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Simonini L, Frijia F, Ait Ali L, Foffa I, Vecoli C, De Gori C, De Cori S, Baroni M, Aquaro GD, Maremmani C, Lombardo F. A Comprehensive Review of COVID-19-Related Olfactory Deficiency: Unraveling Associations with Neurocognitive Disorders and Magnetic Resonance Imaging Findings. Diagnostics (Basel) 2024; 14:359. [PMID: 38396398 PMCID: PMC10888385 DOI: 10.3390/diagnostics14040359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Olfactory dysfunction (OD) is one of the most common symptoms in COVID-19 patients and can impact patients' lives significantly. The aim of this review was to investigate the multifaceted impact of COVID-19 on the olfactory system and to provide an overview of magnetic resonance (MRI) findings and neurocognitive disorders in patients with COVID-19-related OD. Extensive searches were conducted across PubMed, Scopus, and Google Scholar until 5 December 2023. The included articles were 12 observational studies and 1 case report that assess structural changes in olfactory structures, highlighted through MRI, and 10 studies correlating the loss of smell with neurocognitive disorders or mood disorders in COVID-19 patients. MRI findings consistently indicate volumetric abnormalities, altered signal intensity of olfactory bulbs (OBs), and anomalies in the olfactory cortex among COVID-19 patients with persistent OD. The correlation between OD and neurocognitive deficits reveals associations with cognitive impairment, memory deficits, and persistent depressive symptoms. Treatment approaches, including olfactory training and pharmacological interventions, are discussed, emphasizing the need for sustained therapeutic interventions. This review points out several limitations in the current literature while exploring the intricate effects of COVID-19 on OD and its connection to cognitive deficits and mood disorders. The lack of objective olfactory measurements in some studies and potential validity issues in self-reports emphasize the need for cautious interpretation. Our research highlights the critical need for extensive studies with larger samples, proper controls, and objective measurements to deepen our understanding of COVID-19's long-term effects on neurological and olfactory dysfunctions.
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Affiliation(s)
- Ludovica Simonini
- Institute of Clinical Physiology, National Research Council (CNR), 54100 Massa, Italy; (I.F.); (C.V.)
| | - Francesca Frijia
- Bioengineering Unit, Fondazione Toscana G. Monasterio, 56124 Pisa, Italy;
| | - Lamia Ait Ali
- Institute of Clinical Physiology, National Research Council (CNR), 54100 Massa, Italy; (I.F.); (C.V.)
- Pediatric Cardiology and GUCH Unit, Fondazione “G. Monasterio” CNR-Regione Toscana, 54100 Massa, Italy
| | - Ilenia Foffa
- Institute of Clinical Physiology, National Research Council (CNR), 54100 Massa, Italy; (I.F.); (C.V.)
| | - Cecilia Vecoli
- Institute of Clinical Physiology, National Research Council (CNR), 54100 Massa, Italy; (I.F.); (C.V.)
| | - Carmelo De Gori
- Department of Radiology, Fondazione Monasterio/CNR, 56124 Pisa, Italy; (C.D.G.); (S.D.C.); (F.L.)
| | - Sara De Cori
- Department of Radiology, Fondazione Monasterio/CNR, 56124 Pisa, Italy; (C.D.G.); (S.D.C.); (F.L.)
| | - Monica Baroni
- Fondazione “G. Monasterio” CNR-Regione Toscana, 54100 Massa, Italy;
| | - Giovanni Donato Aquaro
- Academic Radiology Unit, Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, 56124 Pisa, Italy;
| | - Carlo Maremmani
- Unit of Neurology, Ospedale Apuane, Azienda USL Toscana Nord Ovest, 54100 Massa, Italy;
| | - Francesco Lombardo
- Department of Radiology, Fondazione Monasterio/CNR, 56124 Pisa, Italy; (C.D.G.); (S.D.C.); (F.L.)
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Lupi L, Bordin A, Sales G, Colaianni D, Vitiello A, Biscontin A, Reale A, Garzino-Demo A, Antonini A, Ottaviano G, Mucignat C, Parolin C, Calistri A, De Pittà C. Persistent and transient olfactory deficits in COVID-19 are associated to inflammation and zinc homeostasis. Front Immunol 2023; 14:1148595. [PMID: 37520523 PMCID: PMC10380959 DOI: 10.3389/fimmu.2023.1148595] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction The Coronavirus Disease 2019 (COVID-19) is mainly a respiratory syndrome that can affect multiple organ systems, causing a variety of symptoms. Among the most common and characteristic symptoms are deficits in smell and taste perception, which may last for weeks/months after COVID-19 diagnosis owing to mechanisms that are not fully elucidated. Methods In order to identify the determinants of olfactory symptom persistence, we obtained olfactory mucosa (OM) from 21 subjects, grouped according to clinical criteria: i) with persistent olfactory symptoms; ii) with transient olfactory symptoms; iii) without olfactory symptoms; and iv) non-COVID-19 controls. Cells from the olfactory mucosa were harvested for transcriptome analyses. Results and discussion RNA-Seq assays showed that gene expression levels are altered for a long time after infection. The expression profile of micro RNAs appeared significantly altered after infection, but no relationship with olfactory symptoms was found. On the other hand, patients with persistent olfactory deficits displayed increased levels of expression of genes involved in the inflammatory response and zinc homeostasis, suggesting an association with persistent or transient olfactory deficits in individuals who experienced SARS-CoV-2 infection.
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Affiliation(s)
- Lorenzo Lupi
- Department of Biology, University of Padova, Padova, Italy
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Anna Bordin
- Department of Neurosciences, Otolaryngology Section, University of Padova, Padova, Italy
| | - Gabriele Sales
- Department of Biology, University of Padova, Padova, Italy
| | | | - Adriana Vitiello
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | | | - Alberto Reale
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Alfredo Garzino-Demo
- Department of Molecular Medicine, University of Padova, Padova, Italy
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, Maryland, United States
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neurosciences, University of Padova, Padova, Italy
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Giancarlo Ottaviano
- Department of Neurosciences, Otolaryngology Section, University of Padova, Padova, Italy
| | - Carla Mucignat
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Cristina Parolin
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Arianna Calistri
- Department of Molecular Medicine, University of Padova, Padova, Italy
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Debbaneh P, McKinnon L, Haidari M, Liang J. Drug-induced olfactory and gustatory dysfunction: Analysis of FDA adverse events reporting system. Auris Nasus Larynx 2023:S0385-8146(22)00240-1. [PMID: 36682949 DOI: 10.1016/j.anl.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/28/2022] [Accepted: 12/22/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVES With the COVID-19 pandemic, there is growing interest and research in olfactory and gustatory dysfunction (OGD). Drug-induced dysfunction is an often overlooked etiology. While several medications include smell or taste disturbance as a side effect, there are no publications describing which medications are most frequently implicated. We aim to describe the patterns of these adverse drug reactions (ADRs) using the FDA Adverse Events Reporting System (FAERS). METHODS The FAERS database was queried from 2011 to 2021 for terms describing ADRs related to OGD. Terms included anosmia, hyposmia, olfactory test abnormal, olfactory nerve disorder, hallucination olfactory, parosmia, ageusia, hypogeusia, dysgeusia, and taste disorder. We identified the top reported medications associated with general smell dysfunction, general taste dysfunction, reduced smell, and altered smell. RESULTS From 2011 to 2021, 16,091 ADRs were reported with OGD, of which13,641 (84.8%) and 2,450 (15.2%) were associated with gustatory and olfactory reactions, respectively. Zinc products (370 reports) and fluticasone propionate (214) were most commonly associated with olfactory dysfunction, specifically reduced olfaction. Varenicline (24) and fluticasone propionate (23) were most commonly associated with altered smell. Lenalidomide (490) and sunitinib (468) were most commonly associated with gustatory dysfunction. Antineoplastic and immunomodulating medications accounted for 21.6% and 36.3% of olfactory and gustatory ADRs, respectively. Among this category, immunoglobulin drugs were the most commonly associated with OGD ADRs. CONCLUSION Gustatory dysfunction is more commonly reported ADR compared with olfactory dysfunction. Immunologic/rheumatologic medications are the leading culprit of reported OGD. With increasing numbers of patients presenting to otolaryngologists for OGD, it is important to consider drug-induced etiology. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Peter Debbaneh
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA.
| | | | - Muhib Haidari
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Jonathan Liang
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
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Kladnik J, Dolinar A, Kljun J, Perea D, Grau-Expósito J, Genescà M, Novinec M, Buzon MJ, Turel I. Zinc pyrithione is a potent inhibitor of PL Pro and cathepsin L enzymes with ex vivo inhibition of SARS-CoV-2 entry and replication. J Enzyme Inhib Med Chem 2022; 37:2158-2168. [PMID: 35943189 PMCID: PMC9367663 DOI: 10.1080/14756366.2022.2108417] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Zinc pyrithione (1a), together with its analogues 1b–h and ruthenium pyrithione complex 2a, were synthesised and evaluated for the stability in biologically relevant media and anti-SARS-CoV-2 activity. Zinc pyrithione revealed potent in vitro inhibition of cathepsin L (IC50=1.88 ± 0.49 µM) and PLPro (IC50=0.50 ± 0.07 µM), enzymes involved in SARS-CoV-2 entry and replication, respectively, as well as antiviral entry and replication properties in an ex vivo system derived from primary human lung tissue. Zinc complexes 1b–h expressed comparable in vitro inhibition. On the contrary, ruthenium complex 2a and the ligand pyrithione a itself expressed poor inhibition in mentioned assays, indicating the importance of the selection of metal core and structure of metal complex for antiviral activity. Safe, effective, and preferably oral at-home therapeutics for COVID-19 are needed and as such zinc pyrithione, which is also commercially available, could be considered as a potential therapeutic agent against SARS-CoV-2.
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Affiliation(s)
- Jerneja Kladnik
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Ljubljana, Slovenia
| | - Ana Dolinar
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Ljubljana, Slovenia
| | - Jakob Kljun
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Ljubljana, Slovenia
| | - David Perea
- Infectious Diseases Department, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, VHIR Task Force COVID-19, Barcelona, Spain
| | - Judith Grau-Expósito
- Infectious Diseases Department, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, VHIR Task Force COVID-19, Barcelona, Spain
| | - Meritxell Genescà
- Infectious Diseases Department, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, VHIR Task Force COVID-19, Barcelona, Spain
| | - Marko Novinec
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Ljubljana, Slovenia
| | - Maria J Buzon
- Infectious Diseases Department, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, VHIR Task Force COVID-19, Barcelona, Spain
| | - Iztok Turel
- Faculty of Chemistry and Chemical Technology, University of Ljubljana, Ljubljana, Slovenia
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Schiavetti I, Carmisciano L, Ponzano M, Cordioli C, Cocco E, Marfia GA, Inglese M, Filippi M, Radaelli M, Bergamaschi R, Immovilli P, Capobianco M, De Rossi N, Brichetto G, Scandellari C, Cavalla P, Pesci I, Confalonieri P, Perini P, Trojano M, Lanzillo R, Tedeschi G, Comi G, Battaglia MA, Patti F, Salvetti M, Sormani MP. Signs and symptoms of Covid‐19 in patients with multiple sclerosis. Eur J Neurol 2022; 29:3728-3736. [PMID: 36086905 PMCID: PMC9538224 DOI: 10.1111/ene.15554] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose Clinical outcomes of multiple sclerosis (MS) patients affected by coronavirus disease 2019 (COVID‐19) have been thoroughly investigated, but a further analysis on main signs and symptoms and their risk factors still needs attention. The objective of this study was to group together and describe based on similarity the most common signs and symptoms of COVID‐19 in MS patients and identify all factors associated with their manifestation. Method Logistic and linear regression models were run to recognize factors associated with each pooled group of symptoms and their total number. Results From March 2020 to November 2021, data were collected from 1354 MS patients with confirmed infection of COVID‐19. Ageusia and anosmia was less frequent in older people (odds ratio [OR] 0.98; p = 0.005) and more in smoker patients (OR 1.39; p = 0.049). Smoke was also associated with an incremental number of symptoms (OR 1.24; p = 0.031), substance abuse (drugs or alcohol), conjunctivitis and rash (OR 5.20; p = 0.042) and the presence of at least one comorbidity with shortness of breath, tachycardia or chest pain (OR 1.24; p = 0.008). Some disease‐modifying therapies were associated with greater frequencies of certain COVID‐19 symptoms (association between anti‐CD20 therapies and increment in the number of concomitant symptoms: OR 1.29; p = 0.05). Differences in frequencies between the three waves were found for flu‐like symptoms (G1, p = 0.024), joint or muscle pain (G2, p = 0.013) and ageusia and anosmia (G5, p < 0.001). All cases should be referred to variants up to Delta. Conclusion Several factors along with the choice of specific therapeutic approaches might have a different impact on the occurrence of some COVID‐19 symptoms.
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Affiliation(s)
| | | | - Marta Ponzano
- Department of Health Sciences University of Genova Genova Italy
| | - Cinzia Cordioli
- Centro Sclerosi Multipla ASST Spedali Civili di Brescia, Montichiari Italy
| | - Eleonora Cocco
- Centro Sclerosi Multipla, ATS Sardegna Cagliari Italy
- Dipartimento Scienze Mediche e Sanità Pubblica, Università di Cagliari Cagliari Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine Tor Vergata University Rome Italy
| | - Matilde Inglese
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) University of Genoa Genoa Italy
- IRCCS Ospedale Policlinico San Martino Genoa Italy
| | - Massimo Filippi
- Neurology Unit IRCCS San Raffaele Scientific Institute Milan Italy
- Neurorehabilitation Unit IRCCS San Raffaele Scientific Institute Milan Italy
- Neurophysiology Unit IRCCS San Raffaele Scientific Institute Milan Italy
- Neuroimaging Research Unit, Division of Neuroscience IRCCS San Raffaele Scientific Institute Milan Italy
- Vita‐Salute San Raffaele University Milan Italy
| | - Marta Radaelli
- Department of Neurology and Multiple Sclerosis Center, ASST ‘Papa Giovanni XXIII’ Bergamo Italy
| | | | - Paolo Immovilli
- Multiple Sclerosis Center, Ospedale Guglielmo da Saliceto Piacenza Italy
| | - Marco Capobianco
- Regional Referral Multiple Sclerosis Centre, Department of Neurology University Hospital San Luigi Orbassano (Torino) Italy
| | - Nicola De Rossi
- Centro Sclerosi Multipla ASST Spedali Civili di Brescia, Montichiari Italy
| | | | - Cinzia Scandellari
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOSI Riabilitazione Sclerosi Multipla Bologna Italy
| | - Paola Cavalla
- MS Center, Department of Neuroscience City of Health and Science University Hospital of Turin Turin Italy
| | - Ilaria Pesci
- Centro SM UOC Neurologia, Fidenza, AUSL PR, Fidenza Italy
| | - Paolo Confalonieri
- Multiple Sclerosis Centre, Neuroimmunology Department ‘Carlo Besta’ Neurological Institute Milan Italy
| | - Paola Perini
- Department of Neurology Multiple Sclerosis Center University of Padua Padova Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs University of Bari Bari Italy
| | | | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences University of Campania Napoli Italy
| | - Giancarlo Comi
- Università Vita Salute San Raffaele, Casa di Cura Privata del Policlinico Milan Italy
| | - Mario Alberto Battaglia
- Research Department, Italian Multiple Sclerosis Foundation Genoa Italy
- Department of Life Sciences University of Siena Siena Italy
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia University of Catania Catania Italy
- Centro Sclerosi Multipla, Policlinico Catania University of Catania Catania Italy
| | - Marco Salvetti
- Department of Neuroscience, Mental Health and Sensory Organs Sapienza University of Rome Rome Italy
- Unit of Neurology, IRCCS Neuromed Pozzilli Italy
| | - Maria Pia Sormani
- Department of Health Sciences University of Genova Genova Italy
- IRCCS Ospedale Policlinico San Martino Genoa Italy
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Khani E, Khiali S, Beheshtirouy S, Entezari-Maleki T. Potential pharmacologic treatments for COVID-19 smell and taste loss: A comprehensive review. Eur J Pharmacol 2021; 912:174582. [PMID: 34678243 PMCID: PMC8524700 DOI: 10.1016/j.ejphar.2021.174582] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/08/2021] [Accepted: 10/18/2021] [Indexed: 12/30/2022]
Abstract
The acute loss of taste and smell following COVID-19 are hallmark symptoms that affect 20-85% of patients. However, the pathophysiology and potential treatments of COVID-19 smell and taste loss are not fully understood. We searched the literature to review the potential pathologic pathways and treatment options for COVID-19 smell and taste loss. The interaction of novel coronavirus with ACE-2 receptors expressed on sustentacular cells and taste buds results in direct damage to the olfactory and gustatory systems. Also, the invasion of the virus to the olfactory neurons and consequent local inflammation are other proposed mechanisms. Therefore, COVID-19 patients with smell or taste loss may benefit from neuroprotective, anti-inflammatory, or depolarizing agents. Based on the current evidence, phosphodiesterase inhibitors, insulin, and corticosteroids can be promising for the management of COVID-19 smell and taste loss. This review provided crucial information for treating COVID-19-related smell and/or taste loss, urging to perform large clinical trials to find optimum treatment options.
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Affiliation(s)
- Elnaz Khani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sajad Khiali
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samineh Beheshtirouy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taher Entezari-Maleki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran,Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran,Corresponding author. Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, P.O. Box: 51664-14766 12, Iran
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Neta FI, Fernandes ACL, Vale AJM, Pinheiro FI, Cobucci RN, Azevedo EPD, Guzen FP. Pathophysiology and possible treatments for olfactory-gustatory disorders in patients affected by COVID-19. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2021; 2:100035. [PMID: 34870148 PMCID: PMC8178068 DOI: 10.1016/j.crphar.2021.100035] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/13/2022] Open
Abstract
SARS-CoV-2 infects host cells mainly through the interaction between the virus's Spike protein and the viral receptors namely Angiotensin-Converting Enzyme 2 (ACE2) and transmembrane serine protease 2 (TMPRSS2). Both are highly expressed in the gastrointestinal tract, in the nasal and bronchial epithelium, as well as in the type II alveolar epithelial cells. The aim of this review is to report the evidences from the scientific literature on the pathophysiology and the available treatments for olfactory-gustatory disorders in patients with COVID-19. The mechanisms involved in these disorders are still unclear and studies on specific therapies are scarce. However, it has been hypothesized that a decrease in the sensitivity of the sensory neurons as well as the co-expression of ACE2 and TMPRSS2 in the alveolar epithelial cells are the main causes of olfactory-gustatory disorders. The possible mechanisms described in the literature for changes in taste perception in patients with COVID-19 include olfactory disorders and a competitive activity of COVID-19 on ACE2 receptors in the taste buds. In addition, SARS-CoV-2 can bind to sialic acid receptors in the taste buds. In general, evidences show that there is no specific treatment for olfactory-taste disorders induced by SARS-CoV-2, even though some treatments have been used and have shown some promising results, such as olfactory training, intranasal application of sodium citrate and vitamin A, as well as systemic use of omega-3 and zinc. Corticosteroids have also been used as a pharmacological approach to treat patients with olfactory dysfunction with some contradictory results. The knowledge of the mechanisms by which SARS-CoV-2 influences the sensory systems and how effective therapies can treat the loss of smell and taste will have important implications on the understanding and clinical management of olfactory-taste disorders.
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Affiliation(s)
- Francisca Idalina Neta
- Postgraduate Program in Physiological Sciences, Department of Biomedical Sciences, Faculty of Health Sciences, State University of Rio Grande do Norte (UERN), Brazil
| | - Amélia Carolina Lopes Fernandes
- Postgraduate Program in Physiological Sciences, Department of Biomedical Sciences, Faculty of Health Sciences, State University of Rio Grande do Norte (UERN), Brazil
- Nurse Department, Nurse School, State University of Rio Grande do Norte (UERN), Mossoró, Brazil
| | - Adson José Martins Vale
- Tocogynecology Department, Medical School, Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
- Postgraduate Program in Biotechnology, Laureate International Universities – Potiguar University (UnP), Natal, Brazil
| | - Francisco Irochima Pinheiro
- Postgraduate Program in Biotechnology, Laureate International Universities – Potiguar University (UnP), Natal, Brazil
- Medical School, Laureate International Universities – Potiguar University (UnP), Natal, Brazil
| | - Ricardo Ney Cobucci
- Tocogynecology Department, Medical School, Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
- Postgraduate Program in Biotechnology, Laureate International Universities – Potiguar University (UnP), Natal, Brazil
- Medical School, Laureate International Universities – Potiguar University (UnP), Natal, Brazil
| | - Eduardo Pereira de Azevedo
- Postgraduate Program in Biotechnology, Laureate International Universities – Potiguar University (UnP), Natal, Brazil
| | - Fausto Pierdoná Guzen
- Postgraduate Program in Physiological Sciences, Department of Biomedical Sciences, Faculty of Health Sciences, State University of Rio Grande do Norte (UERN), Brazil
- Postgraduate Program in Biotechnology, Laureate International Universities – Potiguar University (UnP), Natal, Brazil
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