Neurological associations of COVID-19
Journal: 2020/July - The Lancet Neurology
Abstract:
Background: The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might be expected to be rare.
Recent developments: A growing number of case reports and series describe a wide array of neurological manifestations in 901 patients, but many have insufficient detail, reflecting the challenge of studying such patients. Encephalopathy has been reported for 93 patients in total, including 16 (7%) of 214 hospitalised patients with COVID-19 in Wuhan, China, and 40 (69%) of 58 patients in intensive care with COVID-19 in France. Encephalitis has been described in eight patients to date, and Guillain-Barré syndrome in 19 patients. SARS-CoV-2 has been detected in the CSF of some patients. Anosmia and ageusia are common, and can occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 2-6% of patients hospitalised with COVID-19. So far, 96 patients with stroke have been described, who frequently had vascular events in the context of a pro-inflammatory hypercoagulable state with elevated C-reactive protein, D-dimer, and ferritin. WHERE NEXT?: Careful clinical, diagnostic, and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease (eg, hypoxic encephalopathy and critical care neuropathy) from those caused directly or indirectly by the virus, including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barré syndrome. Recognition of neurological disease associated with SARS-CoV-2 in patients whose respiratory infection is mild or asymptomatic might prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will probably remain small. However, these patients might be left with severe neurological sequelae. With so many people infected, the overall number of neurological patients, and their associated health burden and social and economic costs might be large. Health-care planners and policy makers must prepare for this eventuality, while the many ongoing studies investigating neurological associations increase our knowledge base.
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Neurological associations of COVID-19

Supplementary Material

Supplementary appendix:

National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
The Walton Centre National Health Service (NHS) Foundation Trust, Liverpool, UK
Queen Square Institute of Neurology, University College London, London, UK
Tropical and Infectious Diseases Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
Christian Medical College, Vellore, India
Encephalitis Society, Malton, UK
Alder Hey Children's NHS Foundation Trust, Liverpool, UK
Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
Tom Solomon: ku.ca.looprevil@nomolost
Correspondence to: Prof Tom Solomon, National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 7BE, UK ku.ca.looprevil@nomolost
Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

Calculated using data available up to May 19, 2020. COVID-19 cases based on Johns Hopkins COVID-19 Dashboard. 95% CI calculated with Clopper-Pearson exact method24 for proportions using Ausvet Epitools. SARS=severe acute respiratory syndrome. MERS=Middle East respiratory syndrome. PNS=peripheral nervous system.

Provisional case definitions for the association of COVID-19 with neurological disease

A full version of this table is provided in the appendix (pp 13–23); the studies included here are those that more comprehensively reported patient data or reported novel findings. SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. HSV=herpes simplex virus. VZV=varicella zoster virus. CRP=C-reactive protein. ICU=intensive care unit. PaO2=partial pressure of oxygen. PCO2=partial pressure of carbon dioxide. LDH=lactate dehydrogenase. MOG=myelin oligodendrocyte glycoprotein. NR=not reported. WNV=West Nile virus. FLAIR=fluid-attenuated inversion recovery. HHV=human herpes virus. EBV=Epstein-Barr virus. CMV=cytomegalovirus. RSV=respiratory syncytial virus. LDH=lactate dehydrogenase. GCS=Glasgow Coma Scale.

Contributors

MAE, BDM, JS, and TS devised the idea for this Rapid Review. MAE, LB, BS, SL, BDM, RK, SD, JS, and TS contributed to the literature search. MAE, LB, BS, SL, BDM, and TS designed and drafted the figures. MAE, LB, BS, SL, BDM, RK, SD, JS, and TS prepared the initial manuscript draft. All authors contributed to, reviewed, and approved the final draft of the paper.

Contributors

Declaration of interests

TS was an adviser to the GlaxoSmithKline Ebola Vaccine programme, chaired a Siemens Diagnostics clinical advisory board, and advises the WHO Brain Health Unit Forum on Neurology and COVID-19; TS has also previously filed a patent for a test for bacterial meningitis based on a blood test (GB 1606537.7, April 14, 2016). All other authors declare no competing interests.

Declaration of interests

Footnotes

Definitions for the different neurological diseases and syndromes are in the appendix (pp 5–12).

Detection in CSF or brain tissue by PCR, culture, or immunohistochemistry, as appropriate.

Serological evidence of acute infection can be defined as detection of IgM, IgG seroconversion, or an increase of four times in antibody titres in paired acute and convalescent serum samples.

Detection in non-CNS sample by PCR or culture.

These include infection with one of Campylobacter jejuni, Mycoplasma pneumoniae, Cytomegalovirus, Epstein–Barr virus, hepatitis E virus, Zika virus, or HIV; or vaccination in the last 6 weeks. Associated causes might differ depending on geographical location.

Traditional cardiovascular risk factors include hypertension, current smoker, diabetes, hypercholesterolaemia, and atrial fibrillation.

Footnotes
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