CME INDIA Presentation by Dr N K Singh, Admin, CME INDIA.

CME INDIA Discussion:

Dr Abhishek Kumar Singh, DM, Neuro, Patna:

I have recently treated one COVID with GBS treated with IVIg, improved. Another one COVID with encephalitis, Waiting for RT PCR FOR COVID in CSF. If pcr in CSF is negative, then it won’t be COVID encephalitis. In GBS patient, Patient got admitted with COVID after 7 days developed GBS.

Dr Ujjwal Roy, DM, Neruro, Ranchi, (Audio Message, Must Listen)

Dr Hemshankar Sharma, Asso.Prof .and Nodal Officer COVID,Bhagalpur Medical college

We have seen, 2 GBS,1 Meningitis, 1 Encephalitis,2 CVA, 1 Haemorrhagic stroke, scattered multifocal pattern.

Dr Ashok Kumar,DM,Neuro,Ranchi

So far, I have not encountered Neurological presenting manifestations in Wuhan virus cases. There are, of course, many reports. Huge literature is accumulating. Hope to see some good review next year only — based upon objective date, not anecdotal reports. For example, a few cases of GB Syndrome have been reported. But, causative association is not clear .

Scenario 1.

54-year woman develops aggression and visual hallucinations, sees demons being sent by husband. She had no past psychiatric history. No respiratory symptoms but was found COVID-19. She becomes one of the first known cases of someone developing psychosis after contracting the disease.

Scenario 2.

Cases are being reported of stroke, brain haemorrhage and memory loss and having COVID positivity. Cases are on record of younger people without conventional risk factors who developed stroke and found to COVID positive.

Scenario 3.

Cases are coming with typical features of acute disseminated encephalomyelitis, to symptoms resembling those of multiple sclerosis. Some of the worst-affected patients had only mild respiratory symptoms. “This was the brain being hit as their main disease,” as per Paterson, R. W. et al. Brain https://doi.org/10.1093/brain/ awaa240 (2020).

Journey to Brain:

So, usual story is like this, as shared by Dr Sudhir Ranjan, DM, Neuro, Ranchi…

Mild to moderate COVID 19 infection characterized by mild fever, “distaste for your best” in my experience the salty sensation is the most altered till the end of illness, anosmia i.e. loss of smell, extreme weakness even bathing, shaving and combing hair gives perspiration , most of these weakness felt till first half of the day, muscle ache, proximal muscle weakness  difficulty in turning the side, getting up even from chair become difficult walking without support is not possible. They recovered fully in terms of proximal muscle weakness. Anxiety and depression, sometime agitation and insomnia are the main psychiatric manifestation. One of my friends developed frank psychotic features, on risperidone now showing improvement now after 25th day of illness. This is not the end I think.

Till now we have focused mainly on treating damage to the lungs and circulatory system. But now lots of cases have been reported with neurological manifestations, sometimes as presenting features.

List is increasing…

CME INDIA Learning Points:

• Although viruses can invade and infect the brain, it is not clear whether SARS-CoV-2 does so to a significant extent. The neurological symptoms might instead be a result of overstimulation of the immune system. It is crucial to find out, because these two scenarios require entirely different treatments “If this is direct viral infection of the central nervous system, these are the patients we should be targeting for remdesivir or another antiviral,” “Whereas if the virus is not in the central nervous system, maybe the virus is clear of the body, then we need to treat with anti-inflammatory therapies.” Getting it wrong would be harmful. “It’s pointless giving the antivirals to someone if the virus is gone, and it’s risky giving anti-inflammatories to someone who’s got a virus in their brain,” (Nature,17^th September).
• Lancet Neurology reports: 125 people in the United Kingdom with COVID-19 who had neurological or psychiatric effects. Of these, 62% had experienced damage to the brain’s blood supply, such as strokes and haemorrhages, and 31% had altered mental states, such as confusion or prolonged unconsciousness — sometimes accompanied by encephalitis, the swelling of brain tissue. Ten people who had altered mental states developed psychosis.
• Loss of smell is a common symptom, neurologists wondered whether the olfactory nerve might provide a route of entry.
• Usually Cerebrovascular symptoms began at a median of 10 days (range 0–33) after the onset of respiratory illness.
• Early indicators suggest that cerebrovascular disease in COVID-19 might be due to a coagulopathy. SARS-CoV-2 can cause damage to endothelial cells, activating inflammatory and thrombotic pathways
• Acute ischaemic stroke might also occur through the early inflammatory process, following acute infection, destabilising a carotid plaque or triggering atrial fibrillation.
• For patients with altered consciousness or agitation, all causes of encephalopathy must be considered, including hypoxia, drugs, toxins, and metabolic derangement; encephalitis should be diagnosed only if clinical evidence exists of brain inflammation, such as a CSF pleocytosis, imaging changes, focal seizures, or histological changes
• Even if virus is detected in the CSF, encephalitis should not be diagnosed unless evidence exists of brain inflammation. For patients with possible peripheral nerve disease, clinicians should aim to do CSF examination, looking for evidence of albumin-cytological dissociation (an elevated CSF protein level with a normal CSF cell count), nerve conduction studies, and electromyography during recovery, even if they cannot be done acutely.
• Overall, the proportion of patients with neurological manifestations is small compared with that with respiratory disease. However, the continuing pandemic, and the expectation that 50–80% of the world’s population might be infected before herd immunity develops, suggest that the overall number of patients with neurological disease could become large. (Lancet Neurology).
• Guillain-Barré syndrome or its variants and COVID-19 have been reported, with. Given the number of SARS-CoV-2 infections worldwide, the incidence is not particularly higher than what might be expected. Neurological symptoms started at a median of 7 days (range − 7 to 24) after respiratory or systemic features.
• Most important point to remember is that neurological manifestations are increasingly encountered and could be even the sole manifestation.

Source:

1. Nature | Vol 585 | 17 September 2020
2. https://doi.org/10.1016/S1474-4422(20)30221-0 Lancet Neurology

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