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      Neurologic Features in Severe SARS-CoV-2 Infection

      letter
      , M.D., Ph.D., , M.D., Ph.D., , M.D., , M.D., , M.D., , M.D., , M.D., Ph.D., , M.D., , Pharm.D., Ph.D., , M.D., Ph.D., , M.D., Ph.D. , M.D., Ph.D.
      The New England Journal of Medicine
      Massachusetts Medical Society
      Keyword part (code): 1Keyword part (keyword): Neurology/NeurosurgeryKeyword part (code): 1_1Keyword part (keyword): Neurology/Neurosurgery General , 1, Neurology/Neurosurgery, Keyword part (code): 1_1Keyword part (keyword): Neurology/Neurosurgery General, 1_1, Neurology/Neurosurgery General, Keyword part (code): 10Keyword part (keyword): Emergency MedicineKeyword part (code): 10_1Keyword part (keyword): Emergency Medicine General , 10, Emergency Medicine, Keyword part (code): 10_1Keyword part (keyword): Emergency Medicine General, 10_1, Emergency Medicine General, Keyword part (code): 12Keyword part (keyword): Pulmonary/Critical CareKeyword part (code): 12_1Keyword part (keyword): Pulmonary/Critical Care General , 12, Pulmonary/Critical Care, Keyword part (code): 12_1Keyword part (keyword): Pulmonary/Critical Care General, 12_1, Pulmonary/Critical Care General, Keyword part (code): 18Keyword part (keyword): Infectious DiseaseKeyword part (code): 18_6Keyword part (keyword): Viral Infections , 18, Infectious Disease, Keyword part (code): 18_6Keyword part (keyword): Viral Infections, 18_6, Viral Infections

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          Abstract

          To the Editor: We report the neurologic features in an observational series of 58 of 64 consecutive patients admitted to the hospital because of acute respiratory distress syndrome (ARDS) due to Covid-19. The patients received similar evaluations by intensivists in two intensive care units (ICUs) in Strasbourg, France, between March 3 and April 3, 2020. Six patients were excluded because of paralytic neuromuscular blockade when neurologic data were collected or because they had died without a neurologic examination having been performed. In all 58 patients, reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assays of nasopharyngeal samples were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The median age of the patients was 63 years, and the median Simplified Acute Physiology Score II at the time of neurologic examination was 52 (interquartile range, 37 to 65, on a scale ranging from 0 to 163, with higher scores indicating greater severity of illness). Seven patients had had previous neurologic disorders, including transient ischemic attack, partial epilepsy, and mild cognitive impairment. The neurologic findings were recorded in 8 of the 58 patients (14%) on admission to the ICU (before treatment) and in 39 patients (67%) when sedation and a neuromuscular blocker were withheld. Agitation was present in 40 patients (69%) when neuromuscular blockade was discontinued (Table 1). A total of 26 of 40 patients were noted to have confusion according to the Confusion Assessment Method for the ICU; those patients could be evaluated when they were responsive (i.e., they had a score of −1 to 1 on the Richmond Agitation and Sedation Scale, on a scale of −5 [unresponsive] to +4 [combative]). Diffuse corticospinal tract signs with enhanced tendon reflexes, ankle clonus, and bilateral extensor plantar reflexes were present in 39 patients (67%). Of the patients who had been discharged at the time of this writing, 15 of 45 (33%) had had a dysexecutive syndrome consisting of inattention, disorientation, or poorly organized movements in response to command. Magnetic resonance imaging (MRI) of the brain was performed in 13 patients (Figs. S1 through S3 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). Although these patients did not have focal signs that suggested stroke, they underwent MRI because of unexplained encephalopathic features. Enhancement in leptomeningeal spaces was noted in 8 patients, and bilateral frontotemporal hypoperfusion was noted in all 11 patients who underwent perfusion imaging. Two asymptomatic patients each had a small acute ischemic stroke with focal hyperintensity on diffusion-weighted imaging and an overlapping decreased apparent diffusion coefficient, and 1 patient had a subacute ischemic stroke with superimposed increased diffusion-weighted imaging and apparent diffusion coefficient signals. In the 8 patients who underwent electroencephalography, only nonspecific changes were detected; 1 of the 8 patients had diffuse bifrontal slowing consistent with encephalopathy. Examination of cerebrospinal fluid (CSF) samples obtained from 7 patients showed no cells; in 2 patients, oligoclonal bands were present with an identical electrophoretic pattern in serum, and protein and IgG levels were elevated in 1 patient. RT-PCR assays of the CSF samples were negative for SARS-CoV-2 in all 7 patients. In this consecutive series of patients, ARDS due to SARS-CoV-2 infection was associated with encephalopathy, prominent agitation and confusion, and corticospinal tract signs. Two of 13 patients who underwent brain MRI had single acute ischemic strokes. Data are lacking to determine which of these features were due to critical illness–related encephalopathy, cytokines, or the effect or withdrawal of medication, and which features were specific to SARS-CoV-2 infection.

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          Author and article information

          Journal
          N Engl J Med
          N. Engl. J. Med
          nejm
          The New England Journal of Medicine
          Massachusetts Medical Society
          0028-4793
          1533-4406
          15 April 2020
          : NEJMc2008597
          Affiliations
          Strasbourg University Hospital, Strasbourg, France
          University of Strasbourg, Strasbourg, France
          Author information
          http://orcid.org/0000-0002-4670-1596
          http://orcid.org/0000-0002-8550-4245
          Article
          NJ202004153820004
          10.1056/NEJMc2008597
          7179967
          32294339
          45ca29a0-b7c6-4b44-bb8f-78b816e99637
          Copyright © 2020 Massachusetts Medical Society. All rights reserved.

          This article is made available via the PMC Open Access Subset for unrestricted re-use, except commercial resale, and analyses in any form or by any means with acknowledgment of the original source. These permissions are granted for the duration of the Covid-19 pandemic or until revoked in writing. Upon expiration of these permissions, PMC is granted a license to make this article available via PMC and Europe PMC, subject to existing copyright protections.

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          Custom metadata
          2020-04-15T17:00:00-04:00
          2020
          04
          15
          17
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          00
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