Observational cohort study of neurological involvement among patients with SARS-CoV-2 infection

Abstract

Background:

A growing number of reports suggest that infection with SARS-CoV-2 often leads to neurological involvement; however, data on the incidence and severity are limited to mainly case reports and retrospective studies.

Methods:

This prospective, cross-sectional study of 102 SARS-CoV-2 PCR positive patients investigated the frequency, type, severity and risk factors as well as underlying pathophysiological mechanisms of neurological involvement (NIV) in COVID-19 patients.

Results:

Across the cohort, 59.8% of patients had NIV. Unspecific NIV was suffered by 24.5%, mainly general weakness and cognitive decline or delirium. Mild NIV was found in 9.8%; most commonly, impaired taste or smell. Severe NIV was present in 23.5%; half of these suffered cerebral ischaemia. Incidence of NIV increased with respiratory symptoms of COVID-19. Mortality was higher with increasing NIV severity. Notably, 83.3% with severe NIV had a pre-existing neurological co-morbidity. All cerebrospinal fluid (CSF) samples were negative for SARS-CoV-2 RNA, and SARS-CoV-2 antibody quotient did not suggest intrathecal antibody synthesis. Of the patients with severe NIV, 50% had blood–brain barrier (BBB) disruption and showed a trend of elevated interleukin levels in CSF. Antibodies against neuronal and glial epitopes were detected in 35% of the patients tested.

Conclusion:

Cerebrovascular events were the most frequent severe NIV and severe NIV was associated with high mortality. Incidence of NIV increased with respiratory symptoms and NIV and pre-existing neurological morbidities were independent risk factors for fatality. Inflammatory involvement due to BBB disruption and cytokine release drives NIV, rather than direct viral invasion. These findings might help physicians define a further patient group requiring particular attention during the pandemic.

Keywords

Neuro-COVID Cerebrovascular events COVID-19

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects the lower respiratory tract causing the core clinical symptoms of the coronavirus disease 2019 (COVID-19). However, there is growing evidence that infection with SARS-CoV-2 often leads to neurological signs and symptoms. Cohort studies have reported that up to 30% of hospitalized COVID-19 patients displayed at least one neurological symptom,¹ including cerebrovascular events, meningoencephalitis or viral associated encephalopathy.^2–4 Beyond these severe neurological manifestations, further neurological signs and symptoms including headache, dizziness, confusion, myalgia, and fatigue^5–7 have been described. Neurological involvement (NIV) in COVID-19 may be common and was recently termed NeuroCOVID. However, the precise frequency and severity of the neurological effects of COVID-19 remain elusive and further information on the associated health burden is required. Current knowledge is mainly based on case reports or retrospective studies with small patient numbers, which did not dissect unspecific neurological symptoms and genuine neurological manifestation of COVID-19.

Furthermore, the pathophysiological disease mechanism is still under debate. SARS-CoV-2 might enter the brain through the olfactory nerves, especially given the anosmia in COVID-19, or through disruption of the blood–brain barrier (BBB) to exert direct effects.⁸ Alternatively, immunologic effects may occur through autoantibodies, exuberant immune response or stress-mediated changes in gene expression,^5,9–11 as such autoimmune mechanisms have been described for other coronavirus-mediated complications.^12–14

Here, we present the first prospective study of NIV among a cohort of 102 SARS-CoV-2 infected patients.

Material and methods

Study design, patients and procedures

This prospective trial was conducted to characterize NIV in a cohort of 102 SARS-CoV-2 positive patients (age range 20–95 years, median age 61.5 years; Table 1). Inpatients with SARS-CoV-2 infection were included.

Table 1.

Characteristics of the study cohort.

Age, years
Median ± SD	61.5 ± 16.7
IQR	53.5 – 73.0
Gender – n (%)
Male	71 (70.0)
Female	31 (30.0)
Medical history, pre-existing conditions – n (%)
Neurological diseases	41 (40.2)
Cardiovascular diseases, except arterial hypertension	37 (36.3)
Oncologic disease	20 (19.6)
Arterial hypertension	45 (44.1)
Diabetes	22 (21.6)
Pulmonary disease	29 (28.4)
Allergies	11 (10.8)
COVID-19 severity – n (%)
No symptoms	2 (1.9)
Mild	24 (23.5)
Moderate	38 (37.2)
Severe	38 (37.2)

IQR, interquartile range.

All patients were recruited at the University Hospital of Essen over a period of 4 months (April–July 2020). All patients underwent a structured clinical and neurological examination and were classified for COVID-19 disease severity and NIV as described below. Pre-existing medical conditions, ongoing medication, medical history and course of the disease were obtained from direct questioning/observation or medical files. Blood samples were obtained from all patients; lumbar puncture and electroencephalogram were performed for medical purposes.

Detection of SARS-CoV-2, classification of COVID-19 severity and neurological involvement

Only SARS-CoV-2 positive patients were included in the study cohort. SARS-CoV-2 was detected in nasopharyngeal swaps or in bronchoalveolar lavage fluid by PCR analysis (MagNA Pure 96 DNA and Viral NA Small or Large Volume Kit using MagNA Pure 96, both Roche, Rotkreuz, Switzerland and RealStar SARS-CoV-2 RT-PCR Kit 1.0, Altona Diagnostics GmbH, Hamburg, Germany using CFX 96, Biorad, München, Germany) following the manufacturers’ instructions. Antibody testing was performed in blood and cerebrospinal fluid (CSF) samples using anti-SARS-CoV-2 IgG ELISA (EUROIMMUN AG, Lübeck, Germany). The result is expressed semi-quantitatively as ratio (extinction probe/extinction calibrator).

COVID-19 severity was categorized in terms of pulmonary symptoms into asymptomatic, mild, moderate and severe as described in Buonsenso et al.¹⁵ (Table 2).

Table 2.

Definition of COVID-19 severity (modified according to Buonsenso et al.¹⁵).

Mild COVID-19

Positive RT-PCR test for SARS-CoV-2

Upper respiratory symptoms (e.g. pharyngeal congestion, sore throat and fever) for a short duration or asymptomatic infection

No abnormal radiographic and septic presentation

Moderate COVID-19

Positive RT-PCR test for SARS-CoV-2

Mild pneumonia

Symptoms such as fever, cough, fatigue, headache and myalgia

Severe COVID-19

Positive RT-PCR test for SARS-CoV-2

Mild or moderate clinical features, plus any manifestations that suggest disease progression

Respiratory failure with need for mechanical ventilation (e.g. acute respiratory distress syndrome, persistent hypoxia that cannot be alleviated by inhalation through nasal catheters or masks)
Septic shock

Organ failure that needs to be monitored in the intensive care unit

All patients underwent structured neurological examination by trained neurologists. Anosmia was detected using Quick Smell Identification Test^TM (Sensonics, Inc., Haddon Heights, NJ, USA). Neurological symptoms were regarded as SARS-CoV-2 associated if they had an onset between 10 days prior to and 20 days after a positive SARS-CoV-2 PCR test or after onset of COVID-19 symptoms. Neurological signs and symptoms that had occurred earlier than 10 days prior to onset were classified as ‘pre-existing’. Neurological signs and symptoms were defined and categorized into four groups: no NIV, unspecific, mild and severe NIV (Table 3).

Table 3.

Categorization of neurological involvement (NIV) in COVID-19 patients.

No NIV

No evidence of neurological symptoms assessed by clinical examination and anamnestic evaluation

Unspecific NIV

For example, dizziness, headache, worsening of a pre-existing neurological condition, muscle pain, general weakness, all with onset between 10 days prior to and 20 days after a positive SARS-CoV-2 PCR or after onset of COVID symptoms

Mild NIV

For example, impaired taste or smell, cranial nerve paresis. All with onset between 10 days prior to and 20 days after a positive SARS-CoV-2 PCR or after onset of COVID symptoms

Severe NIV

For example, acute cerebrovascular disease, seizure, myopathy or neuropathy. All with onset between 10 days prior to and 20 days after a positive SARS-CoV-2 PCR or after onset of COVID symptoms

Blood samples and spinal fluid specimen

Peripheral blood and CSF were analysed for routine parameters [leukocytes cell count (number/µl), level of creatinine kinases (U/l), D-dimer (mg/l), lactate dehydrogenase (U/l), lactate (mmol/l), glucose (mmol/l) and C-reactive protein (mg/l), levels of heavy chain neurofilament (ng/ml) as well as the occurrence of a broad spectrum of neuronal antibodies and antibodies against myoproteins]. Blood and CSF parameters were assessed in the central laboratory facility of the University Hospital Essen. Levels of heavy chain neurofilament (ng/ml) were determined in serum and spinal fluid at the laboratory facility EUROIMMUN AG, Lübeck, Germany. An ELISA test (EUROIMMUN AG) was used to measure neurofilament concentration with a detection limit in serum of 0.027 ng/ml and the functional sensitivity of 0.117 ng/ml. Neuronal antibodies against Hu, Ri, ANNA-3, Yo, Tr/DNER, myelin, Ma/Ta, GAD65, amphiphysin, aquaporin-4, glutamate-receptors (Typ NMDA, AMPA), GABA/B receptor, LGI1, CASPR2, ZIC4, DPPX, glycine receptor, mGluR1, mGluR5, Rho-GTPase activating protein 25, ITPR1, Homer 3, MOG, recoverin, neurochondrin, GluRD2, flotillin 1/2, IgLON5, CV2, PNMA2, SOX1, titin and Zic4 were determined in serum of patients. Concentrations of antibodies against myelin basic protein, gangliosides (GM1, GM2, GM3, GD1a, GD1b, GT1b, GO1b) were measured. Furthermore, we screened for antibodies against MDA5, NXP2, SAE1, Mi-2alpha, Mi-2beta, TIF1gamma, Ku, PM75, SRP, Pl-7, PL-12, EJ, OJ, Ro-52 and cN-1A. Antibody diagnostics were performed at the laboratory facility EUROIMMUN AG, Lübeck, Germany using test strips with coated membrane chips of purified, biochemically characterized antigens. Cytokine concentrations (IL-6, IL-8 and TNF-alpha) were determined using magnetic bead sandwich immunoassay (Bio-Plex Pro, Human Cytokin Screening Assay, Biorad, Germany) according to the manufacturer’s protocol. Optical density was measured with Bio-Plex 200 (Biorad, Germany).

Statistics

All data are presented as mean, wherever possible with standard error of the mean, and p values, which were calculated using GraphPad Prism software version 7.0 (GraphPad Software, Inc., La Jolla, CA, USA). Group differences were assessed using one-way analysis of variance (Kruskal–Wallis) with Bonferroni’s multiple comparison post-hoc tests, after analysing for parametric distribution with Kolmogorov–Smirnov test. Pearson’s chi-square test was used for categorical comparisons. A p value < 0.05 was considered to be significant.

Standard protocol approvals, registrations and patient consents

The study was performed in accordance with the principles of the Declaration of Helsinki and the local Ethics Committees approved the study plan (Ethics Committee University of Duisburg-Essen, approval number: 20-9284-BO). Signed informed consent was obtained. The study is registered in the German register for clinical trials (DRKS) under the registration number: DRKS00023312.

Results

Among 102 patients with COVID-19 included in the study, 61 (59.8%) were found to have any neurological signs or symptoms. The distribution of neurological signs and symptoms among this cohort is shown below (Table 4).

Table 4.

Neurological signs and symptoms in the cohort.

Neurological involvement
		n (% of NIV)	n (% of total)
Unspecific	Worsening of pre-existing neurological deficit	5 (8.5)
	Reduction of mobility/general weakness	8 (13.6)
	Psychiatric disorder including delirium	6 (10.2)
	Severe headache	1 (1.7)
	Cognitive decline	5 (8.5)
	Total		25 (24.5)
Mild	Impaired taste or smell	9 (15.3)
	Transient ischaemic attack	1 (1.7)
	Total		10 (9.8)
Severe	Cerebral bleeding	5 (8.5)
	Cerebral ischaemia	12 (20.3)
	Seizure	3 (5.1)
	Encephalitis	2 (3.4)
	Neuropathy/myopathy	2 (3.4)
	Total		24 (23.5)

NIV, neurological involvement.

It was found that 25 (24.5%) patients suffered unspecific NIV. Within this group, eight patients (32%) exhibited a reduction of mobility or general weakness, six (24%) had a psychiatric disorder including delirium. Worsening of a pre-existing neurological condition or cognitive decline was present in five (20%) patients and severe headache was found in one (4%) case.

In the whole cohort, 10 patients (9.8%) suffered mild NIV. Within this group, impaired taste or smell was most common (n = 9, 90%), followed by transient ischaemic attack (TIA, n = 1, 1%).

In the whole study population, severe NIV was present in 24 patients (23.5%). Of these patients with severe NIV, half suffered cerebral ischaemia (n = 12), five (20.8%) experienced cerebral bleeding, three (12%) had seizures, and encephalitis and myopathy/neuropathy each occurred in two (8.3%) cases.

COVID-19 patients were categorized by the severity of their respiratory symptoms. Increasing severity of respiratory symptoms was associated with increasing NIV severity (Figure 1A).

Figure 1.

Clinical characteristics of the COVID-19 cohort.

Of the patients with mild COVID-19, 10 (42%) had NIV (unspecific, mild or severe). Of the patients with a moderate COVID-19 course of disease (mainly moderate pneumonia), 19 (50.1%) showed NIV, and 30 (79%) of patients with severe COVID-19 (referring to patients with respiratory failure and the need for mechanical ventilation) had any NIV. Numerical increase in NIV with increasing respiratory COVID-19 severity was detected due to cases of severe and unspecific NIV. Thus, among patients with mild COVID-19, four (14.7%) had unspecific NIV and one (4.2%) had severe NIV. Of patients with moderate COVID-19, 19 (39%) had unspecific NIV and seven (18.4%) had severe NIV. In patients with severe COVID-19, 13 (34.2%) had unspecific NIV and 16 (42%) presented with severe NIV. Thus, the incidence of NIV increases with the severity of respiratory COVID-19.

Mortality increased with increasing NIV severity (Figure 1B). For patients without neurological symptoms, mortality was calculated to be 14.3%; among patients with unspecific NIV, mortality was 32% and in patients with severe NIV mortality was found to be 41.7%. None of the patients with mild NIV died in the current study (Figure 1B). Among all patients with a fatal outcome, 41.7% had severe NIV (Figure 1B, inlay). Severe NIV is thus an independent risk factor for fatality.

Average age did not differ significantly between patients with no, unspecific, mild or severe NIV (no neurological symptoms n = 41, average age 60 years; unspecific NIV, n = 25, average age 61 years; mild NIV, n = 10, average age 51 years; and severe NIV, n = 24, average age 62 years; Figure 1C).

We further investigated the relationship between pre-existing neurological co-morbidities and the presence or severity of NIV and found increasing levels of neurological severity among those patients with pre-existing neurological co-morbidities (Figure 1D). In patients without NIV, we found that only six (14.6%) had a pre-existing neurological co-morbidity; in patients with unspecific NIV, 12 (48%) had a pre-existing co-morbidity; three (30%) patients with mild NIV and 20 patients (83.3%) with severe NIV had a pre-existing neurological co-morbidity.

Additionally, the number of pre-existing co-morbidities in general (not only neurological co-morbidities) was higher in patients with unspecific NIV, compared with patients without any NIV (p = 0.01) and compared with patients with mild NIV (p = 0.002). Furthermore, patients with severe NIV had significantly more pre-existing co-morbidities compared with patients with mild NIV (p = 0.009; Figure 1E). Co-morbidities thus predispose for NIV.

We further assessed potentially underlying mechanisms of NIV in COVID-19 patients. For this, CSF was analysed in 13 patients and blood analyses were performed.

CSF cell leucocyte counts did not show significant differences between groups stratified for NIV (total n = 13 samples; Figure 2A). Although total protein (total number of samples n = 13) was increased in 46% of patients with severe NIV, alterations did not reach the level of statistical significance (Figure 2B). We found that all patients showed oligoclonal bands Type 4 (identical oligoclonal bands in CSF and serum) except one patient with type 1 pattern (no bands in CSF and serum). Elevated intrathecal immunoglobulin fractions were not found in any patient (data not shown).

Figure 2.

Cerebrospinal fluid (CSF) analysis of COVID-19 patients.

To test for a direct viral central nervous system invasion, we tested CSF samples for SARS-CoV-2 RNA using RT-PCR. All samples tested were found negative for SARS-CoV-2 RNA (n = 13). We furthermore performed antibody testing for SARS-CoV-2 S1 IgG in patients’ CSF. Samples from all patients tested revealed low levels of SARS-CoV-2 IgG in CSF, compared with serum IgG (on average 4.68-fold higher in serum); three samples were under the extinction cut-off. Three of the patients with high SARS-CoV-2 IgG extinction concomitantly had high albumin serum/CSF ratio and an age defined [age(y)/15+4] BBB disruption (n = 10; Figure 2C).

Due to this finding, we correlated the presence and severity of NIV to a disruption of the BBB. BBB integrity was neither compromised in the patient without neurological symptoms (n = 1) nor in patients with unspecific NIV (n = 2) or mild NIV (n = 2), but 50% of patients with severe NIV (n = 8) presented with a disruption of the BBB (Figure 2D). Inflammatory involvement of the CSF due to BBB disruption may thus partially drive NIV.

To investigate the underlying mechanism, we analysed inflammatory cytokines in the CSF. A trend towards elevated levels of IL-6, IL-8 and TNF-alpha was seen in patients with severe NIV compared with no, unspecific or mild NIV, but did not reaching the level of significance (n = 12; Figure 3A–C). BBB integrity was assessed according to albumin quotient in CSF and IL-8 increase was significantly correlated with BBB disruption (p = <0.05). Patients with BBB disruption were found to show a trend towards higher levels of IL-6 and TNF-alpha but this did not reach the level of significance (Figure 3A–C; inlays).

Figure 3.

Cerebrospinal fluid (CSF) and blood analysis of COVID-19 patients.

To evaluate autoimmune mediated mechanisms that may facilitate NIV in COVID-19, various antibodies against neuronal or glial proteins (see Methods) were analysed in serum samples (Figure 3D). Overall, 35% of COVID-19 patients who were tested for the presence of neuronal or glial antibodies showed positivity for at least one antibody. We found antibodies against titin, MOG, Yo, Mi2a/2b, neuronal-antigen and DNER, without any association with clinical presentation (Table 5). There was no significant difference between NIV groups. Positivity was found in 45.5% of patients with no NIV (n = 11); 50% of patients with unspecific NIV (n = 4); 20% of patients with mild NIV (n = 5); and 35% of patients with severe NIV (n = 11).

Table 5.

Antibodies against neuronal epitopes and corresponding COVID-19 severity and neurological involvement.

Auto antibody epitopes	COVID-19 severity	Neurological involvement severity	Neurological symptom
Titin	Severe	Severe	Seizures, myopathy
Neuronal antigen	Mild	Unspecific	Mild cognitive deficit
Neuronal antigen	Moderate	Unspecific	Severe headache
PL7, MOG IgG	Mild	Mild	Dysphagia
Yo	Severe	Severe	Cerebral ischaemia
Mi-2a	Moderate	Unspecific	Severe headache
MOG IgG	Severe	Severe	Cerebral bleeding
Mi-2b	Moderate	Unspecific	Severe headache
Neuronal antigen	Mild	Mild	Impaired smell/taste
DNER	Mild	Mild	Impaired smell/taste

Analysis of CSF and blood neurofilament (heavy chain) concentrations did not show significant differences between NIV groups (Figure 3E and F).

Discussion

In this study we prospectively enrolled 102 patients who were positive for SARS-CoV-2 to investigate the nature, frequency and severity of neurological complications of COVID-19. We identified pre-disposing factors for NIV and suggest inflammatory-mediated mechanisms driving neurological manifestations of COVID-19.

We found stroke to be the most frequent severe neurological complication of COVID-19. In this study, 12% of all patients suffered ischaemic stroke including half of all severe NIV cases. This number is higher than that found in previously published retrospective studies, which reported that 5% of COVID-19 patients suffered ischaemic stroke,¹ and higher than a meta-analysis of 10 studies, which found an incidence of 1.8%.¹⁶ Intracerebral haemorrhage was found to be the second most commonly occurring severe NIV in COVID-19 patients; three out of five events occurred during systemic anticoagulation required for extracorporeal membrane oxygenation (ECMO) therapy.¹⁷ Despite the fact that haemorrhages have been reported in other viral conditions such as in H3N2 influenza pneumonia¹⁸ and direct association with SARS-CoV-2 has been discussed before,¹⁹ our data suggest ECMO therapy as the predominant cause. The clinical relevance of this study is underlined not just by the high frequency of severe NIV, but also by the finding that severe NIV tripled mortality compared with patients without NIV.

In contrast to previous findings,²⁰ we found severity of respiratory symptoms in COVID-19 as a key pre-disposing factor for the development of severe NIV. As pre-existing neurological conditions accumulate with increasing age, the average age could be excluded as a risk factor for developing severe NIV.^1,21

Beside these severe NIV endpoints, we furthermore monitored mild neurological signs and symptoms, mainly ageusia and anosmia, which was found in 8.8% of all cases, the frequency of which ranges from 6% to 88% in the literature.^1,22–24 As these signs and symptoms were discussed as the most common forms of NIV in COVID-19,²⁵ a pre-selection bias of our mono-centre university hospital study may have been overestimation of severe cases and underestimation of mild NIV.

We separately assessed unspecific NIV – as a critical advance in scientific knowledge compared with previous studies – and found unspecific NIV, such as cognitive decline, muscular weakness, delirium and impaired consciousness, in 24.5% of all COVID-19 cases in this cohort. This finding has significant clinical relevance, showing that increased mortality is not only contributed to by severe NIV but also by the presence of unspecific NIV. Unspecific NIV is associated with a doubling in mortality compared with patients without NIV. In relation to the role of pre-existing neurological conditions, we found them increased in patients with unspecific NIV and as major risk factor for the development of severe NIV.

The proportion of patients with delirium and cognitive decline in this cohort was high, at almost 19%, comparable to that reported in former studies, which describe confusion and agitation in up to 69% of patients⁷ and impaired consciousness in 14% of patients.¹ Remarkably, this high proportion of patients with unspecific NIV resembles other viral respiratory conditions, such as H1N1, where mild neurological signs and symptoms, most often headache, numbness, paraesthesia, drowsiness and coma,^26–28 are reported in up to 42% of patients. As previously suggested, we considered the assertion that impaired consciousness was related to epileptic activity.^6,24 Indeed, we found seizures in 2.9% of all COVID-19 patients, but no relevant alterations in electroencephalography were recorded (Supplemental Material results online) in patients with impaired consciousness or cognitive decline in our study.

To further delineate the pathophysiologic mechanism underlying NIV in COVID-19 patients we analysed CSF and blood samples. Viral RNA was not detectable in CSF of patients presenting with neurological signs and symptoms. Despite a lot of effort to detect SARS-CoV-2 RNA in CSF, most studies could not detect any or found evidence in a few individuals.^7,29–32 A review article suggests a positive detection of SARS-CoV-2 in 1.28% of the cases among 1018 pooled cases. This result was calculated by including 13 studies reporting positive results in 13 of 67 patients, and 43 reported negative results in 951 patients.³³

In line with our negative PCR results, antibody indices for SARS-CoV-2 did not suggest intrathecal antibody production and argue against cerebral virus replication and cerebral viral invasion.

Still, we cannot completely rule out direct central nervous system infection with SARS-CoV-2 in our study. One limitation is the low patient numbers included in the CSF analysis. Also, the fact that increased leucocytes were found in three patients and SARS-CoV-2 specific antibodies were found in some, despite the fact that these patients mainly were found with BBB disruption, indicates that further studies are needed to address this question.

We found pleocytosis in the CSF of some patients with severe NIV, elevated inflammatory cytokines and BBB disruption in half of all patients with severe NIV. Angiotensin converting enzyme 2, as it binds to SARS-CoV-2,³⁴ is ubiquitously expressed on epithelia and brain tissue.^35,36 Receptor binding can cause a storm of cytokines,^11,37 which may also explain BBB disruption in our patients.³⁸ Back to bench side, an increase of pro-inflammatory cytokines and BBB disruption triggers coagulation,³⁷ and may further explain the high incidence of stroke in COVID-19 patients. The interaction between inflammation and vessel clots has been described for other conditions.^39,40 BBB disruption – particularly in the temporal lobe – can further facilitate seizures⁴¹ and cognitive decline.⁴² Cytokines are also known to affect the peripheral nervous system and consecutive demyelination⁴³ and lead to further organ damage.⁴⁴

We assessed the question whether autoimmune phenomena may further influence the severity and incidence of NIV in SARS-CoV-2 positive patients, as previously considered in relation to Middle East Respiratory Syndrome.⁴⁵ Indeed, a remarkably high proportion of patients (35%) showed positivity for at least one of the antibodies tested against neuronal epitopes.

As there was no correlation between clinical presentation and the detection of neuronal antibodies and no correlation between antibody frequency and NIV frequency/severity, we assume that the detection of these antibodies represents a general immune activation in COVID-19 patients. The inflammatory stimulus of SARS-CoV-2 and the high cytokine release may lead to unmasking of epitopes by unspecific epitope spreading. CSF and blood analysis within our study suggest that BBB disruption and cytokine release as well as autoimmune mechanisms are involved in development of NIV in COVID-19.

As a single centre analysis, this study is limited by the low patient numbers in some of the subgroups, selection bias and the lack of longitudinal long-term data. Despite these limitations, compared with other previous studies that investigated NIV, we present the first prospective cohort of only SARS-CoV-2 PCR positive patients.

We identified clinical risk factors for severe NIV and CSF changes that provide evidence for indirect inflammatory mechanisms driving neurological manifestations of COVID-19 infection.

Supplemental Material

sj-pdf-1-tan-10.1177_1756286421993701 – Supplemental material for Observational cohort study of neurological involvement among patients with SARS-CoV-2 infection

Supplemental material, sj-pdf-1-tan-10.1177_1756286421993701 for Observational cohort study of neurological involvement among patients with SARS-CoV-2 infection by Michael Fleischer, Martin Köhrmann, Sebastian Dolff, Fabian Szepanowski, Karsten Schmidt, Frank Herbstreit, Cansu Güngör, Benjamin Stolte, Katharina Marie Steiner, Christine Stadtler, Joachim Riße, Melanie Fiedler, Gerd Meyer zu Hörste, Anne-K. Mausberg, Clemens Kill, Michael Forsting, Ulrich Sure, Ulf Dittmer, Oliver Witzke, Thorsten Brenner, Christoph Kleinschnitz and Mark Stettner in Therapeutic Advances in Neurological Disorders

Footnotes

Author contributions

Michael Fleischer: major role in acquisition and analysing data; Martin Köhrmann: revised the manuscript for intellectual content; Sebastian Dolff: interpreted the data; revised the manuscript for intellectual content; Fabian Szepanowski: revised the manuscript for intellectual content; Karsten Schmidt: major role in acquisition of the data; Frank Herbstreit: revised the manuscript for intellectual content; Cansu Güngör major role in acquisition of the data; Ben Stolte: major role in acquisition of the data; Christine Stadtler: major role in acquisition of the data; Joachim Riße: major role in acquisition of the data; Oliver Witzke: interpreted the data; revised the manuscript for intellectual content; Melanie Fiedler: major role in acquisition of the data; Anne-Kathrin Mausberg: revised the manuscript for intellectual content; Clemens Kill: major role in acquisition of the data; Gerd Meyer zu Horste: interpreted the data; revised the manuscript for intellectual content; Katharina Steiner: major role in acquisition of the data; Michael Forsting: revised the manuscript for intellectual content; Ulrich Sure: revised the manuscript for intellectual content; Ulf Dittmer: interpreted the data; revised the manuscript for intellectual content; Torsten Brenner: revised the manuscript for intellectual content; Christoph Kleinschnitz: design and conceptualized study; analysed the data; drafted the manuscript for intellectual content; Mark Stettner: design and conceptualized study; analysed the data; drafted the manuscript for intellectual content.

Conflict of interest

M. Fleischer reports no disclosures relevant to the manuscript.

M. Köhrmann reports no disclosures relevant to the manuscript.

S. Dolff reports no disclosures relevant to the manuscript.

F. Szepanowski reports no disclosures relevant to the manuscript.

K. Schmidt reports no disclosures relevant to the manuscript.

F. Herbstreit has received speaker honoraria from Biotest and Maquet Getinge.

C. Güngör reports no disclosures relevant to the manuscript.

B. Stolte reports no disclosures relevant to the manuscript.

Ch. Stadtler reports no disclosures relevant to the manuscript.

J. Riße reports no disclosures relevant to the manuscript.

O. Witzke has received research grants for clinical studies, speaker’s fees, honoraria and travel expenses from Amgen, Alexion, Astellas, Basilea, Biotest, Bristol-Myers Squibb, Correvio, Chiesi, Gilead, Hexal, Janssen, Dr. F. Köhler Chemie, MSD, Novartis, Roche, Pfizer, Sanofi, TEVA and UCB.

M. Fiedler reports no disclosures relevant to the manuscript.

A. Mausberg reports no disclosures relevant to the manuscript.

C. Kill reports no disclosures relevant to the manuscript.

G. Meyer zu Horste has received speaker honoraria and served in advisory boards for LFB Pharma.

K. Steiner reports no disclosures relevant to the manuscript.

M. Forsting reports no disclosures relevant to the manuscript.

U. Sure reports no disclosures relevant to the manuscript.

U. Dittmer reports no disclosures relevant to the manuscript.

T. Brenner reports no disclosures relevant to the manuscript.

C. Kleinschnitz reports no disclosures relevant to the manuscript.

M. Stettner served on the scientific advisory and/or received speaker honoraria or travel funding from UCB, Biogen Idec; Grifols, Genzyme, Roche, Merck, Novartis, Octapharma, Sanofi-Aventis, TEVA, and Bayer Healthcare.

All authors declare approval of the version that is to be published.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was obtained from the Foundation of the University Hospital Essen (Stiftung Universitätsmedizin Essen).

Supplemental material

Supplemental material for this article is available online.

ORCID iD

Mark Stettner

References

Mao

Jin

Wang

, et al Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020; 77: 683–690.

Werner

Scullen

Mathkour

, et al Neurological impact of coronavirus disease of 2019: practical considerations for the neuroscience community. World Neurosurg 2020; 139: 344–354.

Poyiadji

Shahin

Noujaim

, et al COVID-19-associated acute hemorrhagic necrotizing encephalopathy: CT and MRI features. Radiology 2020; 296: E119–E120.

Wong

Craik

Newman

, et al Lessons of the month 1: a case of rhombencephalitis as a rare complication of acute COVID-19 infection. Clin Med (Lond) 2020; 20: 293–294.

Bai

Hashikawa

The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. J Med Virol 2020; 92: 552–555.

Tsai

San

, et al The neurologic manifestations of coronavirus disease 2019 pandemic: a systemic review. Front Neurol 2020; 11: 498.

Helms

Kremer

Merdji

, et al Neurologic features in severe SARS-CoV-2 infection. N Engl J Med 2020; 382: 2268–2270.

Pouga

Encephalitic syndrome and anosmia in COVID-19: do these clinical presentations really reflect SARS-CoV-2 neurotropism? A theory based on the review of 25 COVID-19 cases. J Med Virol. Epub ahead of print 16 July 2020. DOI: 10.1002/jmv.26309.

Desforges

Le Coupanec

Stodola

, et al Human coronaviruses: viral and cellular factors involved in neuroinvasiveness and neuropathogenesis. Virus Res 2014; 194: 145–158.

10.

Blanco-Melo

Nilsson-Payant

Liu

, et al Imbalanced host response to SARS-CoV-2 drives development of COVID-19. Cell 2020; 181: 1036–1045 e1039.

11.

Mehta

McAuley

Brown

, et al COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020; 395: 1033–1034.

12.

Xue

Involvement of the nervous system in SARS-CoV-2 infection. Neurotox Res 2020; 38: 1–7.

13.

Arbour

Day

Newcombe

, et al Neuroinvasion by human respiratory coronaviruses. J Virol 2000; 74: 8913–8921.

14.

Desforges

Le Coupanec

Dubeau

, et al

Human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system?

Viruses 2019; 12: 14.

15.

Buonsenso

Parri

De Rose

, et al Toward a clinically based classification of disease severity for paediatric COVID-19. Lancet Infect Dis. Epub ahead of print 15 May 2020. DOI: 10.1016/S1473-3099(20)30396-0.

16.

Fridman

Bullrich

Jimenez-Ruiz

, et al Stroke risk, phenotypes, and death in COVID-19: systematic review and newly reported cases. Neurology 2020; 95: e3373–e3385.

17.

Cavayas

Del Sorbo

Fan

Intracranial hemorrhage in adults on ECMO. Perfusion 2018; 33: 42–50.

18.

AbdelRazek

Leone

Venna

Hemorrhagic encephalitis associated with H3N2 influenza A viral pneumonia. Neurology 2018; 90: 336–337.

19.

Fotuhi

Mian

Meysami

, et al Neurobiology of COVID-19. J Alzheimers Dis 2020; 76: 3–19.

20.

Oxley

Mocco

Majidi

, et al Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382: e60.

21.

Wang

, et al Acute cerebrovascular disease following COVID-19: a single center, retrospective, observational study. Stroke Vasc Neurol 2020; 382: e60.

22.

Phua

Weng

Ling

, et al Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med 2020; 8: 506–517.

23.

Lechien

Chiesa-Estomba

De Siati

, et al Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol 2020; 277: 2251–2261.

24.

Spinato

Fabbris

Polesel

, et al Alterations in smell or taste in mildly symptomatic outpatients with SARS-CoV-2 infection. JAMA 2020; 323: 2089–2090.

25.

Vaira

Salzano

Deiana

, et al Anosmia and ageusia: common findings in COVID-19 patients. Laryngoscope 2020; 130: 1787.

26.

Asadi-Pooya

Yaghoubi

Nikseresht

, et al The neurological manifestations of H1N1 influenza infection; diagnostic challenges and recommendations. Iran J Med Sci 2011; 36: 36–39.

27.

Nichols

Peck Campbell

Boeckh

Respiratory viruses other than influenza virus: impact and therapeutic advances. Clin Microbiol Rev 2008; 21: 274–290.

28.

Bohmwald

Galvez

NMS

Rios

, et al Neurologic alterations due to respiratory virus infections. Front Cell Neurosci 2018; 12: 386.

29.

Bellon

Schweblin

Lambeng

, et al Cerebrospinal fluid features in SARS-CoV-2 RT-PCR positive patients. Clin Infect Dis. Epub ahead of print 8 August 2020. DOI: 10.1093/cid/ciaa1165.

30.

Bai

Hashikawa

Response to commentary on “The neuroinvasive potential of SARS-CoV-2 may play a role in the respiratory failure of COVID-19 patients”. J Med Virol 2020; 92: 707–709.

31.

Moriguchi

Harii

Goto

, et al A first case of meningitis/encephalitis associated with SARS-Coronavirus-2. Int J Infect Dis 2020; 94: 55–58.

32.

Westhoff

Seibert

Bauer

, et al Allograft infiltration and meningoencephalitis by SARS-CoV-2 in a pancreas-kidney transplant recipient. Am J Transplant 2020; 20: 3216–3220.

33.

Liu

Tan

, et al Evidence of central nervous system infection and neuroinvasive routes, as well as neurological involvement, in the lethality of SARS-CoV-2 infection. J Med Virol. Epub ahead of print 1 October 2020. DOI: 10.1002/jmv.26570.

34.

Bhatraju

Ghassemieh

Nichols

, et al Covid-19 in critically ill patients in the Seattle region - case series. N Engl J Med 2020; 382: 2012–2022.

35.

Liu

, et al Coronavirus disease 2019 (COVID-19): current status and future perspectives. Int J Antimicrob Agents 2020; 55: 105951.

36.

Zhang

, et al Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues. Infect Dis Poverty 2020; 9: 45.

37.

Xiong

Liang

Wei

YD.

Changes in blood coagulation in patients with severe coronavirus disease 2019 (COVID-19): a meta-analysis. Br J Haematol 2020; 189: 1050–1052.

38.

Minagar

Alexander

JS.

Blood-brain barrier disruption in multiple sclerosis. Mult Scler 2003; 9: 540–549.

39.

De Meyer

Denorme

Langhauser

, et al Thromboinflammation in stroke brain damage. Stroke 2016; 47: 1165–1172.

40.

Gob

Reymann

Langhauser

, et al Blocking of plasma kallikrein ameliorates stroke by reducing thromboinflammation. Ann Neurol 2015; 77: 784–803.

41.

van Vliet

Costa

Araujo

Redeker

, et al Blood-brain barrier leakage may lead to progression of temporal lobe epilepsy. Brain 2007; 130: 521–534.

42.

Sweeney

Sagare

Zlokovic

BV.

Blood-brain barrier breakdown in Alzheimer disease and other neurodegenerative disorders. Nat Rev Neurol 2018; 14: 133–150.

43.

Stettner

Lohmann

Wolffram

, et al Interleukin-17 impedes Schwann cell-mediated myelination. J Neuroinflammation 2014; 11: 63.

44.

Spiezia

Boscolo

Poletto

, et al COVID-19-related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure. Thromb Haemost 2020; 120: 998–1000.

45.

Kim

Heo

Kim

, et al Neurological complications during treatment of middle east respiratory syndrome. J Clin Neurol 2017; 13: 227–233.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.13 MB