AC, Dr. Fiorini

FA, Dr. Scorza

Finsterer, Dr. Josef

English

International Journal of Medical Studies

                  International Journal of                                                                                                                                                                                                                                                                                   www.ijmsonline.in                              The spectrum of neuro-COVID is broader than anticipatedJosef Finsterer, MD, PhD1, Scorza FA, MD 1Klinik Landstrasse, Messerli Institute, Austria2Disciplina de Neurociência. Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM). São Paulo, Brasil.3Programa de Estudos Pós-Graduado em Fonoaudiologia, Pontifícia Universidade Católica de São Paulo (PUC-SP), Brazil; Departamento de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, BrazilCorresponding author: Dr. Finsterer J, Postfach 20, 1180 Vienna, AustriaArticle history Received 11 Feb 2021 Received in revised form 21 Feb 2021Accepted 24 Feb 2021 Available online 28 Feb 2021  Keywords: COVID-19, SARS-CoV-This article reviewed by Dr. Prateekonline 28 Feb 2021. IJMS, all rights reserved.  Correspondence  With interest we read the review article by Zhang et al. about the neurological implications and manifestations of an infection with SARSto summarise and discuss the significa(CNS, PNS) invasion by the virus and to improve the understanding of how to manage neuroMedical StudiesAvailable online at www.ijmsonline.in                 IJMS 6(2), 41                 Print ISSN   2542 Correspondence                                International Journal of Medical 2, Fiorini AC, MD3 .  Fonoaudiologia, Escola Paulista de .   2, Central Nervous System, Nerves, Muscle , Dr. Ram. Edited by Dr. Pradeep J., Dr. S Gaur-CoV-2 (neuro-COVID) [1]. The authors intended nce of the central and peripheral nervous system  -44 (2021)                                                              -2766   Studies      41 . Available -                               Dr. Josef Finsterer et al.  www.ijmsonline.in                                                                International Journal of Medical Studies    42  COVID [1]. We have the following comments and concerns. The comprehensive review lacks discussing a number of CNS and PNS manifestations of neuro-COVID, which should be additionally considered by those involved in the management of COVID-19 patients. There is increasing evidence that that the infection with SARS-CoV2 may also cause CNS disorders such as myoclonus-ataxia syndrome, acute, disseminated encephalomyelitis (ADEM), limbic encephalitis, psychosis, intracerebral bleeding, sinus venous thrombosis, vasoconstriction syndrome, optic neuritis, or cerebral vasculitis [2]. Ischemic stroke may not only be due to hypercoagulability or sinus venous thrombosis, but also due to heart failure or arrhythmias, particularly atrial fibrillation. PNS disorders not addressed in the review were myasthenia, single or multiple cranial nerve palsies, and trigeminal neuralgia.  Missing is a discussion about myositis and dermatomyositis as a manifestation of neuro-COVID. Though there is mentioning that the skeletal muscle can be damaged by the virus, it is not addressed that the infection may cause viral myositis, which may clinically manifest as muscle weakness, myalgia, generalised fatigue, or exercise intolerance. Mentioning myositis is crucial as it has been reported to occur in 11-50% of the cases [3] and requires analgesic, anti-inflammatory, or immune-modulating treatment and physiotherapy.  Missing in the review are the neurological complications of drugs given to treat the viral infection. A number of agents applied for the treatment of COVID-19 are neurotoxic. Differentiating primary manifestations of the viral infection from side effects of the treatment is crucial as most of these neurological side effects disappear with discontinuation of the causative agent. Neurotoxic drugs frequently applied for the treatment of COVID-19 include chloroquine, remdesivir/lopinavir, azithromycin, and tocilizumab. From chloroquine it is known that it can trigger myopathy or myasthenic syndrome [4]. Remdesivir, lopinavir, and ritonavir may occasionally trigger myopathy or rhabdomyolysis. Azithromycin may induce rhabdomyolysis. Tocilizumab is known for muscle aching and muscle cramps as rare side effects. Steroids may induce mitochondrial myopathy [4]. Patients requiring ICU treatment may develop critical ill neuropathy or myopathy.  Missing in the review are the neurological complications of primary involvement of the heart and vessels in the SARS-CoV-2 infection. It is well appreciated that SARS-CoV-2 may go along with myocarditis [5]. Complications of myocarditis may not only be heart failure but also conduction defects or arrhythmias, including atrial fibrillation. From heart failure or                                Dr. Josef Finsterer et al.  www.ijmsonline.in                                                                International Journal of Medical Studies    43  arrhythmias it is known that they may be complicated by cardio-embolic events, including ischemic stroke. Thus it is crucial to investigate patients with COVID-19 cardiologically if CNS abnormalities, particularly embolic stroke, occur. There is also no discussion about neurological manifestations as the initial manifestation of COVID-19. Knowing that COVID-19 can start with CNS/PNS disease prior to manifestations in the lungs or other organs is crucial not to overlook the ongoing infection but also to prevent the further spreading of the pandemic.  Overall, the review has a number of limitations, which should be addressed to further strengthen the results and discussion. Neurological involvement in COVID-19 is evidently broader than anticipated and neurological manifestations may be the initial manifestation of the infection in some cases.   DECLARATION OF COMPETING INTEREST There are no conflicts of interest.  FUNDING SOURCE No funding was received.  USEFUL INFO Author contribution: JF: design, literature search, discussion, first draft, critical comments. Informed consent: was obtained. The study was approved by the institutional review board.  REFERENCES  1. Zhang M, Zhou L, Wang J, Wang K, Wang Y, Pan X, Ma A. The nervous system-A new territory being explored of SARS-CoV-2. J Clin Neurosci 2020; 82(Pt A): 87-92. doi: 10.1016/j.jocn.2020.10.056.  2. Zakeri A, Jadhav AP, Sullenger BA, Nimjee SM. Ischemic stroke in COVID-19-positive patients: an overview of SARS-CoV-2 and thrombotic mechanisms for the                                Dr. Josef Finsterer et al.  www.ijmsonline.in                                                                International Journal of Medical Studies    44  neurointerventionalist. J Neurointerv Surg 2020: neurintsurg-2020-016794. doi: 10.1136/neurintsurg-2020-016794.  3. Beydon M, Chevalier K, Al Tabaa O, Hamroun S, Delettre AS, Thomas M, Herrou J, Riviere E, Mariette X. Myositis as a manifestation of SARS-CoV-2. Ann Rheum Dis 2020: annrheumdis-2020-217573. doi: 10.1136/annrheumdis-2020-217573.  4. Finsterer J. Myotoxic drugs and immunodeficiency may contribute to the poor outcome of COVID-19 patients with myotonic dystrophy. Acta Neurol Belg 2020:1–2. doi: 10.1007/s13760-020-01551-8.  5. Agdamag ACC, Edmiston JB, Charpentier V, Chowdhury M, Fraser M, Maharaj VR, Francis GS, Alexy T. Update on COVID-19 Myocarditis. Medicina (Kaunas) 2020; 56: E678. doi: 10.3390/medicina56120678.   

The spectrum of neuro-COVID is broader than anticipated

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The spectrum of neuro-COVID is broader than anticipated

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