As COVID-19 continues to impact patients and healthcare across the world, research indicates new presenting clinical symptoms. We all know the symptoms for COVID-19: fever, cough, shortness of breath, sore throat, loss of taste/smell. From my experience, it was never quite as straight-forward.
I worked on a COVID-19 unit March-May. The patients were in critical conditions; most had little chance of survival on the ventilator, were waiting to be placed on mechanical ventilation, or were in hospice. I noticed rapid decreased mental status in my patients. Upon admission, patients were alert and oriented. As days went on, patients became confused, had vivid hallucinations, and some became combative. Some patients had only altered mental status with no other COVID-19 symptoms. This leads me to wonder how COVID-19 impacts the brain and nervous system.
In a study focusing on the neurological effects of COVID-19, 36% had neurological manifestations. Patients with more severe infection had more neurological manifestations (Mao, et. al, 2020). These neurological manifestations in the patients with severe infection were cerebrovascular disease, impaired consciousness, and skeletal muscle injury.
A recent study from Neurological Sciences discusses two patients in their 60’s diagnosed with COVID-19, both requiring mechanical ventilation. Both patients were started on heparin after admission. Both patients had increased levels of C-reactive proteins, involved in inflammatory responses, and increased D-dimers, involved in degradation of fibrinogen (Díaz-Perez, et. al, 2020). After waking up, both patients had altered mental status. Brain MRI’s on both cases showed ischemic lesions and areas of hemorrhagic transformation (Díaz-Perez, et. al, 2020). Hemorrhagic transformation is secondary bleeding, often associated with ischemic infarction (Internet Stroke Center). Ischemic infarction is also referred to as the “silent stroke”; a brain injury likely caused by blood clot (American Stroke Association). Researchers conclude that altered mental status in COVID-19 patients may be due to multiple brain infarctions (Díaz-Perez, et. al, 2020).
Why do we care? How do we ensure those who have survived COVID-19 don’t have detrimental health issues, and if they do, how do we provide resources to improve their quality of life? As healthcare providers, it’s vital that we care for each person as a whole, cura personalis; we can’t just treat the symptoms in order to do good (beneficence). We must ensure these patients survive, and their quality of life isn’t impacted. This can only be done by more in-depth research to ensure we do no harm (non-maleficence).
Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683–690. doi:10.1001/jamaneurol.2020.1127
Díaz-Pérez, C., Ramos, C., López-Cruz, A. et al. Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVID-19. Neurol Sci 41, 2681–2684 (2020). https://doi-org.dml.regis.edu/10.1007/s10072-020-04679-w
“The Internet Stroke Center.” The Internet Stroke Center. An Independent Web Resource for Information about Stroke Care and Research., www.strokecenter.org/professionals/brain-anatomy/cerebral-embolism-formation/hemorrhagic-conversion/.
“Ischemic Strokes (Clots).” Www.stroke.org, www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots.
First off, thank you for bringing up this topic because I also believe it is important to understand not only the short term affects COVID-19 has on individuals but the long terms affect as well. Like you stated, in order to do good (beneficence) we must learn to try and safely prevent long term sided effects like brain infarctions because they greatly impact all aspects of a person’s life for the remainder of that person’s life. One possible way we begin thinking about how to prevent COVID-19 patients from developing neurologic manifestations is by using previous knowledge of other SARS viruses and human Coronaviruses to learn the mechanisms of how the virus invades the CNS. By understanding the mechanisms, we can develop drugs that could block or inhibit these mechanisms. One proposed mechanism is the movement of coronavirus into the CNS across a blood-brain barrier that is compromised by endotheliitis (inflammation of corneal endothelium), endothelial injury, and direct infection of endothelial cells (Aghagoli et al., 2020). It was also thought that the blood-brain barrier could be compromised from the transmigration of macrophages that carry the virus, meaning we could work to target the macrophages carrying the virus and develop ways to prevent the virus from crossing the blood-brain barrier. This would be beneficial because a study in mice indicated that once the virus is in the CNS, it can cause “rapid transneuronal spread and death of infected neurons” (Aghagoli et al., 2020).
ReplyDeleteAghagoli, G., Gallo Marin, B., Katchur, N. J., Chaves-Sell, F., Asaad, W. F., & Murphy, S. A. (2020). Neurological Involvement in COVID-19 and Potential Mechanisms: A Review. Neurocritical Care. https://doi.org/10.1007/s12028-020-01049-4