Peripheral neuropathy in severe COVID-19 resolved with therapeutic plasma exchange

Neuroinflammatory Findings of Corneal Confocal Microscopy in Long COVID-19 Patients, 2 Years after Acute SARS-CoV-2 Infection

OBJECTIVE

To describe corneal confocal microscopy findings in patients with long COVID-19 with persistent symptoms over 20 months after SARS-CoV-2 infection.

DESIGN

A descriptive cross-sectional study that included a total of 88 patients; 60 patients with Long COVID-19 and 28 controls. Long COVID-19 diagnosis was established according to the World Health Organization criteria. Corneal confocal microscopy using a Heidelberg Retina Tomograph II (Heidelberg Engineering, Heidelberg, Germany) was performed to evaluate sub-basal nerve plexus morphology (corneal nerve fiber density, nerve fiber length, nerve branch density, nerve fiber total branch density, nerve fiber area, and nerve fiber width). Dendritic cell density and area, along with microneuromas and other morphological changes of the nerve fibers were recorded.

RESULTS

Long COVID-19 patients presented with reduced corneal nerve density and branch density as well as shorter corneal nerves compared to the control group. Additionally, Long COVID-19 patients showed an increased density of dendritic cells also with a greater area than that found in the control group of patients without systemic diseases. Microneuromas were detected in 15% of Long COVID-19 patients.

CONCLUSIONS

Long COVID-19 patients exhibited altered corneal nerve parameters and increased DC density over 20 months after acute SARS-CoV-2 infection. These findings are consistent with a neuroinflammatory condition hypothesized to be present in patients with Long COVID-19, highlighting the potential role of corneal confocal microscopy as a promising noninvasive technique for the study of patients with Long COVID-19.

Guillain-Barre syndrome secondary to COVID-19 infection: A case report

Guillain-Barre syndrome (GBS) is a rare autoimmune disease that often manifests as a post-viral complication. However, its association with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. We present a rare case of GBS secondary to COVID-19 infection complicated by rapidly progressive sensorimotor deterioration resistant to plasma exchange therapy.

Therapeutic plasma exchange: A potential therapeutic modality for critically ill adults with severe acute respiratory syndrome coronavirus 2 infection

Background

Severe acute respiratory syndrome coronavirus 2 infection can be severe and fatal due to cytokine storm. Therapeutic plasma exchange (TPE) potentially mitigates the harmful effects of such cytokines. We investigated the use of TPE, as rescue therapy, in patients with severe Coronavirus disease 2019 (COVID‐19) infection.

Study Design and Methods

A retrospective analysis on COVID‐19 patients admitted to the intensive care unit and treated with TPE from April 17, 2020 to July 2, 2020. This group was compared with COVID‐19 patients who received standard therapy without TPE. The following outcomes were analyzed: changes in laboratory parameters, length of hospital stay (LOS), days on mechanical ventilation, mortality at days 14 and overall mortality.

Results

A total of 95 patients were included, among whom 47% (n = 45) received TPE. Patients who received TPE had reductions in C‐reactive protein (P = .002), ferritin (P < .001) and interleukin‐6 (P = .013). After employing entropy‐balancing matching method, those on TPE were also more likely to discontinue inotropes (72% vs 21%; P < .001). However, they were more likely to be associated with longer LOS (23 vs 14 days; P = .002) and longer days on ventilatory support (14 vs 8 days; P < .001). Despite marginal mortality benefit at 14‐days (7.9% vs 24%; P = .071), there was no significant differences in overall mortality (21% vs 31%; P = .315) between the groups.

Conclusions

TPE was effective in reducing inflammatory markers in patients with severe COVID‐19 infection, however, further research is warranted.

Prevalence of peripheral neuropathy and myopathy in patients post-COVID-19 infection

Background

Severe acute respiratory syndrome (SARS‐CoV‐2), caused by the Coronavirus 2019 (COVID‐19), has become a life‐threatening epidemic, affecting multiple organs, including the nervous system. Recent studies have documented that COVID‐19‐associated peripheral neuropathy is a common and frequent problem, with central and peripheral nervous system complications.

Objective

This work aims to evaluate the peripheral nerves and muscle involvement after COVID‐19 infection, in addition to studying the prevalence rate and risk factors of their affection.

Methods

The study involved 400 patients, divided into 2 groups, with a history of COVID‐19 infection with or without symptoms of neuromuscular affection, and 30 gender‐ and age‐matched healthy volunteers were involved as controls. They were referred to the Department of Rheumatology and Rehabilitation for electro‐diagnosis. All participants performed complete clinical examination and laboratory measures with an electrophysiological study.

Results

The prevalence of peripheral neuropathy and myopathy in post‐COVID‐19 patients was 56.3% among all patients. A significant difference was detected among patients of both groups regarding serum creatine phosphokinase level, clinical signs, and electrophysiologic findings of neuropathy and myopathy compared to the control group, with more prominent features among the symptomatic group. Histories of hospitalization, severe and long‐lasting respiratory symptoms were risk factors for developing neuromuscular complications.

Conclusions

The present study could indicate that muscle involvement and peripheral nerve affection are common problems even among asymptomatic patients after COVID‐19 infection, especially in the presence of any risk factors.

Role of Therapeutic Plasmapheresis in SARS-CoV-2 Induced Cytokine Release Syndrome: A Retrospective Cohort Study on COVID-19 Patients

Background

Cytokine release syndrome (CRS) significantly contributes to the pathophysiology and progression of COVID-19. It is speculated that therapeutic plasma exchange (TPE) can dampen CRS via elimination of pathogenic cytokines.

Objectives

The study is intended to compare the outcomes of COVID-19 patients with CRS treated with TPE and standard care (SC) to their counterparts receiving SC alone.

Methodology

A retrospective cohort study of severe COVID-19 confirmed patients presenting with CRS and admitted to the medical ICU was conducted between March and August 2021. Using case-control (CC) matching 1:1, 162 patients were selected and divided into two equal groups. The primary outcome was 28-day in-hospital survival analysis in severe COVID-19 patients with CRS. However, secondary outcomes included the effect of plasmapheresis on inflammatory markers, the need for mechanical ventilation, the rate of extubation, and the duration of survival.

Results

After CC matching, the study cohort had a mean age of 55.41 (range 56.41±11.56 in TP+SC and 54.42±8.94 in SC alone; p=0.22). There were 25.95% males and 74.05% females in both groups. The mean time from first day of illness to hospitalization was 6.53±2.18 days. The majority of patients with CRS had comorbid conditions (75.9%). Diabetes mellitus was the most common comorbidity (40.1%), followed by hypertension (25.3%), and chronic kidney disease (21%). Notable reduction in some inflammatory markers (D-dimers, LDH, CRP and serum ferritin) (p<0.0001) was observed in the group that received TPE+SC. Moreover, the patients in the plasmapheresis plus standard care group required relatively less mechanical ventilation as compared to the group receiving SC alone (46.9% vs 58.1%, respectively; p>0.05). The rate of extubation in the TP+SC group vs SC alone was 60.5% vs 44.7%, respectively (p>0.05). Similarly, the mortality percentages in both groups were 19.8% and 24.7%, respectively.

Conclusion

For this particular group of matched patients with COVID-19-induced CRS, TPE+SC was linked with relatively better overall survival, early extubation, and earlier discharge compared to SC alone. As these results were not statistically significant, multi-centered randomized control trials are needed to further elaborate the role of therapeutic plasmapheresis in COVID-19 induced CRS.

Role of therapeutic plasma exchange in the management of COVID-19-induced cytokine storm syndrome

The risk of mortality in patients with coronavirus disease 2019 (COVID-19) is largely related to an excessive immune response, resulting in a hyperinflammatory and hypercoagulable condition collectively referred to as cytokine storm syndrome (CSS). Management of critically ill patients with COVID-19 has included attempts to abate this process, prevent disease progression, and reduce mortality. In this context, therapeutic plasma exchange (TPE) offers an approach to eliminate inflammatory factors and cytokines, offset the pathologic coagulopathy, and reduce the CSS effects. The aim of this review is to analyze available data on the use of TPE for the treatment of CSS in patients with COVID-19. Systematic searches of PubMed, Scopus and COVID-19 Research were conducted to identify articles published between March 1, 2020 and May 26, 2021 reporting the use of TPE for the treatment of COVID-19-induced CSS. A total of 34 peer-reviewed articles (1 randomized controlled trial, 4 matched case-control series, 15 single-group case series, and 14 case reports), including 267 patients, were selected. Despite the low evidence level of the available data, TPE appeared to be a safe intervention for critically ill patients with COVID-19-induced CSS. Although inconsistencies exist between studies, they showed a general trend for decreased interleukin-6, C-reactive protein, ferritin, D-dimer, and fibrinogen levels and increased lymphocyte counts following TPE, supporting the immunomodulatory effect of this treatment. Moreover, TPE was associated with improvements in clinical outcomes in critically ill patients with COVID-19. While TPE may offer a valuable option to treat patients with COVID-19-induced CSS, high-quality randomized controlled clinical trials are needed to confirm its potential clinical benefits, feasibility, and safety. Moreover, clear criteria should be established to identify patients with CSS who might benefit from TPE.

Lower limb axonal mononeuropathies as sequelae of COVID-19: a case report and review of literature

Background

Neurological symptoms and complications of Coronavirus disease 2019 (COVID-19) were seldom discussed in the literature initially. Neurological symptoms such as headache, dizziness, anosmia, hypogeusia, and neuralgia are, however, now being reported commonly. Mononeuropathies are rare complications of COVID-19, with most cases associated with prolonged intensive care stay.

Case presentation

A 61-year-old gentleman with prior history of well-controlled diabetes and hypertension was recently treated for COVID-19 pneumonia with supplemental oxygen and positive pressure ventilation. He now presented with left-sided foot weakness two weeks after recovering from the viral illness. On examination he had normal bulk and tone and a power of 4/5 in proximal and distal muscles of bilateral lower limbs except for ankle dorsiflexion on the left which was 2/5. He also had absent ankle and knee reflexes bilaterally with bilateral flexor plantar reflexes. Since the patient had no back pain and the sensory system was normal, the lesion was localized to the peripheral nerves and a Nerve Conduction Studies and Electromyography (NCS/EMG) was done. NCS/EMG showed findings suggestive of axonal mononeuropathies. Relevant workup done to identify the cause of mononeuropathy was negative including infectious and autoimmune workup. Since diabetes was well-controlled and he had no intensive care stay his findings were presumed to be associated with resolving COVID-19 infection. The patient underwent aggressive daily physical therapy and has started to show improvement in symptoms.

Conclusions

Complications such as mononeuropathies should be kept in mind in patients recovering from COVID-19 infection, since timely diagnosis can improve clinical outcomes in patients.

COVID-19 and the Peripheral Nervous System. A 2-year review from the pandemic to the vaccine era

Increasing literature has linked COVID‐19 to peripheral nervous system (PNS) diseases. In addition, as we move from the pandemic to the vaccination era, literature interest is shifting towards the potential association between COVID‐19 vaccines and PNS manifestations. We reviewed published literature on COVID‐19, COVID‐19 vaccines and PNS manifestations between 1 January 2020 and 1 December 2021. For Guillain‐Barré syndrome (GBS), isolated cranial neuropathy (ICN) and myositis associated with COVID‐19, the demographic, clinical, laboratory, electrophysiological and imaging features were included in a narrative synthesis. We identified 169 studies on COVID‐19‐associated complications, including 63 papers (92 patients) on GBS, 29 papers (37 patients) on ICN and 11 papers (18 patients) on myositis. Additional clinical phenotypes included chronic inflammatory demyelinating polyneuropathy, vasculitic neuropathies, neuralgic amyotrophy, critical care‐related complications, and myasthenia gravis. PNS complications secondary to COVID‐19 vaccines have been reported during randomized clinical trials, in real‐world case reports, and during large‐scale surveillance programs. These mainly include cases of GBS, Bell's palsy, and cases of neuralgic amyotrophy. Based on our extensive review of the literature, any conclusion about a pathophysiological correlation between COVID‐19 and PNS disorders remains premature, and solely supported by their temporal association, while epidemiological and pathological data are insufficient. The occurrence of PNS complications after COVID‐19 vaccines seems limited to a possible higher risk of facial nerve palsy and GBS, to a degree that widespread access to the ongoing vaccination campaign should not be discouraged, while awaiting for more definitive data from large‐scale surveillance studies.

The report from ASFA COVID-19 taskforce: Considerations and prioritization on apheresis procedures during the SARS-CoV-2 coronavirus disease (COVID-19) pandemic

Since vaccination for SARS‐CoV‐2 coronavirus started, the trajectory of patient numbers infected with the virus has improved once; however, variants of SARS‐CoV‐2 have emerged and more people have been infected; therefore, pandemic status is still far from resolution. Government and social efforts to prevent coronavirus infection continue in most states in the US and globally even after the Centers for Disease Control and Prevention declared some restriction relief for fully vaccinated people in March 2021. Healthcare institutions and various professional organizations have developed guidelines or policies to prevent the spread of these coronaviruses in the setting of apheresis. In this report, the issues that apheresis services may encounter under the current COVID‐19 (SARS‐CoV‐2 coronavirus disease) pandemic will be discussed with potential strategies that can be adapted for efficient and optimum use of apheresis resources.

Corneal confocal microscopy identifies corneal nerve fibre loss and increased dendritic cells in patients with long COVID

Background/Aims

Long COVID is characterised by a range of potentially debilitating symptoms which develop in at least 10% of people who have recovered from acute SARS-CoV-2 infection. This study has quantified corneal sub-basal nerve plexus morphology and dendritic cell (DC) density in patients with and without long COVID.

Methods

Forty subjects who had recovered from COVID-19 and 30 control participants were included in this cross-sectional comparative study undertaken at a university hospital. All patients underwent assessment with the National Institute for Health and Care Excellence (NICE) long COVID, Douleur Neuropathique 4 (DN4) and Fibromyalgia questionnaires, and corneal confocal microscopy (CCM) to quantify corneal nerve fibre density (CNFD), corneal nerve branch density (CNBD), corneal nerve fibre length (CNFL), and total, mature and immature DC density.

Results

The mean time after the diagnosis of COVID-19 was 3.7±1.5 months. Patients with neurological symptoms 4 weeks after acute COVID-19 had a lower CNFD (p=0.032), CNBD (p=0.020), and CNFL (p=0.012), and increased DC density (p=0.046) compared with controls, while patients without neurological symptoms had comparable corneal nerve parameters, but increased DC density (p=0.003). There were significant correlations between the total score on the NICE long COVID questionnaire at 4 and 12 weeks with CNFD (ρ=−0.436; p=0.005, ρ=−0.387; p=0.038, respectively) and CNFL (ρ=−0.404; p=0.010, ρ=−0.412; p=0.026, respectively).

Conclusion

Corneal confocal microscopy identifies corneal small nerve fibre loss and increased DCs in patients with long COVID, especially those with neurological symptoms. CCM could be used to objectively identify patients with long COVID.

Peripheral neuropathy in COVID-19 is due to immune-mechanisms, pre-existing risk factors, anti-viral drugs, or bedding in the Intensive Care Unit

BACKGROUND

This mini-review aims to summarize and discuss previous and recent advances in the clinical presentation, pathophysiology, diagnosis, treatment, and outcome of SARS-CoV-2-associated peripheral neuropathies.

METHODS

Literature review.

RESULTS

Altogether, 105 articles about SARS-CoV-2-associated neuropathy describing 261 patients were retrieved. Peripheral neuropathy in patients with COVID-19 is frequent and predominantly due to immune mechanisms or neurotoxic side effects of drugs used to treat the symptoms of COVID-19 and, to a lesser extent, due to the compression of peripheral nerves resulting from prolonged bedding in the Intensive Care Unit (ICU) and pre-existing risk factors such as diabetes. SARS-CoV-2 does not cause viral neuropathy. Neurotoxic drugs such as daptomycin, linezolid, lopinavir, ritonavir, hydro-chloroquine, cisatracurium, clindamycin, and glucocorticoids should be administered with caution and patients should be appropriately bedded in the ICU to prevent SARS-CoV-2-associated neuropathy. Patients with Guillain-Barré syndrome (GBS) benefit from immunoglobulins, plasma exchange, and steroids.

CONCLUSIONS

Neuropathies of peripheral nerves in patients with COVID-19 are frequent and mostly result from immune mechanisms or neurotoxic side effects of drugs used to treat the symptoms of COVID-19 and, to a lesser extent, from the compression of peripheral nerves due to prolonged bedding on the ICU. SARS-CoV-2 does not cause infectious neuropathy.

COVID-19-Induced Left Sciatic Neuropathy Requiring Prolonged Physical Medicine and Rehabilitation

A growing number of case reports and series have described a wide spectrum of neurological manifestations of COVID-19 disease including encephalopathy, cerebrovascular disease, and Guillain-Barre syndrome (GBS). However, peripheral neuropathy associated with COVID-19 disease has been uncommonly reported. Here, we describe a young patient with a COVID-19 infection who developed unilateral sciatic neuropathy during the course of treatment requiring prolonged physical medicine and rehabilitation stay. She was treated in the intensive care unit (ICU) for hypoxic respiratory failure for 22 days total, during which she was intubated, sedated, and paralyzed for 14 days. She received dexamethasone, convalescent plasma, and remdesivir for COVID-19; she also received ceftriaxone and azithromycin for possible superimposed bacterial pneumonia. The hypoxic respiratory failure was improved progressively, and she was extubated. On day 17 of ICU stay, she reported numbness and weakness in left leg and had 0/5 motor strength at the left ankle in all directions. She was able to move left hip and knee and had decreased sensation to light touch and pain from the level of the left knee to the toes. Imaging of the brain and spine showed no obvious findings that would explain the neurological symptoms. On electromyography (EMG), there was acute denervation in the left tibialis anterior muscle. She required prolonged physical medicine and rehabilitation care, greater than 60 days during which she had some improvement in sensation, but remained without ankle movement for two more months. This could be a rare manifestation of COVID-19-induced sciatic mono-neuropathy given her symptoms, EMG reports, clinical exam, and normal imaging studies.

Cerebrospinal fluid from COVID-19 patients with olfactory/gustatory dysfunction: A review

Objective

We reviewed the literature on cerebrospinal fluid (CSF) testing in patients with altered olfactory/gustatory function due to COVID-19 for evidence of viral neuroinvasion.

Methods

We performed a systematic review of Medline and Embase to identify publications that described at least one patient with COVID-19 who had altered olfactory/gustatory function and had CSF testing performed. The search ranged from December 1, 2019 to November 18, 2020.

Results

We identified 51 publications that described 70 patients who met inclusion criteria. Of 51 patients who had CSF SARS-CoV-2 PCR testing, 3 (6%) patients had positive results and 1 (2%) patient had indeterminate results. Cycle threshold (Ct; the number of amplification cycles required for the target gene to exceed the threshold, which is inversely related to viral load) was not provided for the patients with a positive PCR. The patient with indeterminate results had a Ct of 37 initially, then no evidence of SARS-CoV-2 RNA on repeat testing. Of 6 patients who had CSF SARS-CoV-2 antibody testing, 3 (50%) were positive. Testing to distinguish intrathecal antibody synthesis from transudation of antibodies to the CSF via breakdown of the blood-brain barrier was performed in 1/3 (33%) patients; this demonstrated antibody transmission to the CSF via transudation.

Conclusion

Detection of SARS-CoV-2 in CSF via PCR or evaluation for intrathecal antibody synthesis appears to be rare in patients with altered olfactory/gustatory function. While pathology studies are needed, our review suggests it is unlikely that these symptoms are related to viral neuroinvasion.

Motor demyelinating tibial neuropathy in COVID-19

Ten patients suffering from residual symptoms after the resolution of COVID-19, which manifested as fatigue in the lower limbs, have been submitted to nerve conduction studies. Motor demyelinating neuropathy features mainly of the tibial nerves but also the peroneal, median, and ulnar nerves were objectified. These findings might be considered as new neurological characteristics of SARS-CoV-2 infection.

Therapeutic plasma exchange in patients with life-threatening COVID-19: a randomised controlled clinical trial

Assessment of efficacy of therapeutic plasma exchange (TPE) following life-threatening COVID-19. This was an open-label, randomised clinical trial of ICU patients with life-threatening COVID-19 (positive RT-qPCR plus ARDS, sepsis, organ failure, hyperinflammation). Study was terminated after 87/120 patients enrolled. Standard treatment plus TPE (n = 43) versus standard treatment (n = 44), and stratified by PaO2/FiO2 ratio (>150 vs. ≤150), were compared. Primary outcomes were 35-day mortality and TPE safety. Secondary outcomes were association between TPE and mortality, improvement in SOFA score, change in inflammatory biomarkers, days on mechanical ventilation (MV), and ICU length of stay (LOS). Eighty-seven patients [median age 49 (IQR 34-63) years; 82.8% male] were randomised (44 standard care; 43 standard care plus TPE). Days on MV (P = 0.007) and ICU LOS (P = 0.02) were lower in the TPE group. 35-Day mortality was non-significantly lower in the TPE group (20.9% vs. 34.1%; Kaplan-Meier, P = 0.582). TPE was associated with increased lymphocytes and ADAMTS-13 activity and decreased serum lactate, lactate dehydrogenase, ferritin, d-dimers and interleukin-6. Multivariable regression analysis provided several predictors of 35-day mortality: PaO2/FiO2 ratio (HR, 0.98, 95% CI 0.96-1.00; P = 0.02]; ADAMTS-13 activity (HR, 0.89, 95% CI 0.82-0.98; P = 0.01); pulmonary embolism (HR, 3.57, 95% CI 1.43-8.92; P = 0.007). Post-hoc analysis revealed a significant reduction in SOFA score for TPE patients (P < 0.05). In critically-ill COVID-19 patients, addition of TPE to standard ICU therapy was associated with faster clinical recovery and no increased 35-day mortality.

Cerebrospinal fluid in COVID-19: A systematic review of the literature

OBJECTIVE

We sought to review the literature on cerebrospinal fluid (CSF) testing in patients with COVID-19 for evidence of viral neuroinvasion by SARS-CoV-2.

METHODS

We performed a systematic review of Medline and Embase between December 1, 2019 and November 18, 2020 to identify case reports or series of patients who had COVID-19 diagnosed based on positive SARS-CoV-2 polymerase chain reaction (PCR) or serologic testing and had CSF testing due to a neurologic symptom.

RESULTS

We identified 242 relevant documents which included 430 patients with COVID-19 who had acute neurological symptoms prompting CSF testing. Of those, 321 (75%) patients had symptoms that localized to the central nervous system (CNS). Of 304 patients whose CSF was tested for SARS-CoV-2 PCR, there were 17 (6%) whose test was positive, all of whom had symptoms that localized to the central nervous system (CNS). The majority (13/17, 76%) of these patients were admitted to the hospital because of neurological symptoms. Of 58 patients whose CSF was tested for SARS-CoV-2 antibody, 7 (12%) had positive antibodies with evidence of intrathecal synthesis, all of whom had symptoms that localized to the CNS. Of 132 patients who had oligoclonal bands evaluated, 3 (2%) had evidence of intrathecal antibody synthesis. Of 77 patients tested for autoimmune antibodies in the CSF, 4 (5%) had positive findings.

CONCLUSION

Detection of SARS-CoV-2 in CSF via PCR or evaluation for intrathecal antibody synthesis appears to be rare. Most neurological complications associated with SARS- CoV-2 are unlikely to be related to direct viral neuroinvasion.

Peripheral neuropathy in severe COVID-19 resolved with therapeutic plasma exchange

Peripheral neuropathies including Guillain-Barré syndrome may be linked to life-threatening COVID-19. Plasma exchange is a safe rescue therapy in severe COVID-19 with associated neurological manifestations and thromboinflammation.