Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients

Link to article: Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients

by Julie Helms, Stéphane Kremer, Hamid Merdji, Malika Schenck, François Severac, Raphaël Clere-Jehl, Antoine Studer, Mirjana Radosavljevic, Christine Kummerlen, Alexandra Monnier, Clotilde Boulay, Samira Fafi-Kremer, Vincent Castelain, Mickaël Ohana, Mathieu Anheim, Francis Schneider…

Critical Care volume 24, Article number: 491 (2020) 08 August 2020

Background

Neurotropism of SARS-CoV-2 and its neurological manifestations have now been confirmed. We aimed at describing delirium and neurological symptoms of COVID-19 in ICU patients.

Methods

We conducted a bicentric cohort study in two French ICUs of Strasbourg University Hospital.

All the 150 patients referred for acute respiratory distress syndrome due to SARS-CoV-2 between March 3 and May 5, 2020, were included at their admission. Ten patients (6.7%) were excluded because they remained under neuromuscular blockers during their entire ICU stay. Neurological examination, including CAM-ICU, and cerebrospinal fluid analysis, electroencephalography, and magnetic resonance imaging (MRI) were performed in some of the patients with delirium and/or abnormal neurological examination. The primary endpoint was to describe the incidence of delirium and/or abnormal neurological examination. The secondary endpoints were to describe the characteristics of delirium, to compare the duration of invasive mechanical ventilation and ICU length of stay in patients with and without delirium and/or abnormal neurological symptoms.

Results

The 140 patients were aged in median of 62 [IQR 52; 70] years old, with a median SAPSII of 49 [IQR 37; 64] points. Neurological examination was normal in 22 patients (15.7%). One hundred eighteen patients (84.3%) developed a delirium with a combination of acute attention, awareness, and cognition disturbances. Eighty-eight patients (69.3%) presented an unexpected state of agitation despite high infusion rates of sedative treatments and neuroleptics, and 89 (63.6%) patients had corticospinal tract signs. Brain MRI performed in 28 patients demonstrated enhancement of subarachnoid spaces in 17/28 patients (60.7%), intraparenchymal, predominantly white matter abnormalities in 8 patients, and perfusion abnormalities in 17/26 patients (65.4%). The 42 electroencephalograms mostly revealed unspecific abnormalities or diffuse, especially bifrontal, slow activity. Cerebrospinal fluid examination revealed inflammatory disturbances in 18/28 patients, including oligoclonal bands with mirror pattern and elevated IL-6. The CSF RT-PCR SARS-CoV-2 was positive in one patient. The delirium/neurological symptoms in COVID-19 patients were responsible for longer mechanical ventilation compared to the patients without delirium/neurological symptoms. Delirium/neurological symptoms could be secondary to systemic inflammatory reaction to SARS-CoV-2.

Conclusions and relevance

Delirium/neurological symptoms in COVID-19 patients are a major issue in ICUs, especially in the context of insufficient human and material resources.

Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis

Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis

by Yuting Li, Hongxiang Li and Dong Zhang 

Critical Care volume 24, Article number: 488 (2020)  06 August 2020

Background

The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock.

Methods

We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI).

Results

Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = − 1.39; 95% CI, − 1.81 to − 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = − 0.50; 95% CI, − 0.68 to − 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = − 0.11; 95% CI, − 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%).

Conclusions

Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.

Cardiac injury associated with severe disease or ICU admission and death in hospitalized patients with COVID-19: a meta-analysis and systematic review

Link to article: Cardiac injury associated with severe disease or ICU admission and death in hospitalized patients with COVID-19: a meta-analysis and systematic review

by Xinye Li, Xiandu Pan, Yanda Li, Na An, Yanfen Xing, Fan Yang, Li Tian, Jiahao Sun, Yonghong Gao, Hongcai Shang and Yanwei Xing

Critical Care volume 24, Article number: 468 (2020) 28 July 2020

Background

Cardiac injury is now a common complication of coronavirus disease (COVID-19), but it remains unclear whether cardiac injury-related biomarkers can be independent predictors of mortality and severe disease development or intensive care unit (ICU) admission.

Methods

Two investigators searched the PubMed, EMBASE, Cochrane Library, MEDLINE, Chinese National Knowledge Infrastructure (CNKI), Wanfang, MedRxiv, and ChinaXiv databases for articles published through March 30, 2020. Retrospective studies assessing the relationship between the prognosis of COVID-19 patients and levels of troponin I (TnI) and other cardiac injury biomarkers (creatine kinase [CK], CK myocardial band [CK-MB], lactate dehydrogenase [LDH], and interleukin-6 [IL-6]) were included. The data were extracted independently by two investigators.

Results

The analysis included 23 studies with 4631 total individuals. The proportions of severe disease, ICU admission, or death among patients with non-elevated TnI (or troponin T [TnT]), and those with elevated TnI (or TnT) were 12.0% and 64.5%, 11.8% and 56.0%, and 8.2% and. 59.3%, respectively. Patients with elevated TnI levels had significantly higher risks of severe disease, ICU admission, and death (RR 5.57, 95% CI 3.04 to 10.22, P < 0.001; RR 6.20, 95% CI 2.52 to 15.29, P < 0.001; RR 5.64, 95% CI 2.69 to 11.83, P < 0.001). Patients with an elevated CK level were at significantly increased risk of severe disease or ICU admission (RR 1.98, 95% CI 1.50 to 2.61, P < 0.001). Patients with elevated CK-MB levels were at a higher risk of developing severe disease or requiring ICU admission (RR 3.24, 95% CI 1.66 to 6.34, P = 0.001). Patients with newly occurring arrhythmias were at higher risk of developing severe disease or requiring ICU admission (RR 13.09, 95% CI 7.00 to 24.47, P < 0.001). An elevated IL-6 level was associated with a higher risk of developing severe disease, requiring ICU admission, or death.

Conclusions

COVID-19 patients with elevated TnI levels are at significantly higher risk of severe disease, ICU admission, and death. Elevated CK, CK-MB, LDH, and IL-6 levels and emerging arrhythmia are associated with the development of severe disease and need for ICU admission, and the mortality is significantly higher in patients with elevated LDH and IL-6 levels.

Incidence and mortality of pulmonary embolism in COVID-19: a systematic review and meta-analysis

Link to article: Incidence and mortality of pulmonary embolism in COVID-19: a systematic review and meta-analysis

by Shu-Chen Liao, Shih-Chieh Shao, Yih-Ting Chen, Yung-Chang Chen and Ming-Jui Hung 

Critical Care volume 24, Article number: 464 (2020) 27 July 2020

Coronavirus disease 2019 (COVID-19) remains an increasing global pandemic, with significant morbidity and mortality. Severe complications of COVID-19 associated with coagulation changes, mainly characterized by increased D-dimer and fibrinogen levels with higher thrombosis risk, in particular pulmonary embolism (PE), have been reported recently [1]. However, the epidemiology of PE among COVID-19 patients is currently only based on small case series and retrospective studies. This systematic review and meta-analysis addresses this gap in knowledge, facilitating first-line healthcare providers’ understanding of PE incidence and mortality in COVID-19…

SARS-CoV-2 post-infective myocarditis: the tip of COVID-19 immune complications?

link to article: SARS-CoV-2 post-infective myocarditis: the tip of COVID-19 immune complications?

by Pierre Tissières and Jean-Louis Teboul 

Annals of Intensive Care volume 10, Article number: 98 (2020) 23 July 2020

Recent paediatric cases of acute myocarditis following a SARS-CoV-2 infection have raised the possibility of post-infective complications of COVID-19. This short editorial is reviewing current understanding of this new complication, its pathophysiology, diagnosis and therapeutic strategy.

COVID-19 post-infective acute myocarditis, an unrecognized complication?

Recent descriptions of a short outbreak of acute myocarditis in otherwise healthy children raise the hypothesis of additional critical complications of SARS-CoV-2 infection [1,2,3,4,5,6]. Grimaud et al. just reported in Annals of Intensive Care, a series of 20 critically ill children with shock admitted, during a 12-day period, in four pediatric intensive care units in the Paris urban area [1]. This outbreak occurred after 4–6 weeks of strict lockdown. All children had acute myocardial dysfunction requiring cardiovascular support. This study confirmed similar observations from United Kingdom, France and Switzerland [2,3,4,5,6]. In the Grimaud et al. study, 19 out of 20 children had either positive SARS-CoV-2 detection by quantitative PCR or positive serology. The remaining child had a typical SARS-CoV-2 chest tomography scan. Note that all children had abdominal symptoms [1].

Acute heart failure is clearly a dissonant clinical feature of COVID-19 infection in children that is known to be less frequent and less severe than in adults and with very low mortality [7, 8]. Besides its unusual nature, the main characteristic of COVID-19 acute myocarditis is its association with major multisystem inflammatory syndrome, mimicking a well-known pediatric entity, the Kawasaki disease. Currently three case definitions issued from the World Health Organization, the Centers for Disease Control and Prevention and the Royal College of Paediatrics and Child Health related to this emerging inflammatory condition during COVID-19 pandemic exist. Those definitions identify the multisystem inflammatory syndrome in children (MIS-C) or the Pediatric Inflammatory Multisystem Syndrome (PIMS) [4]. All three case definitions include either partial or full criteria for Kawasaki disease and evidence of COVID-19 diagnosis (clinical and/or biological—serology/PCR). Kawasaki disease’s, which affect mostly young children of less than 5 years of age, has typical clinical features including: (1) prolonged fever, (2) conjunctivitis, (3) dry cracked lips, ((4) cervical adenopathy (5) diffuse skin rash involving the trunk and extremities, subsequent desquamation of the tips of the toes and fingers, and 6) edema. In addition to classical manifestations of Kawasaki disease, MIS-C patients, who are much older, display digestive symptoms, shock and myocardial involvement more frequently [9]. Kawasaki disease pathophysiology refers to a systemic arteritis with the most severe complication being coronary aneurysm. Kawasaki disease can follow by a few days or weeks a wide range of infection involving numerous viruses such as EBV, MERS- and SARS-CoV-1, H1N1 influenza and other respiratory illnesses [10]… cont

Could the severity of COVID-19 be increased by low gastric acidity?

Link to article: Could the severity of COVID-19 be increased by low gastric acidity?

by Elizabeth Price 

Critical Care volume 24, Article number: 456 (2020) 22 July 2020

Could low gastric acidity increase the risk of a severe COVID-19 illness? Although it is primarily a respiratory infection, gastrointestinal involvement from swallowed coronaviruses is reported for SARS-CoV-2 (the virus of COVID-19 [1, 2]), as well as SARS-CoV-1 [3] and MERS-CoV viruses [4].

The gastrointestinal tract may be a secondary route for spread to the lungs and other parts of the body. A possible hypothesis might be that the upper respiratory tract is attacked by viruses which are breathed in and coughed up in sputum while the lower respiratory tract is similarly infected, but is also attacked at the same time by blood-borne viruses (following translocation from a significant viral load in the gastrointestinal tract). The former might result in mild or moderate illnesses only. The latter may cause a more severe illness, as the lungs are being attacked by viruses coming from two routes simultaneously…

Efficacy of early prone position for COVID-19 patients with severe hypoxia: a single-center prospective cohort study

Link to article: Efficacy of early prone position for COVID-19 patients with severe hypoxia: a single-center prospective cohort study

Xuefeng Zang, Qian Wang, Hua Zhou, Sanhong Liu, Xinying Xue  COVID-19 Early Prone Position Study Group

Intensive Care Medicine (2020) 22 July 2020

With the global epidemic of COVID-19, as of July 8, 2020, 12,025,348 people have been infected with 4.56% mortality [1]. Many COVID-19 patients died due to severe hypoxia [2, 3]. It is particularly important to find a simple and effective way for COVID-19 patients’ treatment. Recent studies reported that prone position was used to treat non-intubated COVID-19 patients and hypoxemic acute respiratory failure [4, 5]. However, the number of patients was small, the follow-up was short, clinical outcomes were not assessed in their study. In this study, we aimed to explore whether the early prone position can effectively improve severe hypoxia, CT imaging performance and survival prognosis of COVID-19 patients with severe hypoxia…

Advanced organ support (ADVOS) in the critically ill: first clinical experience in patients with multiple organ failure

Link to article: Advanced organ support (ADVOS) in the critically ill: first clinical experience in patients with multiple organ failure

by Valentin Fuhrmann, Theresa Weber, Kevin Roedl, Jasmin Motaabbed, Adel Tariparast, Dominik Jarczak, Aritz Perez Ruiz de Garibay, Johannes Kluwe, Olaf Boenisch, Harald Herkner, John A. Kellum and Stefan Kluge

Annals of Intensive Care volume 10, Article number: 96 (2020)  16 July 2020

Background

Prevalence of multiple organ failure (MOF) in critically ill patients is increasing and associated mortality remains high. Extracorporeal organ support is a cornerstone in the management of MOF. We report data of an advanced hemodialysis system based on albumin dialysis (ADVOS multi device) that can regulate acid–base balance in addition to the established properties of renal replacement therapy and albumin dialysis systems in critically ill patients with MOF.

Methods

34 critically ill patients with MOF received 102 ADVOS treatment sessions in the Department of Intensive Care Medicine of the University Medical Center Hamburg-Eppendorf. Markers of metabolic detoxification and acid–base regulation were collected and blood gas analyses were performed. A subgroup analyses were performed in patients with severe acidemia (pH < 7.2).

Results

Median number of treatment sessions was 2 (range 1–9) per patient. Median duration of treatment was 17.5 (IQR 11–23) hours per session. Treatment with the ADVOS multi-albumin dialysis device caused a significant decrease in bilirubin levels, serum creatinine, BUN and ammonia levels. The relative elimination rate of bilirubin was concentration dependent. Furthermore, a significant improvement in blood pH, HCO3− and PaCO2, was achieved during ADVOS treatment including six patients that suffered from severe metabolic acidosis refractory to continuous renal replacement therapy. Delta pH, HCO3− and PaCO2 were significantly affected by the ADVOS blood flow rate and pH settings. This improvement in the clinical course during ADVOS treatments allowed a reduction in norepinephrine during ADVOS therapy. Treatments were well tolerated. Mortality rates were 50% and 62% for 28 and 90 days, respectively.

Conclusions

In this case series in patients with MOF, ADVOS was able to eliminate water-soluble and albumin-bound substances. Furthermore, the device corrected severe metabolic and respiratory acid–base disequilibrium. No major adverse events associated with the ADVOS treatments were observed.

Cytokine adsorption in patients with severe COVID-19 pneumonia requiring extracorporeal membrane oxygenation

Link to article: Cytokine adsorption in patients with severe COVID-19 pneumonia requiring extracorporeal membrane oxygenation

by Marina Rieder, Tobias Wengenmayer, Dawid Staudacher, Daniel Duerschmied and Alexander Supady 

Critical Care volume 24, Article number: 435 (2020) 14 July 2020

The treatment of patients with severe COVID-19 requiring support with veno-venous extracorporeal membrane oxygenation (vv-ECMO) is particularly challenging from a medical point of view and consumes a tremendous amount of human, physical, and financial resources. Recommendations for initiation of vv-ECMO in COVID-19 are being developed, though under continuous review [1, 2]. However, despite all therapeutic efforts, these critically ill patients have a high mortality rate according to studies published so far [3, 4].

At our hospital, a major referral center for extracorporeal support, we have treated several COVID-19 patients with vv-ECMO. Knowing interleukin-6 (IL-6) as a predictor of negative outcome, some patients received cytokine adsorption using the CytoSorb® adsorber (CytoSorbents Europe, Berlin, Germany) shortly after initiation of ECMO for up to 72 h [5]. Based on experience in septic patients, the adsorber was exchanged every 24 h [6]. Integration of the adsorber in the ECMO circuit was feasible and safe. Preliminary data from eight cases (4 patients receiving ECMO with cytokine adsorption, the remaining 4 received ECMO without cytokine adsorption) shows that cytokine adsorption may result in a more pronounced decrease of IL-6 after initiation of ECMO (Fig. 1)…

Prone positioning under VV-ECMO in SARS-CoV-2-induced acute respiratory distress syndrome

Link to article: Prone positioning under VV-ECMO in SARS-CoV-2-induced acute respiratory distress syndrome

by Bruno Garcia, Nicolas Cousin, Claire Bourel, Mercé Jourdain, Julien Poissy and Thibault Duburcq

Critical Care volume 24, Article number: 428 (2020) 14 July 2020

Background 

Infection due to severe acute respiratory coronavirus 2 (SARS-CoV-2) may lead to an atypical acute respiratory distress syndrome (ARDS) [1], requiring in the most severe cases veno-venous extracorporeal membrane oxygenation (VV-ECMO). The management of persistent severe hypoxemia under VV-ECMO requires a multi-step clinical approach including prone positioning (PP), which could improve oxygenation [2].

Methods

We performed a retrospective study of patients with SARS-CoV-2-induced ARDS submitted to PP during VV-ECMO. We aimed to describe mechanical ventilation parameters and gas exchanges before and after PP. We assess the safety of PP and compare patients with PP under ECMO (prone ECMO group) to those maintained in the supine position (supine ECMO group). Patients were treated in accordance with the recommendation guidelines on ARDS [3]. During VV-ECMO, PP was considered in case of severe hypoxemia (PaO2/FiO2 ratio below 80 mmHg) despite FDO2 and FiO2 both at 100% and in case of extensive lung consolidation (ECL) on chest imaging (> 50% of lung volume).

Results

We enrolled 208 COVID-19 patients. Among the 125 patients with ARDS, 25 (20%) required VV-ECMO, and 14 (56%) were placed at least once in PP for a total of 24 procedures with a median duration of 16 (15–17) h. The delay from ECMO implantation therapy to PP was 1.5 days [1,2,3]. The resultant changes in ventilator/ECMO settings and blood gas analysis before and after PP are displayed in Table 1. The median PaO2/FiO2 ratio improvement after PP was 28% [2–36]. High responders (increase PaO2/FiO2 ratio > 20%) were 62.5%, moderate-responders (increase PaO2/FiO2 < 20%) were 16.7%, and non-responders (decrease PaO2/FiO2) were 20.8%. We did not observe any major safety concerns but only pressure sores after 6 procedures, three minor hemorrhages at the injection cannula, and three moderate drops in VV-ECMO flow requiring fluid resuscitation. Pre-ECMO characteristics, ventilator/ECMO settings, and outcomes are exposed in Table 2. Patients in the prone ECMO group were less likely to be weaned from ECMO, and 28-day mortality rate was significantly higher.

Discussion

We report that during VV-ECMO, PP improved oxygenation without a change in respiratory system compliance and PaCO2 at constant levels of minute ventilation and sweep gas flow. This does not suggest lung recruitment by PP but rather an optimization of ventilation and perfusion matching. Three explanations could be advanced for the mortality rate in the prone ECMO group (78.6%). First, prone ECMO patients may be more severe than supine ECMO patients. As described by Gattinoni et al., worsening patients progress from type 1 to type 2 (higher percentage of non-aerated tissue) [1], which is associated with a higher mortality rate [4]. Prone ECMO patients had much more consolidations, obviously because ECL was the main indication to be prone (n = 10/14). Furthermore, prone ECMO patients need a higher respiratory rate for a higher sweep gas flow suggesting that they may be exposed to a higher mechanical power, and they possibly had also a higher dead space. Second, postmortem biopsies, performed in 6 patients with ECL in the prone ECMO group, found a fibrin exudative presence both in the alveolar spaces and bronchioles followed by a fibroblastic phase [5] and raise the question of the use of corticosteroids (only one patient in the prone ECMO group). Third, as already described by Zeng et al. [6], more than half (8/11) of the patients died from septic shock and multiple organ failure, for which ECMO may be useless.

Conclusion

Prone positioning under VV-ECMO improves oxygenation in SARS-CoV-2-induced ARDS without compromising the safety of the patients. The high mortality rate in prone ECMO patients may be explained by the greater illness severity and the lack of an immunomodulatory therapy such as corticosteroids.

Role of angiotensin-converting enzyme 2 (ACE2) in COVID-19

Link to article: 

by Wentao Ni, Xiuwen Yang, Deqing Yang, Jing Bao, Ran Li, Yongjiu Xiao, Chang Hou, Haibin Wang, Jie Liu, Donghong Yang, Yu Xu, Zhaolong Cao and Zhancheng Gao

Critical Care volume 24, Article number: 422 (2020) 13 July 2020

Abstract

An outbreak of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that started in Wuhan, China, at the end of 2019 has become a global pandemic. Both SARS-CoV-2 and SARS-CoV enter host cells via the angiotensin-converting enzyme 2 (ACE2) receptor, which is expressed in various human organs. We have reviewed previously published studies on SARS and recent studies on SARS-CoV-2 infection, named coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO), confirming that many other organs besides the lungs are vulnerable to the virus. ACE2 catalyzes angiotensin II conversion to angiotensin-(1–7), and the ACE2/angiotensin-(1–7)/MAS axis counteracts the negative effects of the renin-angiotensin system (RAS), which plays important roles in maintaining the physiological and pathophysiological balance of the body. In addition to the direct viral effects and inflammatory and immune factors associated with COVID-19 pathogenesis, ACE2 downregulation and the imbalance between the RAS and ACE2/angiotensin-(1–7)/MAS after infection may also contribute to multiple organ injury in COVID-19. The SARS-CoV-2 spike glycoprotein, which binds to ACE2, is a potential target for developing specific drugs, antibodies, and vaccines. Restoring the balance between the RAS and ACE2/angiotensin-(1–7)/MAS may help attenuate organ injuries.

Neurological manifestations of COVID-19: a systematic review

Link to article: Neurological manifestations of COVID-19: a systematic review

by Gaurav Nepal, Jessica Holly Rehrig, Gentle Sunder Shrestha, Yow Ka Shing, Jayant Kumar Yadav, Rajeev Ojha, Gaurab Pokhrel, Zhi Lan Tu and Dong Ya Huang

Critical Care volume 24, Article number: 421 (2020) 13 July 2020

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the global spread of coronavirus disease (COVID-19). Our understanding of the impact this virus has on the nervous system is limited. Our review aims to inform and improve decision-making among the physicians treating COVID-19 by presenting a systematic analysis of the neurological manifestations experienced within these patients.

Methods

Any study, released prior to May 20, 2020, that reported neurological manifestations in patients infected by SARS-CoV-2 was systematically reviewed using the PRISMA (Preferred Reporting Items for Systemic review and Meta-Analysis) statement.

Results

Our systematic review included data from 37 articles: twelve retrospective studies, two prospective studies, and the rest case reports/series. The most commonly reported neurological manifestations of COVID-19 were myalgia, headache, altered sensorium, hyposmia, and hypogeusia. Uncommonly, COVID-19 can also present with central nervous system manifestations such as ischemic stroke, intracerebral hemorrhage, encephalo-myelitis, and acute myelitis, peripheral nervous manifestations such as Guillain-Barré syndrome and Bell’s palsy, and skeletal muscle manifestations such as rhabdomyolysis.

Conclusion

While COVID-19 typically presents as a self-limiting respiratory disease, it has been reported in up to 20% of patients to progress to severe illness with multi-organ involvement. The neurological manifestations of COVID-19 are not uncommon, but our study found most resolve with treatment of the underlying infection. Although the timeliness of this review engages current challenges posed by the COVID-19 pandemic, readers must not ignore the limitations and biases intrinsic to an early investigation.