NEWS & PERSPECTIVE
Long-term neurologic symptoms emerge in 1 out of 3 patients hospitalized with COVID-19
With confirmed cases of the 2019 coronavirus disease (COVID-19) on the rise, neurological symptoms and syndromes have been reported by a significant proportion of patients in addition to the predominant respiratory symptoms.1-3 A recent study from Italy further demonstrated that long-term neurologic manifestations were seen in more than a third of previously hospitalized COVID-19 patients who had no prior neurological disease.4 The study also noted that multiple neurological abnormalities, including mild cognitive impairment, are associated with the severity of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.4
Shortly after the first case was reported in Wuhan, China, COVID-19 has rapidly developed into pandemic.4 Clinical findings on previously hospitalized and non-hospitalized patients with COVID-19 reported the persistence of multiple symptoms, particularly fatigue and dyspnea.5 Accordingly, some authors have suggested the so-called, but not yet defined, “post-COVID-19 syndrome” based on the symptoms reported after three months of SARS-CoV-2 infection.6 Few follow-up studies, however, have investigated COVID-19 patients discharged from hospitals after recovery, but with no data published on the persistent neurological manifestations in such patients.4
Dr. Padovani and his colleagues, thus developed a longitudinal study to evaluate the neurological manifestations of SARS-CoV-2 after 6 months of follow-up and the potential relationship between pre-morbid conditions and the severity of SARS-CoV-2 infection.4 COVID-19 survivors without pre-morbid neurologic disease and discharged from the Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili Hospital in Italy between February and April 2020 were recruited in a follow-up study which included a standardized neurologic symptoms checklist and a neurologic exam at 6 months.4 The neurological checklist included symptoms related to central, peripheral, myopathic and cognitive manifestations, whereas the neurological examination assessed cranial nerves, motor, sensory, cerebellar, basal ganglia-related function, deep tendon reflexes, pyramidal signs and global cognitive function using the Montreal Cognitive Assessment (MoCA).4 Premorbid conditions were recorded at hospital admission using the Cumulative Illness Rating Scale (CIRS).4,7 Hospitalization data included the severity of the COVID-19 disease which was classified according to the Brescia COVID Respiratory Severity Scale (BCRSS).4,8
At 6 months of follow-up, the most common symptoms reported were fatigue (34.0%), memory complaints (30.8%), sleep disorders (30.8%) and myalgias (29.6%), followed by depression or anxiety symptoms (26.0%), loss of dependency in instrumental activities of daily living (IADL), blurring or other visual disturbances (19.5%), numbness or tingling (18.3%) and hyposmia or hypogeusia (16.5%).4 Patients with higher BCRSS scores reported a higher number of symptoms at follow-up (p=0.004), memory complaints (p=0.015) and visual disturbances (p=0.006) after correction for age and CIRS.4
105 patients were further evaluated with a neurologic exam and cognitive screening. Among them, 42 patients were identified with neurologic abnormalities consisting of dysgeusia/hyposmia (n=19), enhanced physiological tremor (n=15), low-limb hypoesthesia (n=6), low-limb motor deficits (n=3) and cognitive deficits (n=17) according to the Italian validated version of MoCA.4,9 Neurologic abnormalities at examination were associated with older age (p=0.005), higher premorbid comorbidity index (p=0.001), worse BCRSS (p=0.05), longer hospitalization duration (p=0.002), and higher number of neurologic symptoms reported (p=0.007).4 Length of hospitalization (p=0.02) and premorbid comorbidity index (p=0.03) were also predictors of neurologic abnormalities.4
In summary, findings from this study demonstrated that previously hospitalized COVID-19 patients reported a wide array of neurological symptoms at 6 months after SAR-CoV-2 infections which could be predicted by the combination of age, premorbid conditions and severity of COVID-19.4 These findings supported the observation of a high prevalence of post-COVID-19 clinical manifestations and the claim that long-term consequences of COVID-19 involve both central and peripheral nervous systems.4 Dr. Padovoni concluded, “[These results] suggest the importance of long-term follow-up programs to properly care for patients and to evaluate the real impact of SARS-CoV-2 infection on brain health status which is still uncertain.”4
