMC7604480 DOI: 10.3389/fneur.2020.587226] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/24/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction: Neurological manifestations are emerging as relatively frequent complications of corona virus disease 2019 (COVID-19), including stroke and encephalopathy. Clinical characteristics of the latter are heterogeneous and not yet fully elucidated, while the pathogenesis appears related to neuroinflammation in a subset of patients. Case: A middle-aged man presented with acute language disturbance at the emergency department. Examination revealed expressive aphasia, mild ideomotor slowing, and severe hypocapnic hypoxemia. Multimodal CT assessment and electroencephalogram (EEG) did not reveal any abnormalities. COVID-19 was diagnosed based on chest CT findings and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription PCR (RT-PCR) on nasopharyngeal swab. The following day, neurological symptoms progressed to agitated delirium and respiratory status worsened, requiring admission to the ICU and mechanical ventilation. Brain MRI and cerebrospinal fluid (CSF) studies were unremarkable. RT-PCR for SARS-CoV-2 on CSF was negative. He received supportive treatment and intravenous low-dose steroids. His neurological and respiratory status resolved completely within 2 weeks. Conclusions: We report a patient with reversible COVID-19-related encephalopathy presenting as acute aphasia, mimicking stroke or status epilepticus, eventually evolving into delirium. Although large-vessel stroke is frequently encountered in COVID-19, our case suggests that focal neurological deficits may occur as the earliest feature of encephalopathy. Neurological status reversibility and the absence of abnormalities on brain MRI are consistent with a functional rather than a structural neuronal network impairment.
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Affiliation(s)
- Umberto Pensato
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Lorenzo Muccioli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Elena Pasini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Maria Tappatà
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Lorenzo Ferri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Lilia Volpi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Laura Licchetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Stella Battaglia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Giada Rossini
- Microbiology Unit, DIMES, University of Bologna, Bologna, Italy
| | - Isabella Bon
- Microbiology Unit, DIMES, University of Bologna, Bologna, Italy
| | - Maria Carla Re
- Microbiology Unit, DIMES, University of Bologna, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Luigi Simonetti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | | | | | - Pietro Cortelli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
| | - Francesca Bisulli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy‡
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49
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Muccioli L, Pensato U, Bernabè G, Ferri L, Tappatà M, Volpi L, Cani I, Henry OJ, Ceccaroni F, Cevoli S, Stofella G, Pasini E, Fornaro G, Tonon C, Vidale S, Liguori R, Tinuper P, Michelucci R, Cortelli P, Bisulli F. Intravenous immunoglobulin therapy in COVID-19-related encephalopathy. J Neurol 2020; 268:2671-2675. [PMID: 33030607 PMCID: PMC7543032 DOI: 10.1007/s00415-020-10248-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/17/2020] [Accepted: 09/19/2020] [Indexed: 12/15/2022]
Abstract
Objective To report on efficacy and safety of intravenous immunoglobulin (IVIg) therapy in a case series of patients with COVID-19-related encephalopathy. Methods We retrospectively collected data on all patients with COVID-19 hospitalized at two Italian hospitals who developed encephalopathy during disease course and were treated with IVIg. Results Five patients (two females, mean age 66.8 years) developed encephalopathy after a mean of 12.6 days, since the onset of respiratory/constitutional symptoms related to COVID-19. Four patients suffered severe respiratory distress, three of which required invasive mechanical ventilation. Neurological manifestations included impaired consciousness, agitation, delirium, pyramidal and extrapyramidal signs. EEG demonstrated diffuse slowing in all patients. Brain MRI showed non-specific findings. CSF analysis revealed normal cell count and protein levels. In all subjects, RT-PCR for SARS-CoV-2 in CSF tested negative. IVIg at 0.4 g/kg/die was commenced 29.8 days (mean, range: 19–55 days) after encephalopathy onset, leading to complete electroclinical recovery in all patients, with an initial improvement of neuropsychiatric symptoms observed in 3.4 days (mean, range: 1–10 days). No adverse events related to IVIg were observed. Conclusions Our preliminary findings suggest that IVIg may represent a safe and effective treatment for COVID-19-associated encephalopathy. Clinical efficacy may be driven by the anti-inflammatory action of IVIg, associated with its anti-cytokine qualities. Electronic supplementary material The online version of this article (10.1007/s00415-020-10248-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lorenzo Muccioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy
| | - Umberto Pensato
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy
| | | | - Lorenzo Ferri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy
| | - Maria Tappatà
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lilia Volpi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Ilaria Cani
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy
| | | | | | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Gloria Stofella
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Elena Pasini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giacomo Fornaro
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Pietro Cortelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesca Bisulli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bellaria Hospital, Via Altura 3 40139, Bologna, Italy. .,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
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50
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Azizi SA, Azizi SA. Neurological injuries in COVID-19 patients: direct viral invasion or a bystander injury after infection of epithelial/endothelial cells. J Neurovirol 2020; 26:631-641. [PMID: 32876900 PMCID: PMC7465881 DOI: 10.1007/s13365-020-00903-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/11/2020] [Accepted: 08/24/2020] [Indexed: 02/06/2023]
Abstract
A subset of patients with coronavirus 2 disease (COVID-19) experience neurological complications. These complications include loss of sense of taste and smell, stroke, delirium, and neuromuscular signs and symptoms. The etiological agent of COVID-19 is SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), an RNA virus with a glycoprotein-studded viral envelope that uses ACE2 (angiotensin-converting enzyme 2) as a functional receptor for infecting the host cells. Thus, the interaction of the envelope spike proteins with ACE2 on host cells determines the tropism and virulence of SARS-CoV-2. Loss of sense of taste and smell is an initial symptom of COVID-19 because the virus enters the nasal and oral cavities first and the epithelial cells are the receptors for these senses. Stroke in COVID-19 patients is likely a consequence of coagulopathy and injury to cerebral vascular endothelial cells that cause thrombo-embolism and stroke. Delirium and encephalopathy in acute and post COVID-19 patients are likely multifactorial and secondary to hypoxia, metabolic abnormalities, and immunological abnormalities. Thus far, there is no clear evidence that coronaviruses cause inflammatory neuromuscular diseases via direct invasion of peripheral nerves or muscles or via molecular mimicry. It appears that most of neurologic complications in COVID-19 patients are indirect and as a result of a bystander injury to neurons.
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Affiliation(s)
- Sayed Ausim Azizi
- Global Neuroscience Institute, 1 Medical Center Blvd., Chester, PA, 19013, USA.
| | - Saara-Anne Azizi
- Pritzker School of Medicine, University of Chicago, Chicago, USA
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