139 CMAAO CORONA FACTS and MYTH BUSTER Unusual CNS Manifestations
Dr K Aggarwal
President CMAAO
961: Update on Covid-19
IMA-CMAAO Webinar on
“Neurological complications in Covid-19 – Part 2”
27th
June, 2020
4-5pm
Participants
Dr
KK Aggarwal, President CMAAO
Dr
RV Asokan, Hony Secretary General IMA
Dr
Ramesh K Datta, Hony Finance Secretary IMA
Dr
Sanchita Sharma
Faculty
Dr MV Padma
Shrivastava
Prof
& Head, Dept of Neurology
AIIMS,
New Delhi
Key points from the
discussion
- Covid-19 is very
similar to SARS coronavirus of 2003 as it shares the same ACE2 receptor.
The initial clinical manifestations are fever, cough, dyspnea and fatigue.
The most important lab parameter is lymphopenia. In severe cases, viral
pneumonia may lead to severe acute respiratory syndrome, which may be
fatal.
- Diagnosis: rapid
antigen test, Nucleic Acid Amplification Test (NAAT), which
gives results in 2 hours and RT PCR test (nasopharyngeal swab), which
gives results in 8-12 hours.
- ACE2 receptors
are present in nervous system and skeletal muscles.
- Coronaviruses go
beyond the respiratory tract and may invade the CNS resulting in neurological
complications (CNS, PNS and skeletal muscle injury). Although the exact
route by which the virus enters the nervous system is not known.
- A missed
diagnosis of patient presenting with neurological manifestations increases
the chances of spread of infection to HCWs.
- The Covid-19
virus may enter the CNS through the hematogenous or retrograde neuronal
route (evident by the symptom of anosmia).
- Patients with
severe disease have greater likelihood of developing neurological symptoms
compared to patients who have mild or moderate disease.
- It has been
shown that intranasal administration of SARS CoV and MERS CoV led to rapid
invasion of the virus into the brain, the likely route being through the
olfactory bulb via trans-synaptic route.
- Neurological
damage that follows invasion of the Covid-19 virus in the CNS is partially
responsible for the acute respiratory failure seen in these patients.
- Neurological
complications seen include HCoV related meningitis, encephalitis, acute
flaccid paralysis, early onset olfactory and gustatory dysfunction and
changes in smell and taste perception. Anosmia, hyposmia and dysgeusia
have been added in flu screen now.
- The first
observational case series from Wuhan was published in April this year in
JAMA Neurology, where around 40% of hospitalized patients had some
neurological complaints. The CNS manifestations were dizziness, headache,
impaired consciousness, stroke, ataxia and seizures were found in
patients, while the peripheral nervous system manifestations included aguesia,
anosmia, vision impairment, neuropathies, GBS. There were skeletal
muscular injury manifestations.
- Red flags in lab
parameters, which increase the chances of neurological complications, are
lymphopenia, decreased platelet count and high BUN.
- Older Covid-19 patients
with risk factors are more at risk of developing new onset cerebrovascular
accident during hospitalization (did not present with stroke), which is an
important negative prognostic factor. Most of strokes were ischemic stroke
(Lancet).
- Older patients
and those with diseases like HT, DM, CVD, and malignancy are more
susceptible to Covid-19 and are also more likely to develop serious
infection.
- Nervous system
manifestations, which include acute ischemic stroke, intracerebral
hemorrhage, encephalopathy, skeletal muscle injury, seizures are more
common in patients with severe infections.
- Patients with
severe infection had raised TLC, increased neutrophils, lymphopenia and
high CRP; they also had high d-dimer levels (JAMA).
- Lymphopenia is
indicative of immunosuppression in hospitalized patients; high d-dimer
levels suggest a consumptive coagulopathy.
- Another paper
published in last week of March has summarized the spectrum of
neurological presentations in Covid-19 patients: Headache, malaise, fatigue,
imbalance, anosmia/ageusia, cerebral hemorrhage, acute neuropathies,
encephalitis, and seizures.
- Neurological
presentations could be a manifestation of hypoxia, metabolic/respiratory
acidosis, multiorgan dysfunction and sepsis, and certain medications.
- Inflammation
could potentially be related to stroke occurrence (directly/indirectly) or
could follow an acute stroke. Atherosclerosis is an inflammatory process;
plaque destabilization and rupture may contribute to stroke.
- Covid-19 is also
a prothrombotic state as high levels of d-dimer have been observed in
these patients.
- Measures of
protection for health professionals while managing neurological
emergencies like stroke in the time of Covid-19 include PPE (level 2) for
all team members, team member role designation, green corridor for stroke;
CT scan machines need to be sanitized.
- Contact and
droplet precautions: aerosol generating procedures such as
oropharyngeal/nasal suctioning, bag valve mask ventilation, intubation,
chest compression, NIPPV, nebulization and CPR are minimized; early
extubation is not recommended; avoid CPAP, BiPAP and nasal high flow
therapy due to the risk of aerosol formation.
