By Dr,M.V.Padma Srivastava
India, as in the rest of the developing world has traditionally remained faithful to containing and preventing communicable diseases till very recently. It is only after the publication in November 2017 in Lancet Neurology of the land-mark cumulative effort of Ministry of Health and Family Welfare, Indian Council of Medical Research and Public Health Foundation of India that the paradigm shift from communicable diseases to non-communicable diseases was discerned and documented in terms of both mortality and morbidity.
Even then, the big chunk of communicable disease remain, as constant companions in the burgeoning slums, in rural India and in the largely un monitored sectors of underprivileged and socioeconomically backward communities. Infections have spurted as epidemics in India from times immemorial, some known, some unknown scourging populations and Indian economy.
What is happening now is unwitnessed and unexperienced in perhaps three generations! The developed world is struck by an avalanche of acute devastating viral infections with unprecedented speed and severity. The world is watching in alarm and dismay. Carefully planned fortification of health systems and scientific proves is challenged.
We in the developing world have witnessed these epidemics in regional outbreaks! What is anticipated is the magnitude of losses if what is being witnessed in the developed world happens here, to our health systems, to our societal fabric, to our ethos and economy, so unique in so many ways. Future stays poised so precariously.
Crossing the several millions mark of infections globally, we now are aware that the spectrum of clinical manifestations is protean and much beyond our original conviction of “only” febrile respiratory symptom complex.
The emerging syndrome is showing a range of neurologic complications in severely affected patients. These could be altered mental status ( encephalopathy) to acute strokes ( hemorrhagic/ischemic/venous sinus thrombosis). These complications are relatively easy to comprehend. SARI leading to multi-organ dysfunction or cytokine storms culminating in ARDS is often associated with altered mentation and coma. This could be sepsis/hypoxia/hypercarbia/acidosis induced encephalopathy. Elevated levels of D-Dimer deranged liver functions with prolonged PT/INR coupled with cytopenias may enhance coagulopathies resulting in both hemorrhagic and thrombotic complications; foremost being acute strokes.
We are also witnessing a direct injury to the nervous system by the virus. Recent publications of the case -reports showcase a deluge of neurological “presentations” of COVID-19 as against a mere manifestation of a COVID-19 patient during the course of a severe illness. These include : Encephalitis, ADEM, GBS, acute skeletal muscle injury, cranial neuropathies, and strokes.
The neuroimaging picture of an affected COVID-19 positive patient with acute hemorrhagic encephalitis is ominously reminiscent of neurotropic encephalitis!
In an earlier paper of 214 patients studied from China, 37% had neurological manifestations, including nearly 50% of those with severe COVID-19 infection.
Altered mentation accounted for in 15% of the severe cases. More often the complaints were mild and on specific with headache and dizziness.
Another paper published in last week of March enumerates the neurological manifestations encountered in COVID-19 patients as:
1. Headache, malaise, fatigue, imbalance ( whether these could be the presenting features in absence of conventional features of fever, cough and breathing difficulty need to be ascertained).
2. Anosmia/ ageusia
3. Cerebral haemorrhage/infarction
4. Acute neuropathies, encephalitis/ADEM/Acute hemorrhagic encephalitis/brain-stem encephalitis
5. Seizures/? Autoimmune
We now also are aware of the post COVID syndromes, some call it the Covid Tail!. This includes occurrence of sudden thrombotic phenomena and more commonly encountered “ Brain Fog”. The sensation of confusion, lack of clarity and extreme fatigue besides headaches and loss of memory. A host of neurobehavioural issues are increasingly being reported. There is also an alarming thought of the development of degenerative issues such as dementia or Parkinsons disease in survivors over a period of time. No one knows for sure. Research teams are very active across the world to investigate and discern. So, we continue to be on the learning curve.
What are the implications?
1. In a triage for acute stroke, where treatment needs to be time-bound, adequate PPE will become mandatory since COVID-19 patient may present as a stroke in a pandemic or an asymptomatic COVID-19 positive patient may have a conventional stroke.
2. Since testing currently does not include a point of care device to be able to provide results in minutes, universal precautions to HCWs become even more crucial.
3. Acute stroke interventions and management guidelines in suspects/cases of COVID-19 patients are evolving and have been recently published.
4. Missed or erroneous diagnosis of a patient presenting with neurological manifestations may enhance the chance of inadvertently transmitting the infection in the ER and to HCWs with disastrous results.
5. Infected patients are contagious during the incubations period and hence patients with atypical presentations represent an important hidden source of virus spread.
With the current pandemic and increasingly changing scenarios, we should be vigilant for the presence of neurological symptoms similar to those reported for infections by previous human infectious corona viruses.
Dr.M.V.Padma Srivastava MD, DM , FRCP (Edin), FAMS, FNASc, FIAN
Professor, Head, Department of Neurology,
Chief, Neurosciences Center
AIIMS, New Delhi