For June 2020, we have selected: Mao L. et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China JAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1127
The outbreak of the COVID-19 infection in Wuhan (China) has brought clinicians there to investigate different manifestations, including neurological presentations, of this novel infection.
Our paper of the month reports a retrospective observational case series study with the aim of describing characteristic neurologic manifestations of Covid-19 infection in 78 of 214 patients (36.4%) with laboratory confirmed diagnosis and treated at at 3 centers (Main District, West Branch, and Tumor Center) of Union Hospital
of Huazhong University of Science and Technology (Wuhan, China). These hospitals were assigned by the government to treat patients with COVID-19.
The following demographic and clinical data were collected: age, sex, comorbidities (hypertension, diabetes, cardiac or cerebrovascular disease, malignancy and chronic kidney disease), typical symptoms from onset to hospital admission (fever, cough, anorexia, diarrhoea, throat pain, abdominal pain), nervous system symptoms, laboratory findings and CT scan (chest and head if available).Furthermore, patients who were conscious, cognitively and mentally normal as well as linguistically competent were allowed to report subjective symptoms. Patients were assessed by two neurologists and neurological manifestations were divided in three categories (central nervous system manifestations, peripheral nervous system manifestations and skeletal muscular injury manifestations).
The results of this study confirmed the involvement of the nervous system in this infection. 24.8 % of participants had central nervous system manifestation (especially dizziness (16.8%) and headache (13.1%)), 8.9 % showed an involvement of the peripheral nervous system (commonly taste impairment [5.6%] and smell impairment [5.1%]) and 10.7% had muscle-skeletal injury. Of note, nervous system manifestations were significantly more common in severe infections compared with non-severe infections (45.5% vs 30.2%, P =n .02) and they included cerebrovascular diseases (5.7%).
Patients with severe infection were older, had more hypertension and multiple organ involvement. Moreover, their laboratory tests showed more increased inflammatory response and consumptive coagulation system.
The pathophysiological mechanisms leading to neurological dysfunctions in the COVID-19 infection are still unknown. However, it is hypothesized that ACE, which has been found as the functional receptor for SARS CoV-2, might be involved in some neurologic manifestations through direct or indirect mechanisms.
The authors investigated whether the neurological manifestations of this virus might be present without respiratory symptoms and they found that some patients without typical symptoms (fever, cough, anorexia, and diarrhea) of COVID-19 came to the hospital with only neurologic manifestation as their presenting symptoms and then develop severe respiratory dysfunction. These results open a new scenario in the clinical practice where it is mandatory to pay attention to patients with neurological and muscle skeletal symptoms admitted to our hospitals during the pandemia and should consider SARS-CoV-2 infection as a differential diagnosis in this group to avoid misdiagnosis and prevention of transmission.
These patients have also the hight risk of rapid clinical deterioration or worsening due to a severe neurologic event such as stroke, which would contribute to its high mortality rate.
The main limitation of this study is the small size of the studied group and the recruitment from a single area of the pandemia. Further, multicentre studies are needed to confirm these results and to improve our knowledge of the manifestations of this viral infection.