In serious cases of corona SARS-CoV-2 enters the lungs, which results in lasting damage of the lungs. However, the virus, or the body’s response to it, can injure other organs as well. Scientists are just performing research on the scope and nature of that harm. Recent news indicates that various organs may be affected, and it appears that neurological symptoms are seen in around one third of the COVID-19 patients. What are the indications thus far that the brain is affected in COVID-19 diseased patients? Arjen Brussaard interviews Suzanne Geerlings, infectious disease specialist at Amsterdam UMC, on this topic.

One of the striking set of symptoms in COVID-19 patients centers on the brain and central nervous system. Suzanne Geerlings, infectious disease physician and principal investigator of Amsterdam UMC believes that neurologists are needed to assess coronavirus patients: “We must learn from our patients in the acute phase of the disease. For example, which subgroup has an increased risk of these neurological manifestations and needs more monitoring and evaluation. A prospective cohort with a follow-up in the post COVID-19 outpatient clinic can help us to give more insight into the pathogenesis and hopefully also in prevention and treatment possibilities, because the manifestations can be very severe and even lead to death.”

Intensivists have seen patients with encephalitis, with seizures, and with a ‘sympathetic storm’, a hyperreaction of the sympathetic nervous system that causes seizure-like symptoms. Some people with COVID-19 briefly lose consciousness, others have strokes. Even mildly affected patients report losing their sense of smell. And intensivists wonder whether in some cases, infection depresses the brain stem reflex that senses oxygen starvation. This is another explanation for anecdotal observations that some patients aren’t gasping for air, despite dangerously low blood oxygen levels.

SARS-CoV2 might affect the brain via the ACE2 receptor mediated endocytosis (see info box below). This is now confirmed in case studies reported by Ling Mao et al. in JAMA Neurol. 2020 who describes that patients with severe infections that are more likely to develop neurologic manifestations, especially acute cerebrovascular disease, conscious disturbance, and skeletal muscle injury; most neurologic manifestations occurred early-on in the illness and some patients without typical symptoms (fever, cough, anorexia, and diarrhea) of COVID-19 came to the hospital with only neurologic manifestation as their presenting symptoms.

Hence, in patients with COVID-19, Geerlings says: “We need to pay close attention to their neurologic manifestations, especially for those with severe infections, not only in the Intensive Care Units (ICU), but in all patients who are admitted to the hospital, because these neurologic manifestations may contribute to their chance of mortality.” In line with this, the Amsterdam UMC team of Suzanne Geerlings, Alexander Vlaar, Matthijs Brouwer and Diederik van de Beek is currently setting up a prospective observational clinical trial protocol in COVID-19 patients in which all neurological symptoms (including also an MRI) are assessed throughout the disease.

About ACE2: When an infected person expels virus-laden droplets and someone else inhales them, the novel coronavirus, called SARS-CoV2, enters the nose and throat. Once inside the human body, cells that are rich in a cell-surface receptor called angiotensin-converting enzyme 2 (ACE2), which normally helps regulate blood pressure, marks tissues vulnerable to SARS-CoV2 infection, because the virus requires that receptor to enter a cell. Once inside the cells, the virus hijacks the cell’s machinery, making myriad copies of itself and invading new cells.    

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