It is just over 100 days, as I write this now, since the World Health Organisation was first alerted to an outbreak of a novel respiratory virus. We are all familiar with the subsequent spread of the coronavirus, COVID-19 and the upheaval to our personal and professional lives. What has captured the headlines, inevitably so, is the number of deaths. The public health, epidemiology, and infectious disease specialists had the unenviable task of plotting national strategy based on incomplete data. Parallel to this clinicians have been desperately trying to learn about clinical course and complications of this virus, as different regions are affected at varying rates and times.
A pre-print on bioRXiv, now published in JAMA Neurology was the first major source of information that there were neurological features at presentation from Wuhan, China (Mao et al 2020). Some presenting features were nonspecific such as headache (13%) or dizziness (17%) however 2.8% had an acute cerebrovascular accident at presentation and 8.9% presented with peripheral nervous system symptoms – most notably impaired taste and smell. Outside of medical journals, (Neurology Today) there were reports from Northern Italy that neurological COVID-19 wards were opening, quoting Alessandro Pezzini as saying “… on the 18-bed unit, patients are being treated for stroke, delirium, epileptic seizures, and non-specific neurologic syndromes that look very much like encephalitis”. Alessandro Padovini of Brescia noted that for some the neurological symptoms preceded the respiratory disease “… many of the patients on the neuro-COVID-19 unit initially presented with stroke, delirium, or encephalitis, and then developed respiratory distress.” The most recent case series comes from the neuro-intensivists in France, who report 14% of those who are sick enough to need ICU have neurological features before intubation (Helms et al. 2020).
Severe neurological complications of COVID-19 have been reported. Haemorrhagic necrotising encephalopathy in a woman in her fifties (Poyiadji et al. 2020) and meningitis/encephalitis from Japan (with COVID-19 detected via PCR in CSF) (Moriguchi et al. 2020) are notable such cases. It is very hard to learn from anecdotes, which is why we need a national collaboration to identify the pattern and scope of these presentations; preferably rapidly.
In the UK we have set up CoroNerve, a collaborative initiative to describe the rare and severe neurological features of COVID-19. This initiative is led by Benedict Michael, Liverpool, Ian Galea, Southampton, Rhys Thomas, Newcastle, Rachel Kneen, Liverpool and Sarah Pett, UCL – with a great number of multi-disciplinary study group members. We are very fortunate to have partnered with the ABN (Association of British Neurologists), BPNA (British Paediatric Neurological Association), BASP (British Association of Stroke Physicians), BNPA (British Neuro Psychiatry Association), and the NACCS (Neuro Anaesthesia and Critical Care Society). This is essential so that in the UK we have a coordinated response, we can rapidly compare cases that may present to different clinicians and so that there is no dual reporting of cases.
Although each of the five of us are seeing cases coming through our centres, we cannot do this alone and are really grateful for the support that we have received from the individual members of these societies to notify us of their cases. We then contact the clinicians and our admin support and clinical fellows help lessen the burden of reporting cases by helping them through the clinical reporting template. It has become clear from colleagues in the UK and overseas that we are seeing a number of unusual parainfectious features; but we also want to be well positioned to capture any post infectious consequences of COVID-19.
CoroNerve is a growing collaboration with international teams – but we can’t do this without you. Thanks to all who have notified us so far! If you want to report a case, please either do so via the appropriate national society; such as RaDAR for the ABN – http://www.theabn.org/page/radar_7 There are two short forms that really only take a couple of minutes to complete.
Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China [published online ahead of print, 2020 Apr 10]. JAMA Neurol. 2020;10.1001/jamaneurol.2020.1127. doi:10.1001/jamaneurol.2020.1127
Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features [published online ahead of print, 2020 Mar 31]. Radiology. 2020;201187. doi:10.1148/ radiol.2020201187
Moriguchi T, Harii N, Goto J, et al. A first Case of Meningitis/ Encephalitis associated with SARS-Coronavirus-2 [published online ahead of print, 2020 Apr 3]. Int J Infect Dis. 2020;S1201- 9712(20)30195-8. doi:10.1016/j.ijid.2020.03.062
Helms J, Kremer S, Merdji H, et al. Neurologic Features in Severe SARS-CoV-2 Infection [published online ahead of print, 2020 Apr 15]. N Engl J Med. 2020;10.1056/NEJMc2008597.