GENERALIZED MYOCLONUS IN COVID-19


COVID-19 presents with various neurological manifestations in about 37% of patients. A recent report from Spain described generalised myoclonus in 3 patients with COVID-19. Patients were in older age group and had usual symptoms of COVID-19 such as fever, cough, breathing difficulty and anosmia at admission. Myoclonus developed in the second week of illness, characterised by jerky movements involving face, neck and upper limbs. Anti-epileptic drugs such as valproate, levetiracetam and clonazepam were of no use in controlling these myoclonic jerks. Myoclonus responded to immunotherapy with methylprednisolone in 2 patients, and one patient required plasmapheresis. MRI brain and EEG were normal.

Conclusions

1. Myoclonus can occur in patients with COVID-19.

2. Underlying mechanism could be immune-mediated or direct virus spread, affecting brainstem and hypothalamus.

3. Anti-epileptic drugs do not work. Immunotherapy is useful.

(Source: Neurology, May 21, 2020)

Life During COVID Times: A New Normal


Life during COVID Times: A New Normal?
Dr Sudhir Kumar

COVID-19 caused by SARS CoV2 virus is a pandemic, which started from China in December 2019, and since has rapidly spread to around 200 countries. After China, many European countries such as Italy, Spain and France saw huge numbers of COVID-19 cases and deaths due to it. Currently, USA too is reporting large number of cases and deaths.
The infection was relatively late to arrive in India, sometime in early March 2020. However, since then, the number of infected has been steadily increasing (crossed 75,000 cases and 2600 deaths). Governments swung into action and enforced lockdown (we have just completed 50 days of lockdown).
Routine lives have been disrupted, with people confined mostly to homes except venturing out for essential services (we have seen some relaxation over the past week or so, when industries and businesses were allowed to function with skeletal staff).
Our lives as doctors too have changed. I am a neurologist working at Apollo Hospital in Jubilee Hills, a leading multi-specialty hospital in Hyderabad. Our OPDs are functioning “normally” for the past 10 days. Let me describe this “new normal”. The patient and one attendant (only one attendant is allowed now; in pre-COVID times, it was not unusual to have 3-4 attendants per patient in OPD and dozen or more attendants for a patient admitted in ICU) are checked for fever (with a thermal scanner) at the entrance. Those with fever are asked to report to “Fever Clinic OPD”. If the temperature is normal, patients are allowed in after sanitising hands and with face-masks on. They are also asked to fill a questionnaire that capture details such as presence of symptoms of cough/fever, any recent travel, etc, as a screening tool for COVID. Once the hospital staff declares the patient “safe”, he is allowed to enter the OPD waiting area. In the waiting area, seating is modified to allow social distancing (alternate chairs are kept vacant). Patients are encouraged to come at their scheduled appointment times so as to minimize wait times to see the doctor. In pre-COVID times, it was not unusual to find several “walk-in patients” who would land up without any prior appointments, so that at any given time, 5-6 patients and their attendants could be waiting to get inside my consultation room.
Inside my OPD room also, there are several changes, which have become “normal” now. Patient’s chairs are kept at 1.5 meters distance from my chair across the table to ensure adequate social distancing. The side chair near my right side (which was within 2-3 feet from me) has been removed. I wear an N95 mask (without a valve) throughout the day. The patient and the attendant should have their masks on. Conversation with the patient often involves a few aspects of COVID- such as how they are coping during lockdown… how deadly the virus is… when will it go…and so on. Clinical examination that require touching a patient is avoided, if possible. So, sensory system examination is often skipped. Motor system examination to check for grade 4 or 5 power is also skipped. If examination is performed, I wear gloves, which are single use and discarded after every patient. Wearing gloves in OPD is a “new normal” for me, as we do not usually perform any procedures in OPD. If reflexes are checked, the knee hammer is sanitised after every patient. I attempt to complete the examination as quickly as possible, as it is not possible to maintain safe social distancing while examining a patient. I prefer patient not talking during examination so that aerosol generation is minimised. Prescription is generated on computer. MRI and CT scans are seen on computer (PACS) so that I touch as little things as possible. Shaking hands with patients to greet is a strict no. I can no longer comfort a patient or caregiver by holding their hands or by patting their shoulders. Healing comes through these acts of empathy and compassion too and not merely from medicines. I hope we can go back to the “old normal” where we could hold our patients’ hands again. For follow-up of reports or other minor queries, patients are encouraged to use online consultation option on Apollo 24/7 app. Once the patient leaves, a hospital staff comes in and sanitises the chairs and table (this is done after each patient). This is also a “new normal”.
A few of my patients with cough or fever are denied entry into my OPD, (as per the hospital protocol). I feel bad as those symptoms could be due to infections other then COVID. However, I am able to give opinion after emergency physician or Infectious disease physician sees them.
Driving between home and hospital are a pleasure these days, as traffic is significantly less. Police have stopped me a few times during this commute to check about the reason of my travel. There is a sticker pasted on my car’s windshield “Apollo Hospital On Duty”. However, sometimes they check my ID card to ensure I am not misusing such a sticker.
OPDs are not busy (about 40-50% of usual work load). This is because state and country borders are sealed. Many of my patients come from other states such as Maharashtra, Andhra Pradesh, Karnataka, West Bengal, etc. We also get patients from Middle East and Africa. These patients have been waiting for borders to open and transport to resume so that they can travel to Hyderabad. I have been providing online support, however, this should not become the “new normal”.
On account of lesser workload, I reach home earlier than usual. I discard my hospital clothes and keep them aside for washing. After taking shower, I have more time to spend with kids and parents. I feel sorry for them, as they have been confined to home for more than 50 days. Kids have no school but online classes are on. However, no outdoor games at all. Is this going to be a “new normal” for kids? I hope not…Parents are in the older age group and belong to the high-risk group for acquiring severe disease, so they have strictly remained indoors. No going out for walks or socialising with their friends in the community. I hope this also does not become the “new normal”.
Another change in our daily routine has been a flurry of webinars, where various experts have discussed almost all neurology topics in the past 50 days (I too have been a speaker for some of those webinars). On many days, there are 5-6 webinars in a day, where international and national experts deliver lectures on recent advances in management of various neurological diseases. These webinars were interesting during the initial few days, however, now, webinar fatigue has set in. The enthusiasm to log on to attend virtual webinars has waned over the past 50 days.
A not so hectic work schedule has allowed me some time for singing, one of my hobbies since childhood.
All in all, the situation has not turned out to be as bad as we had imagined. Most of the hospitals are not overwhelmed and our frontline medical workers have handled the workload well. Deaths have been relatively lesser, and I hope it stays that way. I hope the uncertainty ends soon and people can resume their daily activities without fear. Which one is better: the “old normal” or the “new normal”? I would any day pick the “old normal”. However, we do not have a choice for now. It is better we stick to the basics to contain the disease: hand hygiene, using face cover and maintaining social distancing at least for the next several months (until there is a vaccine, or the virus mysteriously disappears in the same manner as it appeared in Wuhan).

Focal Status Epilepticus as a Presenting Symptom of SARS CoV2 Infection


Focal Status Epilepticus as a Presenting Symptom of SARS CoV2 Infection

COVID 19, caused by SARS CoV2 virus is a global pandemic and has affected more than 3 million people worldwide. Most patients with COVID 19 present with respiratory symptoms, however, neurological involvement is not uncommon. Previously, stroke, Guillain Barre Syndrome, meningitis and encephalitis have been reported as the presenting manifestation of COVID 19, in the absence of respiratory symptoms. The current case report is of the first patient, who presented with focal status epilepticus as the initial symptom of COVID 19.

78-year old Italian lady presented with recurrent focal myoclonic jerks affecting right eyelid and upper lip of two hours duration. She had a history of herpes simplex encephalitis two years ago. She was left with aphasia and mild right hemiparesis due to post-encephalitic damage of left fronto-temporal lobe. She also had a post-encephalitic epilepsy, well controlled on valproate (VPT) and levetiracetam.

She was alert and afebrile. EEG showed features left focal status epilepticus, with epileptiform discharges arising from left fronto-centro-temporal regions. MRI showed old gliotic changes in left fronto-temporal regions without any new acute lesions. Seizures were controlled with IV VPT and IV midazolam.

12 hours after admission to ER, she developed fever. Chest X-ray was normal. Blood and urine culture were sterile. Blood counts showed decrease in lymphocyte count. Blood gases were normal. Fever did not respond to empirical antibiotics. In view of history of contact with her son, whose friends had tested positive for Covid 19 infection, her nasopharyngeal swab was tested by RT-PCR, which turned out positive for SARS-CoV2. Lumbar puncture was not done. She was treated with lopinavir-ritonavir plus hydroxychloroquine. She responded to the treatment and became afebrile. She was discharged 16 days after admission, after COVID tests turned negative on two occasions.

Glial cells and neurons exhibit angiotensin-converting enzyme 2 (ACE 2). SARS CoV2 viruses are known to enter cells that express ACE 2. This can explain the neuroinvasive propensity of corona viruses.

(Reference: Seizure, April 21, 2020)

LARGE VESSEL STROKE AS PRESENTING FEATURE OF COVID-19


Large Vessel Stroke as Presenting Feature of Covid 19

Dr Sudhir Kumar MD DM,

Consultant Neurologist, Apollo Hospitals, Hyderabad

drsudhirkumar@yahoo.com

COVID-19 caused by SARS CoV2 is a global pandemic, which has affected about 3 million people worldwide, and has resulted in more than 2,00,000 deaths. Respiratory system seems to be the main target of COVID-19 as patients usually present with cough, chest pain and breathing difficulty. Recent data has shown involvement of other systems too. Neurological involvement in COVID-19 is not uncommon. This article focuses on large vessel stroke as a presenting feature of COVID-19.

A recent report from Mount Sinai Health System, New York described 5 patients who presented with features of large vessel stroke. The main features were as follows:

  1. They were young patients, with age ranging from 33 to 49 years.
  2. They were predominantly males (4 out of 5),
  3. 3 of them had no known risk factors for stroke,
  4. Two had diabetes (one de novo), one hypertension and one dyslipidemia,
  5. One had a prior history of stroke, and was on aspirin and atorvastatin,
  6. Strokes were of moderate severity, with NIHSS scores ranging from 13 to 23,
  7. Onset of symptoms to time of presentation to ED ranged from 2 to 28 hours (some patients delayed going to hospital due to fear of Covid-19),
  8. Vascular territory affected were: middle cerebral artery in 3, internal carotid artery and posterior cerebral artery in 1 each,
  9. Clot retrieval was done in 4 patients (with stent in one and one patient received IV tPA),
  10. Two patients were treated with apixaban, two with aspirin and one with aspirin/clopidogrel combination,
  11. Only two patients had typical COVID-19 symptoms (fever and cough), one had lethargy and two had no other symptoms,
  12. One patient had mild thrombocytopenia, one patient had mildly prolonged PT and two patients had prolonged PTT,
  13. Three patients had elevated fibrinogen; d-dimer and ferritin were elevated in 3 patients.
  14. There was no death. Two patients were in rehabilitation unit, one each in stroke unit and ICU, and one was discharged home.  
  15. Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19, which could be responsible for large vessel strokes in young.

(Source: NEJM, 28th April, 2020

COVID-19 IN INDIA: WHAT AFTER LOCKDOWN


Covid-19 in India: What after Lockdown

Covid-19 pandemic, which started from China in December 2019, rapidly spread to about 200 countries, affecting about 3 million people, resulting in more than 2,00,000 deaths. In India, the first case was reported on January 30th, 2020. Three months later, as on 26th April 2020, there have been a total of 26,500 cases, resulting in 824 deaths.

COVID-19 different from other known infections

Corona virus 2019 disease (COVID-19), caused by SARS-CoV2 virus is a new infection and hence there are a lot of unknowns about this. This mystery has forced governments to take extreme measures in order to halt the spread of infection.

The basic nature of an infectious disease is that it spreads from one person to another. For known infections, the person-to-person spread is lesser due to several reasons: Immunization, immunity acquired from a prior infection and by adopting measures to contain the spread. For COVID-19, there is no vaccine and only a small fraction of population has acquired immunity after getting infected from it. So, in these circumstances, lockdown seems to be the most effective solution.

Usually, the infected person is isolated. For example, a person with lung tuberculosis (TB) can spread the infection to others for almost a month, even after starting anti-TB treatment. So, a person with lung TB is advised to be isolated for at least a month. Common viral flu can also spread from person to person, so, the affected person is advised to be in isolation for a few days. In the case of COVID-19 the entire population has been advised isolation to slow down the spread.

Lockdown was timely and it has served its purpose

Today, we have completed 33 days (out of planned 40 days) of nationwide lockdown, which is supposed to end on 3rd May 2020. As per various estimates, lockdown has been very effective in containing the spread of infection. Doubling rate of infection has slowed down from 3 days (prior to lockdown) to 12.5 days now. Without lockdown, we would have had more than 10,00,000 cases of Covid-19 infection, which would have been about 44 times more than the current number of cases. We have lost less than 900 people to Covid-19 in our country, a number much lesser than countries far smaller than ours.

Why do we need to look beyond lockdown?

Lockdown has brought with it many hardships affecting multiple spheres such as financial losses, unemployment, poverty, and neglect of diseases other than COVID-19.

  1. Daily wage labourers have been unable to work for several weeks now. Their meagre savings have vanished and they are surviving with help from government and NGOs. However, this cannot go on indefinitely. They have other needs such as house rents to pay, school fees of their children and expenditure for treatment of chronic illnesses to name a few.
  2. Lower middle class too will get affected, as they still need to pay their EMIs and school fees of their children. Salary cuts are imminent and this group would find the going tough in the coming months.
  3. Rise in unemployment: It is a no brainer that hiring would be low this year. Moreover, there could be firing leading to job losses.
  4. Neglect of other serious conditions: Public as well as government are highly focused on Covid-19, and much of infrastructure and manpower are devoted to providing care for Covid 19 patients. Most hospitals have recorded a drastic fall in admissions from heart attacks, stroke and cancer, the three most common causes of death and disability. It is difficult to believe that the incidence of these diseases has come down so drastically just because COVID-19 has arrived! People are staying at homes despite having symptoms and the exact toll due to lack of treatment of these diseases would emerge in a month or two. People are also unable to take good care of chronic conditions such as diabetes, hypertension, heart diseases, lung diseases, which could result in greater risk of death and disability. Preventive health check ups have come to a standstill, which removes any chance of people being able to detect diseases in early stage. In fact, one need not wait for lockdown to end for seeking treatment for life-threatening emergencies. People with suspected stroke and heart attacks should seek emergency treatment, without the fear of contracting corona infection.

Strategy post lockdown

It is obvious that lockdown restrictions cannot be lifted at once. There has to be a gradual easing of restriction, taking into account the infection rate (new cases per day) and other parameters. Some general guidelines could be:

  1. Complete easing of lockdown in districts, where no new cases have been reported in the recent 2-4 weeks,
  2. Jobs, where a single person is involved (such as push cart vendors, mechanics, etc) may be allowed,
  3. Companies and business establishments may be allowed with fewer staff, and adequate social distancing,
  4. Permit all health-related activities, including master heath check ups, OPDs, routine and emergency treatment (with appropriate precautions).
  5. Most of the deaths due to Covid-19 occur in older people. So, we can also have an age-based criteria for lockdown restriction. Allow younger people to join work and keep older (>60 years) within the comforts of home.
  6. Presence of comorbidities also have a bearing on the outcomes due to Covid19. People with obesity, diabetes mellitus, high BP, heart diseases, lung diseases and cancer have a higher risk of death and complications due to COVID-19. People with these illnesses would need to be more careful and limit any outdoor activities.
  7. Restrictions can continue for- tourism & leisure travel, religious gatherings, marriage and other parties, etc. Restrictions on movie theaters, shopping malls, political or sports gatherings may also be continued.

What are your views?

Now that we are in the last week of 40-day lockdown, we need to think beyond that. What are your views about what should be done post lockdown? What should be allowed and what shouldn’t? Post your comments.

Headaches Associated with Personal Protection Equipment (PPE)


HEADACHES ASSOCIATED WITH PERSONAL PROTECTIVE EQUIPMENT

Dr Sudhir Kumar MD DM

Consultant Neurologist

Apollo Hospitals, Hyderabad

drsudhirkumar@yahoo.com

Introduction

Coronavirus disease 2019 (COVID-19) caused by SARS-CoV2 is a global pandemic, which has already affected about 2.6 million people in about 200 countries. Healthcare workers working in high-risk areas (such as emergency room, isolation wards, ICU, etc) are mandated to wear personal protective equipment (PPE), including close-fitting N95 face mask and protective eyewear (mainly goggles) while attending to the patients.

Types of PPE

Aims of the study

A recent study was conducted at Singapore to study the effects of PPE in development of de novo headaches as well as their impact on personal health and work performance. The impact of COVID 19 on pre-existing headache disorders was also investigated.

Participants in the study

158 healthcare workers participated in the study, 78% of whom were in 21-35 year age group. 70% were females. Majority were nurses (65%) or doctors (32%). 29% had pre-existing headache disorders (19% had migraine and 10% had tension-type headaches).

Out of 158 healthcare workers, 128 (81%) developed de novo PPE-associated headaches. Persons with pre-existing primary headaches were 4.2 times more likely to develop de novo PPE-associated headaches. People using PPE for more than 4 hours per day had a 3.9 fold higher risk of developing PPE-associated headaches.  HCW working in emergency department had a 2.4 times higher risk of developing PPE-associated headaches.

Type of headaches

Headaches were bilateral in location. The location of discomfort corresponded to the areas of contact from the face mask or goggles and their corresponding head straps. Discomfort was described as a sensation of pressure or heaviness of affected sites in 87% and throbbing or pulling pain in 12%.

Location of headaches

The time interval between donning of face mask or protective eyewear and onset of headache was less than 60 minutes in most people. After removal of PPE, the headache resolved within 30 minutes.

Most people reported an attack frequency of 1-4 days in a 30-day period. The intensity of headache was mild in most. 23% reported accompanying symptoms of nausea, vomiting, phonophobia or photophobia.

About 70% did not take any painkillers. 30% took either paracetamol or NSAIDs.

83% opined that PPE-associated headaches resulted in a slight decrease in work performance.

Pathogenesis of de novo PPE-associated headaches

  1. Mechanical compression
  2. Hypoxemia
  3. Hypercarbia
  4. Stress

What could mitigate the risks of PPE-associated headaches?

  1. Shorter duty shifts and resultant shorter duration PPE usage could be a better strategy.
  2. Better cushioning of head straps to minimize mechanical compression over scalp.
  3. Reducing stress

Key points

  1. New-onset headaches are common after using PPE (N95 face mask and protective eye gears),
  2. Healthcare workers in emergency department and those using PPE for more than 4 hours daily have a higher chance of developing headaches.
  3. People with pre-existing headaches also have a higher chance of getting headaches.
  4. Headaches begin within 60 minutes of donning PPE and subside within 30 minutes of removing PPE,
  5. Headaches affect both sides of head and are usually mild in nature,
  6. Headaches respond to paracetamol and NSAIDs,
  7. Headaches decrease the work performance,
  8. Shorter shift duration (resulting in shorter duration use of PPE) could be the way forward,
  9. Though the primary aim of PPE is to reduce the risk of virus spread and transmission, we also need to make them user friendly in future.

(Reference: Headache, 30 March 2020)

SARS CoV2 INFECTION IN PREGNANT WOMEN: Clinical Features and Outcome


Covid 19 in Pregnancy: Clinical Features and Outcome

Dr Sudhir Kumar  MD DM

drsudhirkumar@yahoo.com

Covid 19, caused by SARS CoV2 virus is a global pandemic, which has infected more than 2.2 million people worldwide and resulted in death of about 1,50,000 people. Data regarding the effects of Covid 19 in pregnant women are lacking.

A recent case series of Covid 19 affecting pregnant women was reported from Wuhan, China. Following are the salient features:

  1. 118 pregnant women with SARS CoV 2 infection, with median age 31 years (range 28 to 34), were included,
  2. 52% were nulliparous,
  3. 64% got the infection in 3rd trimester,
  4. Most common symptoms were fever and cough,
  5. Lymphopenia was noted in 44%,
  6. CT chest showed infiltrates in both lungs in 79%,
  7. 92% had mild disease and 8% had severe disease with hypoxemia,
  8. One patient required noninvasive mechanical ventilation after delivery,
  9. 94% were discharged,
  10. There were no deaths,
  11. 68 women delivered 70 babies (2 sets of twins) during the study period,
  12. 93% underwent caesarian section.
  13. There were 3 spontaneous abortions and 2 ectopic pregnancies. 4 had induced abortion (due to concerns about Covid 19),
  14. No babies had neonatal asphyxia,
  15. Testing for SARS CoV2 was performed on neonatal throat swabs of 8 newborns and breast milk samples of 3 mothers- all were negative.

Conclusions

  1. Pregnant women tend to have lesser risk of severe Covid-19 disease as compared to general population (8% vs 16%).
  2. Pregnancy outcomes are generally good.
  3. Covid 19 does not seem to be transmitted from mothers to babies.

(Reference: NEJM, April 17, 2020)

PHYSICAL THERAPY is better than STEROID INJECTION for KNEE OSTEOARTHRITIS


PHYSICAL THERAPY is BETTER than STEROID INJECTION for KNEE OSTEOARTHRITIS

Osteoarthritis (OA) of knees is a common disease, affecting people in their middle and old ages. The commonest symptom is knee pain, which increases on standing and walking. OA is a common cause of disability.

Treatment for OA includes: 1. Pain killer medicines, 2. Steroid injections in knee joint, 3. Physical therapy, 4. Knee replacement surgery.

In a recent research, a comparison was made between physiotherapy and steroid injection in knee, to decide which is better.

78 patients (mean age 56 years) each were assigned to either physiotherapy or steroid injection in knee. At the end of one year, group that received physical therapy had lesser pain and lesser functional disability.

Conclusions

1. Physical therapy is superior to steroid injection in knee for patients suffering from osteoarthritis.

2. People with OA, who receive physiotherapy have lesser pain and better functional ability, as compared to those who take steroid injection in the knees.

(Source: NEJM, April 9, 2020).

https://www.nejm.org/doi/full/10.1056/NEJMoa1905877

Dr Sudhir Kumar MD DM
Apollo Hospitals, Hyderabad

HOW DOES COVID 19 AFFECT THE NERVOUS SYSTEM


How does COVID 19 affect Nervous System?

Covid 19, caused by SARS CoV2 virus, is a global pandemic, which has infected about 1.88 million people in about 200 countries, resulting in about 1,16,800 deaths. Covid 19 predominantly affects respiratory system. Common symptoms include fever, cough, breathing difficulty, fatigue and chest pain. Severe cases manifest with pneumonia, necessitating the use of mechanical ventilator in many of them. However, viral infections are known to result in multi-system involvement, and Covid 19 is no exception. In this article, we would focus on neurological manifestations of Covid 19.

Guillain Barre syndrome (GBS)

GBS is an immune-mediated polyradiculoneuropathy resulting in acute onset, rapidly progressive weakness of all 4 limbs. Weakness usually starts in lower limbs, and ascends upwards to involve upper limbs in a few days. Severe cases develop difficulty in swallowing & speaking and breathing difficulty. The diagnosis is confirmed by nerve conduction studies and CSF analysis. A case of GBS was reported from China. [1] What was interesting was that GBS was the presenting feature of Covid 19 (the patient had no typical symptoms of Covid 19 such as fever, cough or breathing difficulty). After admission, neurological symptoms worsened and only after a week, respiratory symptoms typical of Covid 19 developed. At that point, testing confirmed SARS CoV 2 infection. Patient responded to treatment with intravenous immunoglobulins.

Learning points

  1. GBS can be a presenting symptom of Covid 19.
  2. Usually GBS is a post-infectious syndrome (symptoms of GBS begin about 2 weeks after the viral infection). In this case, however, symptoms of GBS and Covid 19 started together (so, the GBS was para-infectious).
  3. Usual treatment of GBS (IVIG) works in GBS related to Covid 19 also.

Stroke

There have been a few reports of stroke in patients with SARS CoV2 infection. In a case reported from China, a 79-year old man was admitted with right hemiparesis and aphasia. [2] He also had low-grade fever and cough at admission. Investigations confirmed it to be a case of SARS CoV2 infection. CT brain showed lacunar infarction. The patient also had paroxysmal atrial fibrillation and hypertension. It was hypothesised that SARS-CoV-2 infection caused hypoxemia and excessive secretion of inflammatory cytokines, which induced acute ischemic stroke.

He was treated with clopidogrel and atorvastatin. For SARS CoV 2, he was given antivirals. Patient had significant improvement by day 12 of admission.

Another 72-year-old patient presented with symptoms of stroke and was admitted in Neurology ward at AIIMS, New Delhi, India.[3] He had no symptoms of Covid 19 at admission, however, he complained of chest pain and breathing difficulty two days later. Investigations confirmed it to be a case of SARS CoV 2 infection. More details are awaited about this case.

In a recent case series, cerebrovascular diseases occurred in about 5.7% (5/88) patients with severe Covid 19. [4]

Learning points

  1. Ischemic stroke can be the first manifestation of Covid 19.
  2. Treatment of ischemic stroke in Covid 19 is similar to the patients without Covid 19.

Encephalitis

The first case of acute necrotising encephalopathy in Covid 19 was reported from the USA. [5] A 58-year-old woman presented with a 3-day history of fever, cough and altered mental status. A diagnosis of SARS CoV 2 was confirmed with a nasopharyngeal swab specimen. CT brain showed bilateral thalamic hpodensities. MRI brain showed symmetrical T2W/FLAIR hyperintense lesions involving thalami and medial temporal lobes. There was evidence of hemorrhages in the affected areas on SWI MRI. There was rim enhancement on post contrast MRI images.  A diagnosis of acute nectrotizing encephalopathy (ANE) was made. ANE is a rare complication of influenza and other viral infections and has been related to intracranial cytokine storms, which result in blood-brain-barrier breakdown, but without direct viral invasion or parainfectious demyelination. Patient was treated with immunoglobulins. Steroids were avoided as it could worsen concomitant bacterial infection.

CT Brain- Bilateral thalamic hypodensities
FLAIR MRI showing bilateral symmetrical thalamic hyperintensities
FLAIR MRI showing bilateral medial temporal lobe hyperintensity
SWI MRI showing hemorrhages in thalami
SWI MRI showing hemorrhagic areas in medial temporal lobes

The first case of encephalitis (due to direct brain invasion by SARS CoV2 viruses) was reported from China. [6] The patient was 56-year old admitted with a diagnosis of Covid 19 encephalitis. On March 4, gene sequencing confirmed the presence of SARS-CoV-2 in the cerebrospinal fluid.

The first case of meningitis due to SARS CoV2 was also reported from China. [7] A 24 year old man developed headache, fatigue and fever. He was treated with antiviral and antipyretic by a nearby physician. On day 5, his symptoms worsened and he also developed cough. On day 9, he was found unconscious. He had a seizure on the way to hospital. He had neck stiffness on examination. SARS CoV2 RNA was not detected in nasopharyngeal swab, however, it was detected in CSF. MRI bran showed features of right lateral ventriculitis and encephalitis affecting right medial temporal lobe and hippocampus. CSF showed elevated opening pressure and mild pleocytosis.

Loss of smell (Anosmia) and taste (Dysgeusia)

The typical symptoms of Covid 19 are fever, cough and breathing difficulty. However, several cases have been reported, where patients presented with lack of smell and taste, who were later diagnosed to have Covid 19. Many of these patients had no respiratory symptoms suggestive of Covid 19, when they developed loss of smell and taste.

The mechanism of lack of smell seems to be the involvement of olfactory nerves and their brain connections by the SARS-CoV 2 virus. Lack of smell and taste are not permanent. As patients recover from Covid 19, smell and taste sensations also return to normal.

So, it is recommended that persons who develop new onset lack of smell and taste (without any common cold) should self-isolate themselves and if they develop symptoms suggestive of Covid 19 later, should present themselves for covid 19 testing.

The guidelines in this regard were published by American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) on 22nd march, 2020 [8]

What are the different ways SARS CoV2 can affect nervous system?

  1. Direct hematogenous spread- viruses can travel from lungs to brain via blood, resulting in meningitis or encephalitis
  2. Spread via olfactory nerves- Viruses can enter via nose and then travel via olfactory nerves (through cribriform plate) into the brain. This can result in loss of smell and later encephalitis.
  3. Spread via neural synapses- viruses can travel from lungs via neural synapses to respiratory center located in medulla oblongata. This can result in respiratory failure.
  4. Cytokine storm syndrome- A group of COVID 19 patients present with cytokine storm syndrome resulting in release of inflammatory mediators. This can result in acute necrotising encephalopathy and stroke.
  5. Immune-mediated demyelination- Antibodies produced against SARS CoV2 viruses can result in demyelinating disorders such as GBS and acute disseminated encephalomyelitis (ADEM).

Conclusions

Covid 19 caused by SARS CoV2 virus can present with neurological diseases affecting central as well as peripheral nervous system.  Common neurological symptoms include headache, fatigue and muscle pains. In more severe cases, there could be a decrease in alertness, loss of smell, seizures and focal neurological deficits. In many cases, neurological symptoms can be the first (presenting) symptom of Covid 19. Therefore, one should have a high index of suspicion to diagnose Covid 19 early. Universal precautions to prevent the spread and transmission of Covid 19 should be taken while dealing with neurology outpatients as well as inpatients.

References

  1. Lancet Neurology, April 1, 2020
  2. Infectious Diseases, March 31, 2020
  3. Economic Times newspaper, April 8, 2020
  4. MEDRXIV. Feb 25, 2020
  5. Radiology, March 31, 2020 (all CT and MRI images are from this reference)
  6. Travel Medicine and Infectious Disease, March 24, 2020
  7. International Journal of Infectious Diseases, March 25, 2020
  8. https://www.entnet.org/content/coronavirus-disease-2019-resources

SMARTPHONE USE and PRIMARY HEADACHES


Smartphone use has increased over time. Smartphone is used for multiple functions other than phone, such as browsing internet, playing games, watching movies/videos, chatting, as a camera, etc. Life without smartphone is unimaginable. The impact of smartphone use on primary headache syndromes is not well known.

In a recent research study, headache characteristics were compared between smartphone users and smartphone non-users. It was found that people using smartphones required higher number of analgesics. Moreover, they had lesser relief with medications used to treat acute headache episodes.

Conclusions

  1. Smartphone use is linked to higher incidence of headache episodes.
  2. Smartphone users need higher number of analgesics to treat their headaches.
  3. Smartphone users have lesser relief in headache with analgesics.

(Ref: Neurology, March 4, 2020)