Q&A: Navigating neurological consequences of COVID-19

A review in JAMA Neurology concluded that clinicians should monitor patients with COVID-19 for neurological disorders, but more research is needed to further examine the role of SARS-CoV-2 as a contributor to postinfectious neurologic complications, one of the review’s authors told Healio Primary Care.

“The biggest issue and recurring theme regarding neurologic manifestations in patients with COVID-19 is that we understand very little about them,” Serena Spudich, MD, MA, division chief of neurological infections and global neurology at Yale University School of Medicine, said in an interview.

Spudich, who has spent most of her career researching how HIV affects the brain, discussed the limited data regarding neurological consequences of COVID-19, when primary care physicians should refer patients to neurologists and more.

Q: What are the most common neurological consequences of COVID-19?

A: For patients with COVID-19 who were sick enough to be hospitalized, one of the main things we saw was change in mental status. But since such changes are hard to differentiate, it was unclear if the change was specific to COVID-19 or another systemic illness. Strokes also have been reported, though in our hospital most patients had other risks for stroke, so we are not sure if these were the result of COVID-19. Some of the other common neurological conditions that we saw in patients with mild COVID-19 were headache and loss of smell.

Q: What are some of the less common neurological complications of COVID-19?

A: Many different types of neurological conditions have been less commonly reported, including seizure, muscle injury and Guillain-Barré syndrome. There are rare reports of severe loss of arm and leg strength in hospitalized patients. In one case, this loss of strength was due to muscle inflammation. In another case it was due to nerve damage. We also saw milder postinfectious complications like patchy skin numbness and severe syndromes such as necrotizing encephalopathy.

Q: What could be causing these complications?

A: There are three possibilities.

One, the virus itself enters the brain and causes damage that way, whether it be an infection, inflammation or stroke. Another possibility is that, like other infections, the body’s response to the virus is making the brain sick, much like how the brains of some patients with HIV are damaged due to the immune system’s response to the virus. The third possibility is that the neurologic problems that we are seeing are related to other illnesses that people have when they are sick with COVID-19. For example, many patients with severe COVID-19 have difficulty breathing, poor oxygenation and below normal levels of oxygen in their blood. We know that patients with low oxygen levels can have altered mental states.

However, we need more studies that examine these possibilities. We have had a lot of case reports so far, but what we really need is more systematic studies where we consistently gather data. We also need follow-up studies that examine the long-term consequences of patients with neurologic conditions and COVID-19 that examine why and how some patients recover from COVID-19.

Q: How can PCPs help manage these conditions?

A: It is too early to tell. But PCPs need to know that patients with confusion, sleepiness, weakness or experience a fall could have COVID-19, even if they do not have fever or cough.

Q: When should a PCP refer a patient to a neurologist for the conditions that you have discussed?

A: We have some reports of patients with mild cases of COVID-19 having severe headaches. These patients and any others with new symptoms of confusion, weakness or numbness should be evaluated by a neurologist to see if a brain MRI or lumbar puncture would be appropriate.