Neurologic Complications of COVID19/SARS-CoV-2 Infection

Coronavirus or COVID19/SARS-Cov-2 is a virus caused by severe acute respiratory syndrome Coronavirus 2. For most individuals this virus presents similarly to a common cold. Some patients are at higher risk including elderly and patients with chronic medical conditions who are predisposed to immune suppression. These patients are thought to be at higher risk of developing severe respiratory symptoms in the setting of an acute SARS-CoV-2 infection.

Coronavirus as a whole is known to have neuroinvasive potential, thought to occur by extension from the nasal mucosa through the cribriform plate via the olfactory bulb into the brain. This is perhaps why many patients present with anosmia - loss of sense of smell.

After reviewing a number of recent publications, it appears that about 36% of patients in an acute setting present with neurologic complications. These complications include: headache, nausea, vomiting, confusion, anosmia, dysgeusia (alteration of sense of taste), ageusia (loss of sense of taste), encephalitis, and stroke. Read full article.

In the acute state, neurologic complications can occur from direct spread of the virus into neural tissue as well as from triggering the body's natural inflammatory response to fight the infection. In some instances the immune system is over active and leads to a cytokine storm. This causes a release of too many inflammatory cells, breakdown in the blood-brain barrier and involvement of various parts of the brain including brain stem, cerebral white matter and cerebellum causing severe clinical complications. The clinical presentation can vary depending on the part of the brain that is affected.

Based on our understanding of other Coronaviruses, I am suspicious that in some instances SARS-CoV-2 can affect the nervous system by triggering an autoimmune response. The manifestation of autoimmune disorders acutely, sub acutely, and chronically is a grave possibility in this pandemic. The virus can trigger the immune system to create antibodies against itself and cause various clinical presentations including a possible increase in cases of autoimmune encephalitis as well as autoimmune neuropathies. At the beginning of the 20th century for a number of decades there has been an epidemic of Encephalitis Lethargic also know as Epidemic Encephalitis/Sleeping sickness affecting millions world wide and now is speculated to be an autoimmune phenomenon triggered by the Spanish flu and other viral/bacterial infections.

It is important for the medical professionals and patients/caretakers to be mindful of patients who present with personality changes, decline in cognitive function, persistent fatigue and inability to get back to their pre-sick selves as this may be a manifestation of autoimmune/epidemic encephalitis.

In my opinion patients who have already had or are currently suffering from disorders such as PANS/PANDAS or autoimmune encephalitis maybe at higher risk of having a recurrence of their symptoms in the setting of SARS-CoV-2, primarily if they have ongoing symptoms and if their symptoms flair up with seasonal allergies or common infections.

Patient with active tick borne infections such as Lyme, Babesia, Bartonella who have active symptoms are also at an increase risk of developing neurologic complications from SARS-CoV-2 as their immune system is suppressed from an acute/chronic infection.

I believe that those patients who are actively being treated for Lyme and co-infections as well as those who are being treated for autoimmune disorders and are doing well - will likely persevere and will continue doing well despite a possible SARS-CoV-2 illness.

MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN (MIS-C)

On May 14th, the Centers for Disease Control and Prevention (CDC) released a Health Advisory about severe illnesses among children associated with SARS-CoV2 which has been named Multisystem Inflammatory Syndrome in Children (MIS-C).

The condition mimics toxic shock syndrome and Kawasaki disease presenting with fever, rash, gastrointestinal problems, cardiac complaints, drop in blood pressure, increased clotting and inflammation of medium size blood vessels. The condition is rare, can be caused by various infections including viral or bacterial and there now maybe an association with the SARS-Cov-2 virus. These inflammatory conditions are treated with supportive care including IVIG in some instances.

Two cases of children presenting with severe inflammatory illnesses with Kawasaki - like features were first reported in the United Kingdom (UK) on April 26th . Similar illnesses were also reported among 102 children in New York City and New York (NY) state, as of May 12th. Among the cases reported from the UK and NY, some children tested positive for COVID-19 by either RT-PCR or serologic testing.

TESTING

There continues to be a high level of interest in the use of serologic testing to detect persons who might have antibodies against the SARS-CoV-2 virus. While there are now tests with Emergency Use Approval from the Food and Drug Administration (FDA), it is still not clear how to interpret results from these tests. It is not yet known if detection of antibodies on a serologic test for the SARS-CoV-2 virus means the person is immune to the virus, how protective those antibodies are, or how long any immunity might last.

TREATMENT

Acute treatment of the virus has been tried with different medication regiments including Plaquenil, Azithromycine, Ivermectin and Zink. It appears that this treatment maybe effective early on in the disease process prior to developing severe respiratory symptoms. Prophylactic use of various combinations of above agents have also been used anecdotally. Treatment is ultimately decided on a case by case basis between the patient and their doctor.

Patients with significant neurologic complication due to the SARS-Cov2 virus have been given IVIG safely and effectively to treat autoimmune disorders triggered by the disease in combination with other treatment regiments.

"In our study, treatment with IVIG within 48 hours of admission not only reduced ventilator use, but also reduced hospital and ICU length of stay, ultimately improving 28-day mortality. Our study demonstrated that IVIG treatment in COVID-19 patients with severe pneumonia can improve the patients’ indicators within a short time and improve the treatment efficiency of the patients with high effectiveness." Read full article

Dr. Elena Frid