Reader response: Neurologic complications of coronavirus infections
ThirugnanamUmapathi, Neurologist, National Neuroscience Institute (Singapore, Singapore)
Submitted April 03, 2020
Dr Nath’s timely editorial1 lists the neurologic complications of coronavirus infections. On behalf of co-authors, I highlight the 5 patients with large artery stroke in the 2003 Severe Acute Respiratory syndrome (SARS) outbreak in Singapore, arising from SARS-CoV1 virus infection.2 Of 206 patients, 48 required intensive care and 32 died. Four of the 5 patients with stroke were critically ill and 3 died. The strokes were deemed thromboembolic. At autopsy, 1 patient had occipital lobe infarction, sterile vegetations in multiple valves, deep venous thrombosis, and pulmonary embolism; this prompted low molecular weight heparin (LMWH) use in subsequent critically ill SARS patients. Nevertheless, a significant number of patients suffered venous thromboembolism in spite of adequate treatment with LMWH.3 Three patients received intravenous immunoglobulin (IVIg) empirically, which might have contributed to stroke. The induction of hfgl2 prothrombinase gene by SARS-CoV1 in experiments raised the possibility of a direct prothrombotic effect of that coronavirus.4 Only 8 patients underwent autopsy; therefore, more strokes may have gone undiagnosed. It is easy to miss stroke in critically ill patients who are heavily sedated and paralyzed. With increasing anecdotal reports (https://journals.lww.com/neurotodayonline), and the use of IVIg in desperately ill COVID-19 patients,5 we reiterate vigilance against strokes and thrombotic complications in critically-ill corona virus infected patients.
Disclosure
The author reports no relevant disclosures. Contact [email protected] for full disclosures.
References
Nath A. Neurologic complications of coronavirus infections. Neurology 2020 Epub Mar 30.
Umapathi T, Kor AC, Venketasubramanian N, et al. Large artery ischaemic stroke in severe acute respiratory syndrome (SARS). J Neurol 2004;251:1227–31.
Lew TW, Kwek TK, Tai D, et al. Acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome. JAMA 2003;290:374–80.
Meifang Han, Weiming Yan, Yuancheng Huang, et al. The nucleocapsid protein of SARS-CoV induces transcription of hfgl2 prothrombinase gene dependent on C/EBP alpha. J Biochem 2008;144:51–62.
Cao W, Liu X, Bai T, et al. High-dose intravenous immunoglobulin as a therapeutic option for deteriorating patients with Coronavirus Disease 2019. Open Forum Infectious Diseases 2020;7;1-6.
Dr Nath’s timely editorial1 lists the neurologic complications of coronavirus infections. On behalf of co-authors, I highlight the 5 patients with large artery stroke in the 2003 Severe Acute Respiratory syndrome (SARS) outbreak in Singapore, arising from SARS-CoV1 virus infection.2 Of 206 patients, 48 required intensive care and 32 died. Four of the 5 patients with stroke were critically ill and 3 died. The strokes were deemed thromboembolic. At autopsy, 1 patient had occipital lobe infarction, sterile vegetations in multiple valves, deep venous thrombosis, and pulmonary embolism; this prompted low molecular weight heparin (LMWH) use in subsequent critically ill SARS patients. Nevertheless, a significant number of patients suffered venous thromboembolism in spite of adequate treatment with LMWH.3 Three patients received intravenous immunoglobulin (IVIg) empirically, which might have contributed to stroke. The induction of hfgl2 prothrombinase gene by SARS-CoV1 in experiments raised the possibility of a direct prothrombotic effect of that coronavirus.4 Only 8 patients underwent autopsy; therefore, more strokes may have gone undiagnosed. It is easy to miss stroke in critically ill patients who are heavily sedated and paralyzed. With increasing anecdotal reports (https://journals.lww.com/neurotodayonline), and the use of IVIg in desperately ill COVID-19 patients,5 we reiterate vigilance against strokes and thrombotic complications in critically-ill corona virus infected patients.
Disclosure
The author reports no relevant disclosures. Contact [email protected] for full disclosures.
References