From Brief19: Neurologic disease in Covid-19 patients with a | Figure 1

From Brief19: Neurologic disease in Covid-19 patients with acute respiratory distress syndrome

May 27, 2020

There have been reports that some patients with covid-19 develop neurologic symptoms. In April, a study appearing in JAMA found that patients with more severe cases of SARS-CoV-2 were more likely to develop neurologic signs including strokes, loss of consciousness (or changes in general levels of alertness) and injury to the muscles of the body. A new study in The New England Journal of Medicine adds to this body of knowledge.

The researchers gathered data on 64 SARS-CoV-2 positive patients who had been admitted to an intensive care unit in France with acute respiratory distress syndrome, a life-threatening complication of many diseases including covid-19.

Concerning findings included evidence of disease to the corticospinal tract of the central nervous system, which is responsible for voluntary muscles, in 67 percent of the patients. These patients were seen to have more brisk reflexes, muscle spasms at the ankle (known as "clonus"), and abnormal reflexes on the soles of the feet. Amongst the patients, two were found to have experienced a stroke, and of eight who were considered at high risk of seizures, one had an abnormal EEG (electroencephalogram) which demonstrated findings that, while abnormal, were not specific to a specific disease. Interpretation of these findings poses significant challenges. It remains unclear whether these neurologic findings are specific to SARS-CoV-2 (including inflammatory crises caused by cytokines, for example), or whether such findings are only being detected because the "magnifying glass" is being applied to patients in ICUs such as the one described in this study. It is known, for example, that prolonged critical illnesses that require ICU medicine are associated with changes in brain cognition and neurologic function. Some of these changes are caused by powerful medications that must be used to keep patients alive and some are caused simply by the fact that the human mind and body are not "designed" to function in an environment like an ICU.

Shared with permission from Brief19, a daily review of #covid-19 research and policy.

Case Studies

Case 1

April 7, 2020
A paper published in JAMA on April 6th describes the outcomes of patients with confirmed SARS-CoV-2 infection who were admitted to Intensive Care Units in Lombardy, Italy. Of the 1,591 patients admitted to the ICUs, most were men (82 percent) and the average age was 63 years old. Almost all patients—99 percent—required at least some help with breathing, including 88 percent who required a mechanical ventilation (a breathing machine). At the time of the study, 26 percent of the patients followed in this study had already died, while another 58 percent remain in the ICU.
This study is notable for several reasons. First, it represents the largest group of ICU patient outcomes described since the start of the covid-19 pandemic. Second, the authors shared intricate details in this publication, providing important insights into the needs of covid-19 patients in ICUs. Finally, the results provide further evidence that older patients with chronic disease (high blood pressure, lung disease, etc) tend to fare poorly when they become sick with covid-19.

Shared with permission from Brief19, a daily review of #covid-19 research and policy.

Case 2

March 30, 2020
A not yet peer-reviewed manuscript from the University of Nebraska Medical Center provides evidence of viral contamination in commonly used items, toilet facilities, and air samples. Researchers studied thirteen covid-19 patients who were housed in the National Biocontainment Unit and National Quarantine Unit. All rooms were “negative pressure” rooms, which draw air in but not back out. In the study, cell phones (83%) were identified as substantial sources of contamination. Other contaminated sources included glasses and stool samples from toilets (of which 81% were positive for SARS-Cov-2). But most concerning is that SARS-Cov-2 particles were found in the air even at distances greater than six feet from patients and were found in the ambient air even when patients who were not coughing. Nasal oxygen tubes (cannulas), a device commonly used in hospitals was found to distribute the highest airborne concentrations of SARS-Cov-2.

Shared with permission from Brief19, a daily review of #covid-19 research and policy.

Additional Notes