Philadelphia Medicine Winter-Spring 2021 - 27

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FEATURE
COVID-19'S COLLATERAL DAMAGE
PANDEMIC'S EFFECTS CAN BE COMPLEX
By Valeriya S Poukas, MD
Associate Professor of Neurology, Temple Comprehensive Epilepsy Center
I
spent February 2020 planning a perfect seventh
birthday party for my daughter.
The reality of March 2020, however, looked
strikingly different: schools closed, our hospital-based
neurology practice transitioned exclusively
to telehealth and I anxiously awaited my KN95
masks that a friend was mailing to me from
Shanghai, China.
Our understanding of the coronavirus disease
2019 (COVID-19) and a myriad of its effects on
the human body was still in infancy in early spring
2020. Since then, thousands of articles have been
published on the subject.
In addition to severe respiratory symptoms,
there is a wide range of central nervous system, or
CNS, complications in patients with COVID-19,
both in acute illness and months following the recovery.
In May I was redeployed to serve as a medicine attending on
an inpatient COVID-19 service. I also covered the neurology ward
and consult services in those months. There I observed firsthand
the neurological effects of the virus: nonspecific dizziness, strokes,
encephalopathy and seizures. Now I am starting to see some of the
long-term neurologic effects of the disease in the outpatient setting.
COVID-19 acts via the angiotensin-converting enzyme 2 (ACE2)
receptor. ACE2 is a membrane-bound protein expressed across different
organs and cells, including skeletal muscle, endothelium, glial cells,
and neurons (reference 1). It has been suggested that COVID-19 can
reach the CNS via circulation or the olfactory pathway.
Neurological manifestations are commonly seen with COVID-19,
regardless of the disease severity and are reported in hospitalized
patients and those not requiring an admission. Most of COVID19-related
data were extracted from the inpatient setting, especially
early in the pandemic.
Neurologic manifestations tend to vary depending on the stage
of the disease and patient's age. Nonspecific symptoms, such as
myalgias, headache and dizziness are present mostly in the early
stages of infection.
Anosmia (loss of smell) and dysgeusia (loss of taste) tend to
occur early (up to 60% as the first clinical manifestation) and are
more frequent in less severe cases. Disorders of consciousness occur
commonly (14.8-31.8%), mostly in older patients and in severe and
advanced COVID-19 stages (references 2-4).
Cerebrovascular diseases are reported in up to
5.7% of hospitalized patients. Large vessel occlusions
(including occlusion of the internal carotid artery,
M1 and M2 segments of the middle cerebral artery
[MCA], and the basilar artery) and multi-territory
involvement appear to be more common (reference 5).
Of all of the neurological COVID-19 manifestations,
encephalopathy and stroke had been found
to be significantly associated with worse discharge
functional outcome or greater mortality (reference 6).
Other less frequent but well described entities
include inflammatory CNS syndromes, including
encephalitis (para- or post-infectious); acute disseminated
encephalomyelitis (ADEM); Guillain-Barre
syndrome; seizures, and movement disorders.
A prolonged coma (up to 31 days) without associated
devastating brain injury was recently reported by WF Abdo et
al (reference 7). The authors chronicled the clinical pattern of arousal
with eye opening seen first, followed by visual tracking and then
obeying commands mostly with facial musculature. Persistent flaccid
pare-sis/paralysis was reported in all cases. All six patients with severe
COVID-19 achieved full recovery of the unconsciousness without
immunologic therapies such as corticosteroids. They cautioned to
provide premature grave neurological prognosis in similar groups
of patients with severe COVID-19 and prolonged encephalopathy.
In the months following the pandemic onset, it became
progressively clear that a large number of patients have prolonged
post-COVID-19 symptoms. Post-COVID care centers (PCCC)
have now opened across the U.S. and internationally in India, the
UK and Canada.
The two centers in Pennsylvania are in Philadelphia (Penn Medicine's
Post-COVID Recovery Clinic) and Pittsburgh (University
of Pittsburgh Medical Center, or UPMC, Post-COVID Recovery
Clinic). However, only two of them focus solely on the neurologic
sequelae of the disease: the Neuro COVID-19 Clinics at Northwestern
Memorial Hospital in Chicago and Yale New Haven Hospital
in New Haven, Conn. A neurology is the top referral, along with
pulmonary and cardiology.
Strikingly many of the patients presenting with neurologic
symptoms at the COVID-19 out-patient clinics never required
hospitalization.
continued on next page
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