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Radke J, Meinhardt J, Aschman T, Chua RL, Farztdinov V, Lukassen S, Ten FW, Friebel E, Ishaque N, Franz J, Huhle VH, Mothes R, Peters K, Thomas C, Schneeberger S, Schumann E, Kawelke L, Jünger J, Horst V, Streit S, von Manitius R, Körtvélyessy P, Vielhaber S, Reinhold D, Hauser AE, Osterloh A, Enghard P, Ihlow J, Elezkurtaj S, Horst D, Kurth F, Müller MA, Gassen NC, Melchert J, Jechow K, Timmermann B, Fernandez-Zapata C, Böttcher C, Stenzel W, Krüger E, Landthaler M, Wyler E, Corman V, Stadelmann C, Ralser M, Eils R, Heppner FL, Mülleder M, Conrad C, Radbruch H. Proteomic and transcriptomic profiling of brainstem, cerebellum and olfactory tissues in early- and late-phase COVID-19. Nat Neurosci 2024; 27:409-420. [PMID: 38366144 DOI: 10.1038/s41593-024-01573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/08/2024] [Indexed: 02/18/2024]
Abstract
Neurological symptoms, including cognitive impairment and fatigue, can occur in both the acute infection phase of coronavirus disease 2019 (COVID-19) and at later stages, yet the mechanisms that contribute to this remain unclear. Here we profiled single-nucleus transcriptomes and proteomes of brainstem tissue from deceased individuals at various stages of COVID-19. We detected an inflammatory type I interferon response in acute COVID-19 cases, which resolves in the late disease phase. Integrating single-nucleus RNA sequencing and spatial transcriptomics, we could localize two patterns of reaction to severe systemic inflammation, one neuronal with a direct focus on cranial nerve nuclei and a separate diffuse pattern affecting the whole brainstem. The latter reflects a bystander effect of the respiratory infection that spreads throughout the vascular unit and alters the transcriptional state of mainly oligodendrocytes, microglia and astrocytes, while alterations of the brainstem nuclei could reflect the connection of the immune system and the central nervous system via, for example, the vagus nerve. Our results indicate that even without persistence of severe acute respiratory syndrome coronavirus 2 in the central nervous system, local immune reactions are prevailing, potentially causing functional disturbances that contribute to neurological complications of COVID-19.
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Affiliation(s)
- Josefine Radke
- Institute of Pathology, Universitätsmedizin Greifswald, Greifswald, Germany.
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Jenny Meinhardt
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tom Aschman
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Lorenz Chua
- Center of Digital Health, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vadim Farztdinov
- Core Facility High Throughput Mass Spectrometry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sören Lukassen
- Center of Digital Health, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Foo Wei Ten
- Center of Digital Health, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ekaterina Friebel
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Naveed Ishaque
- Center of Digital Health, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Franz
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Valerie Helena Huhle
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ronja Mothes
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kristin Peters
- Institute of Pathology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Carolina Thomas
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Shirin Schneeberger
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elisa Schumann
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Leona Kawelke
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Jünger
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Viktor Horst
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Streit
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Regina von Manitius
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Péter Körtvélyessy
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Vielhaber
- Department of Neurology, Otto von Guerike University Magdeburg, Magdeburg, Germany
| | - Dirk Reinhold
- Institute of Molecular and Clinical Immunology, Otto von Guerike University Magdeburg, Magdeburg, Germany
| | - Anja E Hauser
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Immune Dynamics, Deutsches Rheuma-Forschungszentrum, a Leibniz Institute, Berlin, Germany
| | - Anja Osterloh
- Department of Pathology, University Medical Center Ulm, Ulm, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jana Ihlow
- Department of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sefer Elezkurtaj
- Department of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - David Horst
- Department of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Kurth
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel A Müller
- Institute of Virology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils C Gassen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Julia Melchert
- Institute of Virology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina Jechow
- Center of Digital Health, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Camila Fernandez-Zapata
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Chotima Böttcher
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elke Krüger
- Institute of Medical Biochemistry and Molecular Biology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Markus Landthaler
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Institut für Biologie, Humboldt Universität, Berlin, Germany
| | - Emanuel Wyler
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Victor Corman
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Infection Research (DZIF), associated partner, Berlin, Germany
| | - Christine Stadelmann
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Markus Ralser
- Core Facility High Throughput Mass Spectrometry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Roland Eils
- Center of Digital Health, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Frank L Heppner
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
- Cluster of Excellence NeuroCure, Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Mülleder
- Core Facility High Throughput Mass Spectrometry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Conrad
- Center of Digital Health, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Helena Radbruch
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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Nasir A, Samad A, Ullah S, Ali A, Wei DQ, Qian B. Omicron variant (B.1.1.529) challenge the integrity of blood brain barrier: Evidence from protein structural analysis. Comput Biol Med 2024; 169:107906. [PMID: 38154156 DOI: 10.1016/j.compbiomed.2023.107906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/08/2023] [Accepted: 12/24/2023] [Indexed: 12/30/2023]
Abstract
Studies on nonhuman primates, wild-type and transgenic mice have shown the presence of SARS-CoV-2 RNA components in the brains. Despite the Blood-Brain Barrier (BBB) provides protection there are less evidences on how the SARS-CoV-2 crosses the BBB. Given that there is an increase of Omicron reinfection rates, transmissibility rate and involvement to cause neurological dysfunctions, we hypothesized to investigate how the Omicron variant (B.1.1.529) binds structurally to key BBB-maintaining proteins and thus can possibly challenge the integrity and transportation to the brain. By using molecular dynamics simulation approaches we examined the interaction of Omicron variant (B.1.1.529) with different structural and transporter proteins located at the BBB. Our results show that in Zona Ocludin 1-RBD complex, we observe a distinct pattern. Omicron demonstrates a docking score of -88.9 ± 6.8 kcal/mol and six interactions, while the wild type (WT) presents a higher score of -94.0 ± 2.3 kcal/mol, forming eight interactions. Comparing affinities, the WT-RBD displays a stronger preference for Claudin-5, boasting a docking score of -110.2 ± 3.0 and nine interactions, versus Omicron-RBD's slightly reduced engagement, with a docking score of -105.6 ± 0.2 and seven interactions. Interestingly, the Omicron variant exhibits heightened stability in interactions with Glucose Transporter and ABC transporters, registering docking scores of -110.6 ± 1.9 and -112.0 ± 3.6 kcal/mol, respectively. This surpasses the WT's respective scores of -95.2 ± 2.2 and -104.0 ± 6.2 kcal/mol, reflecting a unique interaction profile. Rigorous molecular dynamics simulations validate our findings. Our study emphasizes the Omicron variant's increased affinity towards transporter proteins, illuminating potential implications for BBB integrity and brain transportation. While these insights offer a valuable framework, comprehensive experimental validation is indispensable for a comprehensive understanding.
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Affiliation(s)
- Abdul Nasir
- Medical Research Center, Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Abdus Samad
- Department of Biochemistry, Abdul Wali Khan University Mardan, Pakistan
| | - Sami Ullah
- Department of Biochemistry, Abdul Wali Khan University Mardan, Pakistan
| | - Arif Ali
- Department of Bioinformatics and Biological Statistics, Shanghai Jiao Tong University, Shanghai, China
| | - Dong-Qing Wei
- Department of Bioinformatics and Biological Statistics, Shanghai Jiao Tong University, Shanghai, China; Zhongjing Research and Industrialization Institute of Chinese Medicine, Zhongguancun Scientific Park, Meixi, Nayang, Henan, China.
| | - Bai Qian
- Medical Research Center, Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Fujii T, Rennert RC, Hurth KM, Ward PM, Campan M, Mathew AJ, Dubeau L, Wallace WD, Liu CY, Russin JJ. Neurotropism of SARS-CoV-2: A Pathological Examination of Neurosurgical Specimens. Neurosurgery 2024; 94:379-388. [PMID: 37728367 DOI: 10.1227/neu.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/23/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neurological manifestations may occur in more than 80% of patients hospitalized with COVID-19 infection, including severe disruptions of the central nervous system (CNS), such as strokes, encephalitis, or seizures. Although the primary pathophysiological mechanism for the effects of COVID-19 in CNS remains unknown, evidence exists for both direct injury from neuroinvasion and indirect effects from disruptions in systemic inflammatory and coagulation pathways. In this study, we analyzed CNS tissue from living patients to better understand these processes. METHODS With institutional review board approval and patient consent, samples that would be otherwise discarded from patients with active or recent (within 6 days of surgery) COVID-19 infection undergoing neurosurgical intervention were collected and tested for the presence of SARS-CoV-2 using immunohistochemistry, in situ hybridization, electron microscopy, and reverse transcription polymerase chain reaction. RESULTS Five patients with perioperative mild-to-moderate COVID-19 infection met inclusion criteria (2 male, 3 female; mean age 38.8 ± 13.5 years). Neurosurgical diagnoses included a glioblastoma, a ruptured arteriovenous malformation, a ruptured posterior inferior cerebellar artery aneurysm, a middle cerebral artery occlusion, and a hemorrhagic pontine cavernous malformation. Samples analyzed included the frontal lobe cortex, olfactory nerve, arteriovenous malformation/temporal lobe parenchyma, middle cerebral artery, cerebellum, and cavernous malformation/brainstem parenchyma. Testing for the presence of SARS-CoV-2 was negative in all samples. CONCLUSION The CNS is likely not a significant viral reservoir during mild-to-moderate COVID-19 infection, although direct neuroinvasion is not definitively excluded. Additional testing to help elucidate the relative contributions of direct and indirect pathways for CNS injury from COVID is warranted.
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Affiliation(s)
- Tatsuhiro Fujii
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Kyle M Hurth
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Pamela M Ward
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Mihaela Campan
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Anna J Mathew
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Louis Dubeau
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - William D Wallace
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Charles Y Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
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4
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Meinhardt J, Streit S, Dittmayer C, Manitius RV, Radbruch H, Heppner FL. The neurobiology of SARS-CoV-2 infection. Nat Rev Neurosci 2024; 25:30-42. [PMID: 38049610 DOI: 10.1038/s41583-023-00769-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/06/2023]
Abstract
Worldwide, over 694 million people have been infected with SARS-CoV-2, with an estimated 55-60% of those infected developing COVID-19. Since the beginning of the pandemic in December 2019, different variants of concern have appeared and continue to occur. With the emergence of different variants, an increasing rate of vaccination and previous infections, the acute neurological symptomatology of COVID-19 changed. Moreover, 10-45% of individuals with a history of SARS-CoV-2 infection experience symptoms even 3 months after disease onset, a condition that has been defined as 'post-COVID-19' by the World Health Organization and that occurs independently of the virus variant. The pathomechanisms of COVID-19-related neurological complaints have become clearer during the past 3 years. To date, there is no overt - that is, truly convincing - evidence for SARS-CoV-2 particles in the brain. In this Review, we put special emphasis on discussing the methodological difficulties of viral detection in CNS tissue and discuss immune-based (systemic and central) effects contributing to COVID-19-related CNS affection. We sequentially review the reported changes to CNS cells in COVID-19, starting with the blood-brain barrier and blood-cerebrospinal fluid barrier - as systemic factors from the periphery appear to primarily influence barriers and conduits - before we describe changes in brain parenchymal cells, including microglia, astrocytes, neurons and oligodendrocytes as well as cerebral lymphocytes. These findings are critical to understanding CNS affection in acute COVID-19 and post-COVID-19 in order to translate these findings into treatment options, which are still very limited.
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Affiliation(s)
- Jenny Meinhardt
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Simon Streit
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Carsten Dittmayer
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Regina V Manitius
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Helena Radbruch
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.
| | - Frank L Heppner
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.
- Cluster of Excellence, NeuroCure, Berlin, Germany.
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany.
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Magaki S, Zhang T, Han K, Hilda M, Yong WH, Achim C, Fishbein G, Fishbein MC, Garner O, Salamon N, Williams CK, Valdes-Sueiras MA, Hsu JJ, Kelesidis T, Mathisen GE, Lavretsky H, Singer EJ, Vinters HV. HIV and COVID-19: two pandemics with significant (but different) central nervous system complications. FREE NEUROPATHOLOGY 2024; 5:5-5. [PMID: 38469363 PMCID: PMC10925920 DOI: 10.17879/freeneuropathology-2024-5343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/02/2024] [Indexed: 03/13/2024]
Abstract
Human immunodeficiency virus (HIV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cause significant neurologic disease. Central nervous system (CNS) involvement of HIV has been extensively studied, with well-documented invasion of HIV into the brain in the initial stage of infection, while the acute effects of SARS-CoV-2 in the brain are unclear. Neuropathologic features of active HIV infection in the brain are well characterized whereas neuropathologic findings in acute COVID-19 are largely non-specific. On the other hand, neuropathologic substrates of chronic dysfunction in both infections, as HIV-associated neurocognitive disorders (HAND) and post-COVID conditions (PCC)/long COVID are unknown. Thus far, neuropathologic studies on patients with HAND in the era of combined antiretroviral therapy have been inconclusive, and autopsy studies on patients diagnosed with PCC have yet to be published. Further longitudinal, multidisciplinary studies on patients with HAND and PCC and neuropathologic studies in comparison to controls are warranted to help elucidate the mechanisms of CNS dysfunction in both conditions.
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Affiliation(s)
- Shino Magaki
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
| | - Ting Zhang
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
| | - Karam Han
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
| | - Mirbaha Hilda
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
| | - William H. Yong
- Department of Pathology and Laboratory Medicine, University of California-Irvine School of Medicine, Irvine, CA, USA
| | - Cristian Achim
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, USA
| | - Gregory Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael C. Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Omai Garner
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Noriko Salamon
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christopher K. Williams
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
| | - Miguel A. Valdes-Sueiras
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeffrey J. Hsu
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Theodoros Kelesidis
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Glenn E. Mathisen
- Department of Infectious Diseases, Olive View-University of California Los Angeles Medical Center, Sylmar, CA, USA
| | - Helen Lavretsky
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elyse J. Singer
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Harry V. Vinters
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Brain Research Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Stüdle C, Nishihara H, Wischnewski S, Kulsvehagen L, Perriot S, Ishikawa H, Schroten H, Frank S, Deigendesch N, Du Pasquier R, Schirmer L, Pröbstel AK, Engelhardt B. SARS-CoV-2 infects epithelial cells of the blood-cerebrospinal fluid barrier rather than endothelial cells or pericytes of the blood-brain barrier. Fluids Barriers CNS 2023; 20:76. [PMID: 37875964 PMCID: PMC10598911 DOI: 10.1186/s12987-023-00479-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND As a consequence of SARS-CoV-2 infection various neurocognitive and neuropsychiatric symptoms can appear, which may persist for several months post infection. However, cell type-specific routes of brain infection and underlying mechanisms resulting in neuroglial dysfunction are not well understood. METHODS Here, we investigated the susceptibility of cells constituting the blood-brain barrier (BBB) and the blood-cerebrospinal fluid barrier (BCSFB) of the choroid plexus (ChP) to SARS-CoV-2 infection using human induced pluripotent stem cell (hiPSC)-derived cellular models and a ChP papilloma-derived epithelial cell line as well as ChP tissue from COVID-19 patients, respectively. RESULTS We noted a differential infectibility of hiPSC-derived brain microvascular endothelial cells (BMECs) depending on the differentiation method. Extended endothelial culture method (EECM)-BMECs characterized by a complete set of endothelial markers, good barrier properties and a mature immune phenotype were refractory to SARS-CoV-2 infection and did not exhibit an activated phenotype after prolonged SARS-CoV-2 inoculation. In contrast, defined medium method (DMM)-BMECs, characterized by a mixed endothelial and epithelial phenotype and excellent barrier properties were productively infected by SARS-CoV-2 in an ACE2-dependent manner. hiPSC-derived brain pericyte-like cells (BPLCs) lacking ACE2 expression were not susceptible to SARS-CoV-2 infection. Furthermore, the human choroid plexus papilloma-derived epithelial cell line HIBCPP, modeling the BCSFB was productively infected by SARS-CoV-2 preferentially from the basolateral side, facing the blood compartment. Assessment of ChP tissue from COVID-19 patients by RNA in situ hybridization revealed SARS-CoV-2 transcripts in ChP epithelial and ChP stromal cells. CONCLUSIONS Our study shows that the BCSFB of the ChP rather than the BBB is susceptible to direct SARS-CoV-2 infection. Thus, neuropsychiatric symptoms because of COVID-19 may rather be associated with dysfunction of the BCSFB than the BBB. Future studies should consider a role of the ChP in underlying neuropsychiatric symptoms following SARS-CoV-2 infection.
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Affiliation(s)
- Chiara Stüdle
- Theodor Kocher Institute, University of Bern, Bern, Switzerland.
| | - Hideaki Nishihara
- Theodor Kocher Institute, University of Bern, Bern, Switzerland
- Department of Neurotherapeutics, Yamaguchi University, Yamaguchi, Japan
| | - Sven Wischnewski
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Laila Kulsvehagen
- Departments of Neurology, Biomedicine and Clinical Research, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sylvain Perriot
- Laboratory of Neuroimmunology, Neuroscience Research Centre, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Hiroshi Ishikawa
- Laboratory of Clinical Regenerative Medicine, Department of Neurosurgery, University of Tsukuba, Tsukuba, 305-8575, Ibaraki, Japan
| | - Horst Schroten
- Pediatric Infectious Diseases, Department of Pediatrics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stephan Frank
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nikolaus Deigendesch
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Renaud Du Pasquier
- Laboratory of Neuroimmunology, Neuroscience Research Centre, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Center for Translational Neuroscience and Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Interdisciplinary Center for Neurosciences, Heidelberg University, Heidelberg, Germany
| | - Anne-Katrin Pröbstel
- Departments of Neurology, Biomedicine and Clinical Research, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
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7
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Ma Q, Yao C, Wu Y, Wang H, Fan Q, Yang Q, Xu J, Dai H, Zhang Y, Xu F, Lu T, Dowling JK, Wang C. Neurological disorders after severe pneumonia are associated with translocation of endogenous bacteria from the lung to the brain. SCIENCE ADVANCES 2023; 9:eadi0699. [PMID: 37851811 PMCID: PMC10584344 DOI: 10.1126/sciadv.adi0699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/15/2023] [Indexed: 10/20/2023]
Abstract
Neurological disorders are a common feature in patients who recover from severe acute pneumonia. However, the underlying mechanisms remain poorly understood. Here, we show that the neurological syndromes after severe acute pneumonia are partly attributed to the translocation of endogenous bacteria from the lung to the brain during pneumonia. Using principal components analysis, similarities were found between the brain's flora species and those of the lungs, indicating that the bacteria detected in the brain may originate from the lungs. We also observed impairment of both the lung-blood and brain-blood barriers, allowing endogenous lung bacteria to invade the brain during pneumonia. An elevated microglia and astrocyte activation signature via bacterial infection-related pathways was observed, indicating a bacterial-induced disruption of brain homeostasis. Collectively, we identify endogenous lung bacteria that play a role in altering brain homeostasis, which provides insight into the mechanism of neurological syndromes after severe pneumonia.
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Affiliation(s)
- Qingle Ma
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Chenlu Yao
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Yi Wu
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Heng Wang
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Qin Fan
- Jiangsu Key Laboratory for Biosensors, Institute of Advanced Materials (IAM) and School of Materials Science and Engineering, Nanjing University of Posts & Telecommunications, Nanjing, P. R. China
| | - Qianyu Yang
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Jialu Xu
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Huaxing Dai
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Yue Zhang
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Fang Xu
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
| | - Ting Lu
- Institute of Pharmacology, Laboratory of Aging and Nervous Diseases, Jiangsu Key Laboratory of Neuropsychiatric Disease, College of Pharmaceutical Sciences, Soochow University, Suzhou 215123, China
| | - Jennifer K. Dowling
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medical and Health Sciences, Dublin, Ireland
| | - Chao Wang
- Laboratory for Biomaterial and Immunoengineering, Institute of Functional Nano & Soft Materials (FUNSOM), Soochow University, Suzhou 215123, China
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8
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Wang Y, Luu LDW, Liu S, Zhu X, Huang S, Li F, Huang X, Guo L, Zhang J, Ge H, Sun Y, Hui Y, Qu Y, Wang H, Wang X, Na W, Zhou J, Qu D, Tai J. Single-cell transcriptomic analysis reveals a systemic immune dysregulation in COVID-19-associated pediatric encephalopathy. Signal Transduct Target Ther 2023; 8:398. [PMID: 37848421 PMCID: PMC10582072 DOI: 10.1038/s41392-023-01641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/31/2023] [Accepted: 09/01/2023] [Indexed: 10/19/2023] Open
Abstract
Unraveling the molecular mechanisms for COVID-19-associated encephalopathy and its immunopathology is crucial for developing effective treatments. Here, we utilized single-cell transcriptomic analysis and integrated clinical observations and laboratory examination to dissect the host immune responses and reveal pathological mechanisms in COVID-19-associated pediatric encephalopathy. We found that lymphopenia was a prominent characteristic of immune perturbation in COVID-19 patients with encephalopathy, especially those with acute necrotizing encephalopathy (AE). This was characterized a marked reduction of various lymphocytes (e.g., CD8+ T and CD4+ T cells) and significant increases in other inflammatory cells (e.g., monocytes). Further analysis revealed activation of multiple cell apoptosis pathways (e.g., granzyme/perforin-, FAS- and TNF-induced apoptosis) may be responsible for lymphopenia. A systemic S100A12 upregulation, primarily from classical monocytes, may have contributed to cytokine storms in patients with AE. A dysregulated type I interferon (IFN) response was observed which may have further exacerbated the S100A12-driven inflammation in patients with AE. In COVID-19 patients with AE, myeloid cells (e.g., monocytic myeloid-derived suppressor cells) were the likely contributors to immune paralysis. Finally, the immune landscape in COVID-19 patients with encephalopathy, especially for AE, were also characterized by NK and T cells with widespread exhaustion, higher cytotoxic scores and inflammatory response as well as a dysregulated B cell-mediated humoral immune response. Taken together, this comprehensive data provides a detailed resource for elucidating immunopathogenesis and will aid development of effective COVID-19-associated pediatric encephalopathy treatments, especially for those with AE.
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Affiliation(s)
- Yi Wang
- Experimental Research Center, Capital Institute of Pediatrics, Beijing, 100020, P.R. China.
| | | | - Shuang Liu
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Xiong Zhu
- Central & Clinical Laboratory of Sanya People's Hospital, Sanya, Hainan, 572000, P. R. China
| | - Siyuan Huang
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Fang Li
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Xiaolan Huang
- Experimental Research Center, Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Linying Guo
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Jin Zhang
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Haiyan Ge
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Yuanyuan Sun
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Yi Hui
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Yanning Qu
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Huicong Wang
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Xiaoxia Wang
- Central & Clinical Laboratory of Sanya People's Hospital, Sanya, Hainan, 572000, P. R. China
| | - Weilan Na
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Juan Zhou
- Experimental Research Center, Capital Institute of Pediatrics, Beijing, 100020, P.R. China
| | - Dong Qu
- Department of Critical Medicine, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China.
| | - Jun Tai
- Department of Otorhinolaryngology Head and Neck Surgery, Children's Hospital Affiliated Capital Institute of Pediatrics, Beijing, 100020, P.R. China.
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9
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Plummer AM, Matos YL, Lin HC, Ryman SG, Birg A, Quinn DK, Parada AN, Vakhtin AA. Gut-brain pathogenesis of post-acute COVID-19 neurocognitive symptoms. Front Neurosci 2023; 17:1232480. [PMID: 37841680 PMCID: PMC10568482 DOI: 10.3389/fnins.2023.1232480] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/01/2023] [Indexed: 10/17/2023] Open
Abstract
Approximately one third of non-hospitalized coronavirus disease of 2019 (COVID-19) patients report chronic symptoms after recovering from the acute stage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Some of the most persistent and common complaints of this post-acute COVID-19 syndrome (PACS) are cognitive in nature, described subjectively as "brain fog" and also objectively measured as deficits in executive function, working memory, attention, and processing speed. The mechanisms of these chronic cognitive sequelae are currently not understood. SARS-CoV-2 inflicts damage to cerebral blood vessels and the intestinal wall by binding to angiotensin-converting enzyme 2 (ACE2) receptors and also by evoking production of high levels of systemic cytokines, compromising the brain's neurovascular unit, degrading the intestinal barrier, and potentially increasing the permeability of both to harmful substances. Such substances are hypothesized to be produced in the gut by pathogenic microbiota that, given the profound effects COVID-19 has on the gastrointestinal system, may fourish as a result of intestinal post-COVID-19 dysbiosis. COVID-19 may therefore create a scenario in which neurotoxic and neuroinflammatory substances readily proliferate from the gut lumen and encounter a weakened neurovascular unit, gaining access to the brain and subsequently producing cognitive deficits. Here, we review this proposed PACS pathogenesis along the gut-brain axis, while also identifying specific methodologies that are currently available to experimentally measure each individual component of the model.
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Affiliation(s)
- Allison M. Plummer
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States
| | - Yvette L. Matos
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, United States
| | - Henry C. Lin
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, United States
- Section of Gastroenterology, New Mexico Veterans Affairs Health Care System, Albuquerque, NM, United States
| | - Sephira G. Ryman
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, United States
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, NM, United States
| | - Aleksandr Birg
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, United States
- Section of Gastroenterology, New Mexico Veterans Affairs Health Care System, Albuquerque, NM, United States
| | - Davin K. Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Alisha N. Parada
- Division of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Andrei A. Vakhtin
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, United States
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10
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Wesselingh R. Prevalence, pathogenesis and spectrum of neurological symptoms in COVID-19 and post-COVID-19 syndrome: a narrative review. Med J Aust 2023; 219:230-236. [PMID: 37660309 DOI: 10.5694/mja2.52063] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 09/05/2023]
Abstract
Neurological symptoms are not uncommon during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and reflect a broad spectrum of neurological disorders of which clinicians should be aware. The underlying pathogenesis of neurological disease in coronavirus disease 2019 (COVID-19) may be due to four mechanisms of nervous system dysfunction and injury: i) direct viral neurological invasion; ii) immune dysregulation; iii) endothelial dysfunction and coagulopathy; and iv) severe systemic COVID-19 disease. Neurological manifestations of acute COVID-19 include headache, peripheral neuropathies, seizures, encephalitis, Guillain-Barré syndrome, and cerebrovascular disease. Commonly reported long term neurological sequelae of COVID-19 are cognitive dysfunction and dysautonomia, which despite being associated with severe acute disease are also seen in people with mild disease. Assessment of cognitive dysfunction after COVID-19 is confounded by a high prevalence of comorbid fatigue, anxiety, and mood disorders. However, other markers of neuroaxonal breakdown suggest no significant neuronal injury apart from during severe acute COVID-19. The long term impact of COVID-19 on neurological diseases remains uncertain and requires ongoing vigilance.
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Affiliation(s)
- Robb Wesselingh
- Monash University, Melbourne, VIC
- Alfred Hospital, Melbourne, VIC
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11
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Brown RL, Benjamin L, Lunn MP, Bharucha T, Zandi MS, Hoskote C, McNamara P, Manji H. Pathophysiology, diagnosis, and management of neuroinflammation in covid-19. BMJ 2023; 382:e073923. [PMID: 37595965 DOI: 10.1136/bmj-2022-073923] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Although neurological complications of SARS-CoV-2 infection are relatively rare, their potential long term morbidity and mortality have a significant impact, given the large numbers of infected patients. Covid-19 is now in the differential diagnosis of a number of common neurological syndromes including encephalopathy, encephalitis, acute demyelinating encephalomyelitis, stroke, and Guillain-Barré syndrome. Physicians should be aware of the pathophysiology underlying these presentations to diagnose and treat patients rapidly and appropriately. Although good evidence has been found for neurovirulence, the neuroinvasive and neurotropic potential of SARS-CoV-2 is limited. The pathophysiology of most complications is immune mediated and vascular, or both. A significant proportion of patients have developed long covid, which can include neuropsychiatric presentations. The mechanisms of long covid remain unclear. The longer term consequences of infection with covid-19 on the brain, particularly in terms of neurodegeneration, will only become apparent with time and long term follow-up.
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Affiliation(s)
- Rachel L Brown
- University College London, Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- UCL Institute of Immunity and Transplantation, London, UK
| | - Laura Benjamin
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- UCL Laboratory of Molecular and Cell Biology, London, UK
| | - Michael P Lunn
- University College London, Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Tehmina Bharucha
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Department of Biochemistry, University of Oxford, UK
| | - Michael S Zandi
- University College London, Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Chandrashekar Hoskote
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Patricia McNamara
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Hadi Manji
- University College London, Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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12
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Madden N, Mei YZJ, Jakubiak K, Li J, Hargus G, Goldman JE, Al-Dalahmah O. The link between SARS-CoV-2 related microglial reactivity and astrocyte pathology in the inferior olivary nucleus. Front Neurosci 2023; 17:1198219. [PMID: 37483351 PMCID: PMC10359900 DOI: 10.3389/fnins.2023.1198219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/05/2023] [Indexed: 07/25/2023] Open
Abstract
The pathological involvement of the central nervous system in SARS-CoV2 (COVID-19) patients is established. The burden of pathology is most pronounced in the brain stem including the medulla oblongata. Hypoxic/ischemic damage is the most frequent neuropathologic abnormality. Other neuropathologic features include neuronophagia, microglial nodules, and hallmarks of neurodegenerative diseases: astrogliosis and microglial reactivity. It is still unknown if these pathologies are secondary to hypoxia versus a combination of inflammatory response combined with hypoxia. It is also unknown how astrocytes react to neuroinflammation in COVID-19, especially considering evidence supporting the neurotoxicity of certain astrocytic phenotypes. This study aims to define the link between astrocytic and microglial pathology in COVID-19 victims in the inferior olivary nucleus, which is one of the most severely affected brain regions in COVID-19, and establish whether COVID-19 pathology is driven by hypoxic damage. Here, we conducted neuropathologic assessments and multiplex-immunofluorescence studies on the medulla oblongata of 18 COVID-19, 10 pre-pandemic patients who died of acute respiratory distress syndrome (ARDS), and 7-8 control patients with no ARDS or COVID-19. The comparison of ARDS and COVID-19 allows us to identify whether the pathology in COVID-19 can be explained by hypoxia alone, which is common to both conditions. Our results showed increased olivary astrogliosis in ARDS and COVID-19. However, microglial density and microglial reactivity were increased only in COVID-19, in a region-specific manner. Also, olivary hilar astrocytes increased YKL-40 (CHI3L1) in COVID-19, but to a lesser extent than ARDS astrocytes. COVID-19 astrocytes also showed lower levels of Aquaporin-4 (AQP4), and Metallothionein-3 in subsets of COVID-19 brain regions. Cluster analysis on immunohistochemical attributes of astrocytes and microglia identified ARDS and COVID-19 clusters with correlations to clinical history and disease course. Our results indicate that olivary glial pathology and neuroinflammation in the COVID-19 cannot be explained solely by hypoxia and suggest that failure of astrocytes to upregulate the anti-inflammatory YKL-40 may contribute to the neuroinflammation. Notwithstanding the limitations of retrospective studies in establishing causality, our experimental design cannot adequately control for factors external to our design. Perturbative studies are needed to confirm the role of the above-described astrocytic phenotypes in neuroinflammation.
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13
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de Broucker T. [COVID-19: Neurological manifestations and complications during the acute phase of the disease]. BULLETIN DE L'ACADEMIE NATIONALE DE MEDECINE 2023; 207:S0001-4079(23)00190-5. [PMID: 38620177 PMCID: PMC10293933 DOI: 10.1016/j.banm.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/28/2023] [Indexed: 04/17/2024]
Abstract
The neurological manifestations and complications of the acute phase of COVID-19 are numerous. They mainly concern the central nervous system in the frequent forms of encephalopathy, encephalitis and neurovascular pathologies. Peripheral neurological manifestations mainly include acute polyneuropathies such as Guillain-Barré syndrome and intensive care neuromyopathies. Most of these manifestations were described during the first wave of the pandemic. The epidemiological, clinical, paraclinical, pathophysiological and therapeutic aspects are addressed in this general review of the literature published from 2020 to early 2023.
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14
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Lebrun L, Absil L, Remmelink M, De Mendonça R, D'Haene N, Gaspard N, Rusu S, Racu ML, Collin A, Allard J, Zindy E, Schiavo AA, De Clercq S, De Witte O, Decaestecker C, Lopes MB, Salmon I. SARS-Cov-2 infection and neuropathological findings: a report of 18 cases and review of the literature. Acta Neuropathol Commun 2023; 11:78. [PMID: 37165453 PMCID: PMC10170054 DOI: 10.1186/s40478-023-01566-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/15/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION COVID-19-infected patients harbour neurological symptoms such as stroke and anosmia, leading to the hypothesis that there is direct invasion of the central nervous system (CNS) by SARS-CoV-2. Several studies have reported the neuropathological examination of brain samples from patients who died from COVID-19. However, there is still sparse evidence of virus replication in the human brain, suggesting that neurologic symptoms could be related to mechanisms other than CNS infection by the virus. Our objective was to provide an extensive review of the literature on the neuropathological findings of postmortem brain samples from patients who died from COVID-19 and to report our own experience with 18 postmortem brain samples. MATERIAL AND METHODS We used microscopic examination, immunohistochemistry (using two different antibodies) and PCR-based techniques to describe the neuropathological findings and the presence of SARS-CoV-2 virus in postmortem brain samples. For comparison, similar techniques (IHC and PCR) were applied to the lung tissue samples for each patient from our cohort. The systematic literature review was conducted from the beginning of the pandemic in 2019 until June 1st, 2022. RESULTS In our cohort, the most common neuropathological findings were perivascular haemosiderin-laden macrophages and hypoxic-ischaemic changes in neurons, which were found in all cases (n = 18). Only one brain tissue sample harboured SARS-CoV-2 viral spike and nucleocapsid protein expression, while all brain cases harboured SARS-CoV-2 RNA positivity by PCR. A colocalization immunohistochemistry study revealed that SARS-CoV-2 antigens could be located in brain perivascular macrophages. The literature review highlighted that the most frequent neuropathological findings were ischaemic and haemorrhagic lesions, including hypoxic/ischaemic alterations. However, few studies have confirmed the presence of SARS-CoV-2 antigens in brain tissue samples. CONCLUSION This study highlighted the lack of specific neuropathological alterations in COVID-19-infected patients. There is still no evidence of neurotropism for SARS-CoV-2 in our cohort or in the literature.
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Affiliation(s)
- Laetitia Lebrun
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Lara Absil
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Myriam Remmelink
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Ricardo De Mendonça
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Nicky D'Haene
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, Erasme University Hospital, Brussels, Belgium
| | - Stefan Rusu
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Marie-Lucie Racu
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Amandine Collin
- DIAPath, Center for Microscopy and Molecular Imaging (CMMI), ULB, Gosselies, Belgium
| | - Justine Allard
- DIAPath, Center for Microscopy and Molecular Imaging (CMMI), ULB, Gosselies, Belgium
| | - Egor Zindy
- DIAPath, Center for Microscopy and Molecular Imaging (CMMI), ULB, Gosselies, Belgium
| | - Andrea Alex Schiavo
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Sarah De Clercq
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium
| | - Olivier De Witte
- Department of Neurosurgery, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital ErasmeErasme University Hospital, Brussels, Belgium
| | - Christine Decaestecker
- DIAPath, Center for Microscopy and Molecular Imaging (CMMI), ULB, Gosselies, Belgium
- Laboratory of Image Synthesis and Analysis, Brussels School of Engineering/École Polytechnique de Brussels, ULB, Brussels, Belgium
| | - Maria-Beatriz Lopes
- Department of Pathology, University of Virginia Health System, Charlottesville, VA, USA
| | - Isabelle Salmon
- Department of Pathology, Erasme University Hospital, Université Libre de Bruxelles (ULB)Hôpital Universitaire de Bruxelles (HUB), CUB Hôpital Erasme, 808 Route de Lennik, B-1070, Brussels, Belgium.
- DIAPath, Center for Microscopy and Molecular Imaging (CMMI), ULB, Gosselies, Belgium.
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15
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Gelpi E, Klotz S, Beyerle M, Wischnewski S, Harter V, Kirschner H, Stolz K, Reisinger C, Lindeck-Pozza E, Zoufaly A, Leoni M, Gorkiewicz G, Zacharias M, Haberler C, Hainfellner J, Woehrer A, Hametner S, Roetzer T, Voigtländer T, Ricken G, Endmayr V, Haider C, Ludwig J, Polt A, Wilk G, Schmid S, Erben I, Nguyen A, Lang S, Simonitsch-Klupp I, Kornauth C, Nackenhorst M, Kläger J, Kain R, Chott A, Wasicky R, Krause R, Weiss G, Löffler-Rag J, Berger T, Moser P, Soleiman A, Asslaber M, Sedivy R, Klupp N, Klimpfinger M, Risser D, Budka H, Schirmer L, Pröbstel AK, Höftberger R. Multifactorial White Matter Damage in the Acute Phase and Pre-Existing Conditions May Drive Cognitive Dysfunction after SARS-CoV-2 Infection: Neuropathology-Based Evidence. Viruses 2023; 15:908. [PMID: 37112888 PMCID: PMC10144140 DOI: 10.3390/v15040908] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND There is an urgent need to better understand the mechanisms underlying acute and long-term neurological symptoms after COVID-19. Neuropathological studies can contribute to a better understanding of some of these mechanisms. METHODS We conducted a detailed postmortem neuropathological analysis of 32 patients who died due to COVID-19 during 2020 and 2021 in Austria. RESULTS All cases showed diffuse white matter damage with a diffuse microglial activation of a variable severity, including one case of hemorrhagic leukoencephalopathy. Some cases revealed mild inflammatory changes, including olfactory neuritis (25%), nodular brainstem encephalitis (31%), and cranial nerve neuritis (6%), which were similar to those observed in non-COVID-19 severely ill patients. One previously immunosuppressed patient developed acute herpes simplex encephalitis. Acute vascular pathologies (acute infarcts 22%, vascular thrombosis 12%, diffuse hypoxic-ischemic brain damage 40%) and pre-existing small vessel diseases (34%) were frequent findings. Moreover, silent neurodegenerative pathologies in elderly persons were common (AD neuropathologic changes 32%, age-related neuronal and glial tau pathologies 22%, Lewy bodies 9%, argyrophilic grain disease 12.5%, TDP43 pathology 6%). CONCLUSIONS Our results support some previous neuropathological findings of apparently multifactorial and most likely indirect brain damage in the context of SARS-CoV-2 infection rather than virus-specific damage, and they are in line with the recent experimental data on SARS-CoV-2-related diffuse white matter damage, microglial activation, and cytokine release.
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Affiliation(s)
- Ellen Gelpi
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Sigrid Klotz
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Miriam Beyerle
- Departments of Neurology, Biomedicine and Clinical Research, University Hospital and University of Basel, 4031 Basel, Switzerland; (M.B.); (A.-K.P.)
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Department of Clinical Research, University Hospital and University of Basel, 4031 Basel, Switzerland;
| | - Sven Wischnewski
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany;
- Mannheim Center for Translational Neuroscience and Institute for Innate Immunoscience, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Verena Harter
- Department of Pathology, Klinik Favoriten, 1100 Vienna, Austria (H.K.); (R.S.); (M.K.)
| | - Harald Kirschner
- Department of Pathology, Klinik Favoriten, 1100 Vienna, Austria (H.K.); (R.S.); (M.K.)
| | - Katharina Stolz
- Department of Forensic Medicine, Medical University of Vienna, 1090 Vienna, Austria; (K.S.); (C.R.); (N.K.); (D.R.)
| | - Christoph Reisinger
- Department of Forensic Medicine, Medical University of Vienna, 1090 Vienna, Austria; (K.S.); (C.R.); (N.K.); (D.R.)
| | | | - Alexander Zoufaly
- Intensive Care Unit, Klinik Favoriten, 1100 Vienna, Austria;
- Faculty of Medicine, Sigmund Freud University, 1020 Vienna, Austria
| | - Marlene Leoni
- D&F Institute of Pathology, Neuropathology, Medical University Graz, 8036 Graz, Austria; (M.L.); (G.G.); (M.Z.); (M.A.)
| | - Gregor Gorkiewicz
- D&F Institute of Pathology, Neuropathology, Medical University Graz, 8036 Graz, Austria; (M.L.); (G.G.); (M.Z.); (M.A.)
| | - Martin Zacharias
- D&F Institute of Pathology, Neuropathology, Medical University Graz, 8036 Graz, Austria; (M.L.); (G.G.); (M.Z.); (M.A.)
| | - Christine Haberler
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Johannes Hainfellner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Adelheid Woehrer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Simon Hametner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas Roetzer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Till Voigtländer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Gerda Ricken
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Verena Endmayr
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Carmen Haider
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Judith Ludwig
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Andrea Polt
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Gloria Wilk
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Susanne Schmid
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Irene Erben
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Anita Nguyen
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Susanna Lang
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (I.S.-K.); (C.K.); (M.N.); (R.K.)
| | - Ingrid Simonitsch-Klupp
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (I.S.-K.); (C.K.); (M.N.); (R.K.)
| | - Christoph Kornauth
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (I.S.-K.); (C.K.); (M.N.); (R.K.)
- Münchner Leukämielabor, 81377 Munich, Germany
| | - Maja Nackenhorst
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (I.S.-K.); (C.K.); (M.N.); (R.K.)
| | - Johannes Kläger
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (I.S.-K.); (C.K.); (M.N.); (R.K.)
| | - Renate Kain
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (I.S.-K.); (C.K.); (M.N.); (R.K.)
| | - Andreas Chott
- Institute of Pathology, Klinik Ottakring, 1160 Vienna, Austria; (A.C.); (R.W.)
| | - Richard Wasicky
- Institute of Pathology, Klinik Ottakring, 1160 Vienna, Austria; (A.C.); (R.W.)
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria;
| | - Günter Weiss
- Department of Internal Medicine and Pulmonology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (G.W.); (J.L.-R.)
| | - Judith Löffler-Rag
- Department of Internal Medicine and Pulmonology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (G.W.); (J.L.-R.)
| | - Thomas Berger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
- Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria
| | - Patrizia Moser
- Department of Neuropathology, Tirol Kliniken GmbH, 6020 Innsbruck, Austria; (P.M.); (A.S.)
| | - Afshin Soleiman
- Department of Neuropathology, Tirol Kliniken GmbH, 6020 Innsbruck, Austria; (P.M.); (A.S.)
| | - Martin Asslaber
- D&F Institute of Pathology, Neuropathology, Medical University Graz, 8036 Graz, Austria; (M.L.); (G.G.); (M.Z.); (M.A.)
| | - Roland Sedivy
- Department of Pathology, Klinik Favoriten, 1100 Vienna, Austria (H.K.); (R.S.); (M.K.)
| | - Nikolaus Klupp
- Department of Forensic Medicine, Medical University of Vienna, 1090 Vienna, Austria; (K.S.); (C.R.); (N.K.); (D.R.)
| | - Martin Klimpfinger
- Department of Pathology, Klinik Favoriten, 1100 Vienna, Austria (H.K.); (R.S.); (M.K.)
- Department of Pathology, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (I.S.-K.); (C.K.); (M.N.); (R.K.)
| | - Daniele Risser
- Department of Forensic Medicine, Medical University of Vienna, 1090 Vienna, Austria; (K.S.); (C.R.); (N.K.); (D.R.)
| | - Herbert Budka
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Lucas Schirmer
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Department of Clinical Research, University Hospital and University of Basel, 4031 Basel, Switzerland;
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany;
- Interdisciplinary Center for Neurosciences, Heidelberg University, 69120 Heidelberg, Germany
| | - Anne-Katrin Pröbstel
- Departments of Neurology, Biomedicine and Clinical Research, University Hospital and University of Basel, 4031 Basel, Switzerland; (M.B.); (A.-K.P.)
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Department of Clinical Research, University Hospital and University of Basel, 4031 Basel, Switzerland;
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria; (S.K.); (C.H.); (J.H.); (A.W.); (S.H.); (T.R.); (T.V.); (V.E.); (C.H.); (J.L.); (A.P.); (G.W.); (S.S.); (I.E.); (A.N.); (T.B.); (H.B.)
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
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16
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Normandin E, Valizadeh N, Rudmann EA, Uddin R, Dobbins ST, MacInnis BL, Padera RF, Siddle KJ, Lemieux JE, Sabeti PC, Mukerji SS, Solomon IH. Neuropathological features of SARS-CoV-2 delta and omicron variants. J Neuropathol Exp Neurol 2023; 82:283-295. [PMID: 36847705 PMCID: PMC10025880 DOI: 10.1093/jnen/nlad015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is continually evolving resulting in variants with increased transmissibility, more severe disease, reduced effectiveness of treatments or vaccines, or diagnostic detection failure. The SARS-CoV-2 Delta variant (B.1.617.2 and AY lineages) was the dominant circulating strain in the United States from July to mid-December 2021, followed by the Omicron variant (B.1.1.529 and BA lineages). Coronavirus disease 2019 (COVID-19) has been associated with neurological sequelae including loss of taste/smell, headache, encephalopathy, and stroke, yet little is known about the impact of viral strain on neuropathogenesis. Detailed postmortem brain evaluations were performed for 22 patients from Massachusetts, including 12 who died following infection with Delta variant and 5 with Omicron variant, compared to 5 patients who died earlier in the pandemic. Diffuse hypoxic injury, occasional microinfarcts and hemorrhage, perivascular fibrinogen, and rare lymphocytes were observed across the 3 groups. SARS-CoV-2 protein and RNA were not detected in any brain samples by immunohistochemistry, in situ hybridization, or real-time quantitative PCR. These results, although preliminary, demonstrate that, among a subset of severely ill patients, similar neuropathological features are present in Delta, Omicron, and non-Delta/non-Omicron variant patients, suggesting that SARS-CoV-2 variants are likely to affect the brain by common neuropathogenic mechanisms.
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Affiliation(s)
- Erica Normandin
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Navid Valizadeh
- Division of Neuroimmunology and Neuro-infectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily A Rudmann
- Division of Neuroimmunology and Neuro-infectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rockib Uddin
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Robert F Padera
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Jacob E Lemieux
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pardis C Sabeti
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Shibani S Mukerji
- Division of Neuroimmunology and Neuro-infectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Isaac H Solomon
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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17
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Wesselingh R, Wesselingh SL. An eye to the future: Acute and long-term neuro-ophthalmological and neurological complications of COVID-19. Clin Exp Ophthalmol 2023. [PMID: 36908238 DOI: 10.1111/ceo.14221] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
COVID-19 has had a significant impact on the global population and has produced compelling evidence of non-pulmonary organ dysfunction, including the nervous system. It is vital that specialists in ophthalmology and neurology are informed of the potential complications of COVID-19 and gain a deeper understanding of how COVID-19 can cause diseases of the nervous system. In this review we detail four possible mechanisms by which COVID-19 infection may result in neurological or neuro-ophthalmological complications: (1) Toxic and metabolic effects of severe pulmonary COVID-19 disease on the neural axis including hypoxia and the systemic hyper-inflammatory state, (2) endothelial dysfunction, (3) dysimmune responses directed again the neuroaxis, and (4) direct neuro-invasion and injury by the virus itself. We explore the pathological evidence for each of these and how they may link to neuro-ophthalmological disorders. Finally, we explore the evidence for long-term neurological and neuro-ophthalmological complications of COVID-19, with a focus on neurodegeneration.
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Affiliation(s)
- Robb Wesselingh
- Department of Neurosciences, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 6, Alfred Centre, 99 Commercial Road, Melbourne, 3004, Australia
- Department of Neurology, Alfred Health, 55 Commercial Road, Melbourne, 3004, Australia
| | - Steve L Wesselingh
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, 5000, Australia
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18
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Emmi A, Rizzo S, Barzon L, Sandre M, Carturan E, Sinigaglia A, Riccetti S, Della Barbera M, Boscolo-Berto R, Cocco P, Macchi V, Antonini A, De Gaspari M, Basso C, De Caro R, Porzionato A. Detection of SARS-CoV-2 viral proteins and genomic sequences in human brainstem nuclei. NPJ Parkinsons Dis 2023; 9:25. [PMID: 36781876 PMCID: PMC9924897 DOI: 10.1038/s41531-023-00467-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 01/30/2023] [Indexed: 02/15/2023] Open
Abstract
Neurological manifestations are common in COVID-19, the disease caused by SARS-CoV-2. Despite reports of SARS-CoV-2 detection in the brain and cerebrospinal fluid of COVID-19 patients, it is still unclear whether the virus can infect the central nervous system, and which neuropathological alterations can be ascribed to viral tropism, rather than immune-mediated mechanisms. Here, we assess neuropathological alterations in 24 COVID-19 patients and 18 matched controls who died due to pneumonia/respiratory failure. Aside from a wide spectrum of neuropathological alterations, SARS-CoV-2-immunoreactive neurons were detected in the dorsal medulla and in the substantia nigra of five COVID-19 subjects. Viral RNA was also detected by real-time RT-PCR. Quantification of reactive microglia revealed an anatomically segregated pattern of inflammation within affected brainstem regions, and was higher when compared to controls. While the results of this study support the neuroinvasive potential of SARS-CoV-2 and characterize the role of brainstem inflammation in COVID-19, its potential implications for neurodegeneration, especially in Parkinson's disease, require further investigations.
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Affiliation(s)
- Aron Emmi
- grid.5608.b0000 0004 1757 3470Institute of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy ,grid.5608.b0000 0004 1757 3470Center for Neurodegenerative Disease Research (CESNE), University of Padova, Padova, Italy
| | - Stefania Rizzo
- grid.5608.b0000 0004 1757 3470Department of Cardio-Thoracic-Vascular Sciences & Public Health, University of Padova, Padova, Italy
| | - Luisa Barzon
- grid.5608.b0000 0004 1757 3470Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Michele Sandre
- grid.5608.b0000 0004 1757 3470Center for Neurodegenerative Disease Research (CESNE), University of Padova, Padova, Italy ,grid.5608.b0000 0004 1757 3470Department of Neuroscience, University of Padova, Padova, Italy
| | - Elisa Carturan
- grid.5608.b0000 0004 1757 3470Department of Cardio-Thoracic-Vascular Sciences & Public Health, University of Padova, Padova, Italy
| | - Alessandro Sinigaglia
- grid.5608.b0000 0004 1757 3470Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Silvia Riccetti
- grid.5608.b0000 0004 1757 3470Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Mila Della Barbera
- grid.5608.b0000 0004 1757 3470Department of Cardio-Thoracic-Vascular Sciences & Public Health, University of Padova, Padova, Italy
| | - Rafael Boscolo-Berto
- grid.5608.b0000 0004 1757 3470Institute of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy
| | - Patrizia Cocco
- Pathology and Histopathology Unit, Ospedali Riuniti Padova Sud, Padova, Italy
| | - Veronica Macchi
- grid.5608.b0000 0004 1757 3470Institute of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy ,grid.5608.b0000 0004 1757 3470Center for Neurodegenerative Disease Research (CESNE), University of Padova, Padova, Italy
| | - Angelo Antonini
- grid.5608.b0000 0004 1757 3470Center for Neurodegenerative Disease Research (CESNE), University of Padova, Padova, Italy ,grid.5608.b0000 0004 1757 3470Movement Disorders Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | - Monica De Gaspari
- grid.5608.b0000 0004 1757 3470Department of Cardio-Thoracic-Vascular Sciences & Public Health, University of Padova, Padova, Italy
| | - Cristina Basso
- grid.5608.b0000 0004 1757 3470Department of Cardio-Thoracic-Vascular Sciences & Public Health, University of Padova, Padova, Italy
| | - Raffaele De Caro
- Institute of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy. .,Center for Neurodegenerative Disease Research (CESNE), University of Padova, Padova, Italy.
| | - Andrea Porzionato
- grid.5608.b0000 0004 1757 3470Institute of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy ,grid.5608.b0000 0004 1757 3470Center for Neurodegenerative Disease Research (CESNE), University of Padova, Padova, Italy
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19
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Reinhold D, Farztdinov V, Yan Y, Meisel C, Sadlowski H, Kühn J, Perschel FH, Endres M, Düzel E, Vielhaber S, Guttek K, Goihl A, Venø M, Teegen B, Stöcker W, Stubbemann P, Kurth F, Sander LE, Ralser M, Otto C, Streit S, Jarius S, Ruprecht K, Radbruch H, Kjems J, Mülleder M, Heppner F, Körtvelyessy P. The brain reacting to COVID-19: analysis of the cerebrospinal fluid proteome, RNA and inflammation. J Neuroinflammation 2023; 20:30. [PMID: 36759861 PMCID: PMC9909638 DOI: 10.1186/s12974-023-02711-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Patients with COVID-19 can have a variety of neurological symptoms, but the active involvement of central nervous system (CNS) in COVID-19 remains unclear. While routine cerebrospinal fluid (CSF) analyses in patients with neurological manifestations of COVID-19 generally show no or only mild inflammation, more detailed data on inflammatory mediators in the CSF of patients with COVID-19 are scarce. We studied the inflammatory response in paired CSF and serum samples of patients with COVID-19 (n = 38). Patients with herpes simplex virus encephalitis (HSVE, n = 10) and patients with non-inflammatory, non-neurodegenerative neurological diseases (n = 28) served as controls. We used proteomics, enzyme-linked immunoassays, and semiquantitative cytokine arrays to characterize inflammatory proteins. Autoantibody screening was performed with cell-based assays and native tissue staining. RNA sequencing of long-non-coding RNA and circular RNA was done to study the transcriptome. Proteomics on single protein level and subsequent pathway analysis showed similar yet strongly attenuated inflammatory changes in the CSF of COVID-19 patients compared to HSVE patients with, e.g., downregulation of the apolipoproteins and extracellular matrix proteins. Protein upregulation of the complement system, the serpin proteins pathways, and other proteins including glycoproteins alpha-2 and alpha-1 acid. Importantly, calculation of interleukin-6, interleukin-16, and CXCL10 CSF/serum indices suggest that these inflammatory mediators reach the CSF from the systemic circulation, rather than being produced within the CNS. Antibody screening revealed no pathological levels of known neuronal autoantibodies. When stratifying COVID-19 patients into those with and without bacterial superinfection as indicated by elevated procalcitonin levels, inflammatory markers were significantly (p < 0.01) higher in those with bacterial superinfection. RNA sequencing in the CSF revealed 101 linear RNAs comprising messenger RNAs, and two circRNAs being significantly differentially expressed in COVID-19 than in non-neuroinflammatory controls and neurodegenerative patients. Our findings may explain the absence of signs of intrathecal inflammation upon routine CSF testing despite the presence of SARS-CoV2 infection-associated neurological symptoms. The relevance of blood-derived mediators of inflammation in the CSF for neurological COVID-19 and post-COVID-19 symptoms deserves further investigation.
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Affiliation(s)
- Dirk Reinhold
- grid.5807.a0000 0001 1018 4307Institute of Molecular and Clinical Immunology, Medical Faculty, Otto-Von-Guericke-University, Magdeburg, Germany ,grid.5807.a0000 0001 1018 4307Health Campus Immunology, Infectiology and Inflammation (GC-I3), Medical Faculty, Otto-Von-Guericke-University, Magdeburg, Germany
| | - Vadim Farztdinov
- grid.6363.00000 0001 2218 4662Core Facility, High-Throughput Mass Spectrometry, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Yan Yan
- grid.7048.b0000 0001 1956 2722Interdisciplinary Nanoscience Center, Aarhus University, 8000 Aarhus C, Denmark ,Omiics ApS, 8200 Aarhus N, Denmark
| | | | | | - Joachim Kühn
- Labor Berlin Charité Vivantes GmbH, 13353 Berlin, Germany
| | | | - Matthias Endres
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE) in Berlin, 10117 Berlin, Germany
| | - Emrah Düzel
- grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE) in Magdeburg, 39120 Magdeburg, Germany
| | - Stefan Vielhaber
- grid.5807.a0000 0001 1018 4307Department of Neurology, University Hospital Magdeburg, Otto-Von Guericke University, 39120 Magdeburg, Germany
| | - Karina Guttek
- grid.5807.a0000 0001 1018 4307Institute of Molecular and Clinical Immunology, Medical Faculty, Otto-Von-Guericke-University, Magdeburg, Germany
| | - Alexander Goihl
- grid.5807.a0000 0001 1018 4307Institute of Molecular and Clinical Immunology, Medical Faculty, Otto-Von-Guericke-University, Magdeburg, Germany
| | | | - Bianca Teegen
- Clinical-Immunological Laboratory Prof. Dr. Stöcker, 23627 Groß Grönau, Germany
| | - Winfried Stöcker
- Clinical-Immunological Laboratory Prof. Dr. Stöcker, 23627 Groß Grönau, Germany
| | - Paula Stubbemann
- grid.6363.00000 0001 2218 4662Department of Infectious Diseases and Respiratory Medicine, German Center for Lung Research (DZL), Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Florian Kurth
- grid.6363.00000 0001 2218 4662Department of Infectious Diseases and Respiratory Medicine, German Center for Lung Research (DZL), Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Leif E. Sander
- grid.6363.00000 0001 2218 4662Department of Infectious Diseases and Respiratory Medicine, German Center for Lung Research (DZL), Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Markus Ralser
- grid.6363.00000 0001 2218 4662Core Facility, High-Throughput Mass Spectrometry, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany ,grid.6363.00000 0001 2218 4662Institute for Biochemistry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carolin Otto
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - Simon Streit
- grid.6363.00000 0001 2218 4662Department of Neuropathology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Sven Jarius
- grid.7700.00000 0001 2190 4373Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Klemens Ruprecht
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
| | - Helena Radbruch
- grid.6363.00000 0001 2218 4662Department of Neuropathology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jørgen Kjems
- grid.7048.b0000 0001 1956 2722Interdisciplinary Nanoscience Center, Aarhus University, 8000 Aarhus C, Denmark
| | - Michael Mülleder
- grid.6363.00000 0001 2218 4662Core Facility, High-Throughput Mass Spectrometry, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Frank Heppner
- grid.6363.00000 0001 2218 4662Department of Neuropathology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Körtvelyessy
- Department of Neurology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany. .,German Center for Neurodegenerative Diseases (DZNE) in Magdeburg, 39120, Magdeburg, Germany. .,Department of Neuropathology, Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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20
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Mogensen MA, Filippi CG. Coronavirus Disease: Subacute to Chronic Neuroimaging Findings. Neuroimaging Clin N Am 2023; 33:69-82. [PMID: 36404048 PMCID: PMC9288999 DOI: 10.1016/j.nic.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Several neurologic disorders are associated with coronavirus disease 2019 (COVID-19). In this article, clinical syndromes typically occurring in the subacute to chronic phase of illness and their neuroimaging findings are described with discussion of their COVID-19 specific features and prognosis. Proposed pathogenic mechanisms of these neuroimaging findings and challenges in determining etiology are reviewed.
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Affiliation(s)
- Monique A. Mogensen
- Department of Radiology, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA,Corresponding author
| | - Christopher G. Filippi
- Department of Radiology, Tufts University School of Medicine, 800 Washington Street, Boston, MA 02111, USA
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21
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Michael BD, Walton D, Westenberg E, García-Azorín D, Singh B, Tamborska AA, Netravathi M, Chomba M, Wood GK, Easton A, Siddiqi OK, Jackson TA, Pollak TA, Nicholson TR, Nair S, Breen G, Prasad K, Thakur KT, Chou SHY, Schmutzhard E, Frontera JA, Helbok R, Padovani A, Menon DK, Solomon T, Winkler AS. Consensus Clinical Guidance for Diagnosis and Management of Adult COVID-19 Encephalopathy Patients. J Neuropsychiatry Clin Neurosci 2023; 35:12-27. [PMID: 35872617 DOI: 10.1176/appi.neuropsych.22010002] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Encephalopathy, a common condition among patients hospitalized with COVID-19, can be a challenge to manage and negatively affect prognosis. While encephalopathy may present clinically as delirium, subsyndromal delirium, or coma and may be a result of systemic causes such as hypoxia, COVID-19 has also been associated with more prolonged encephalopathy due to less common but nevertheless severe complications, such as inflammation of the brain parenchyma (with or without cerebrovascular involvement), demyelination, or seizures, which may be disproportionate to COVID-19 severity and require specific management. Given the large number of patients hospitalized with severe acute respiratory syndrome coronavirus-2 infection, even these relatively unlikely complications are increasingly recognized and are particularly important because they require specific management. Therefore, the aim of this review is to provide pragmatic guidance on the management of COVID-19 encephalopathy through consensus agreement of the Global COVID-19 Neuro Research Coalition. A systematic literature search of MEDLINE, medRxiv, and bioRxiv was conducted between January 1, 2020, and June 21, 2021, with additional review of references cited within the identified bibliographies. A modified Delphi approach was then undertaken to develop recommendations, along with a parallel approach to score the strength of both the recommendations and the supporting evidence. This review presents analysis of contemporaneous evidence for the definition, epidemiology, and pathophysiology of COVID-19 encephalopathy and practical guidance for clinical assessment, investigation, and both acute and long-term management.
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Affiliation(s)
- Benedict D Michael
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Dean Walton
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Erica Westenberg
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - David García-Azorín
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Bhagteshwar Singh
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Arina A Tamborska
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - M Netravathi
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Mashina Chomba
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Greta K Wood
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Ava Easton
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Omar K Siddiqi
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Thomas A Jackson
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Thomas A Pollak
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Timothy R Nicholson
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Shalini Nair
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Gerome Breen
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Kameshwar Prasad
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Kiran T Thakur
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Sherry H-Y Chou
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Erich Schmutzhard
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Jennifer A Frontera
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Raimund Helbok
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Alessandro Padovani
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - David K Menon
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Tom Solomon
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
| | - Andrea S Winkler
- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
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- National Institute for Health and Care Research (NIHR) Health Protection Unit for Emerging and Zoonotic Infections, Liverpool, United Kingdom (Michael, Tamborska, Wood, Solomon); Department of Neurology, Walton Center National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom (Michael, Walton, Tamborska, Wood, Solomon); Clinical Infection Microbiology and Immunology, Veterinary and Ecological Sciences, Institute for Infection, University of Liverpool, United Kingdom (Michael, Singh, Tamborska, Wood, Easton, Solomon); Department of Neurology, Center for Global Health, Faculty of Medicine, Technical University of Munich, Germany (Westenberg, Winkler); Department of Neurology, Hospital Clínico Universitario de Valladolid, Spain (García-Azorín); Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, United Kingdom (Singh); Department of Infectious Diseases, Christian Medical College, Vellore, India (Singh); National Institute of Mental Health and Neurosciences, Bangalore, India (Netravathi); Department of Medicine, Neurology Division, University Teaching Hospital, Lusaka, Zambia (Chomba, Siddiqi); Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York (Chomba, Thakur); Encephalitis Society, Malton, United Kingdom (Easton); Department of Neurology, Global Neurology Program, Beth Israel Deaconess Medical Center, Boston (Siddiqi); Department of Internal Medicine, Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston (Siddiqi); College of Medical and Dental Sciences, Institute of Inflammation and Aging, University of Birmingham, United Kingdom (Jackson); Department of Geriatric Medicine, University Hospitals Birmingham, United Kingdom (Jackson); Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Pollak); Social, Genetic and Developmental Psychiatry Center, Institute of Psychiatry, Psychology, and Neuroscience, King's College London (Nicholson, Breen); Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India (Nair); NIHR Maudsley Biomedical Research Center, South London and Maudsley NHS Trust and King's College London (Breen); Department of Neurology and Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India (Prasad); Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh (Chou); Department of Neurology, Northwestern Feinberg School of Medicine, Chicago (Chou); Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Austria (Schmutzhard, Helbok); New York University Grossman School of Medicine, New York (Frontera); Department of Clinical and Experimental Sciences, Institute of Neurology, University of Brescia, Italy (Padovani); Division of Anesthesia, University of Cambridge, United Kingdom (Menon); Faculty of Medicine, Center for Global Health, Institute of Health and Society, University of Oslo, Norway (Winkler)
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Rothstein TL. Cortical Grey matter volume depletion links to neurological sequelae in post COVID-19 "long haulers". BMC Neurol 2023; 23:22. [PMID: 36647063 PMCID: PMC9843113 DOI: 10.1186/s12883-023-03049-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 01/02/2023] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE COVID-19 (SARS-CoV-2) has been associated with neurological sequelae even in those patients with mild respiratory symptoms. Patients experiencing cognitive symptoms such as "brain fog" and other neurologic sequelae for 8 or more weeks define "long haulers". There is limited information regarding damage to grey matter (GM) structures occurring in COVID-19 "long haulers". Advanced imaging techniques can quantify brain volume depletions related to COVID-19 infection which is important as conventional Brain MRI often fails to identify disease correlates. 3-dimensional voxel-based morphometry (3D VBM) analyzes, segments and quantifies key brain volumes allowing comparisons between COVID-19 "long haulers" and normative data drawn from healthy controls, with values based on percentages of intracranial volume. METHODS This is a retrospective single center study which analyzed 24 consecutive COVID-19 infected patients with long term neurologic symptoms. Each patient underwent Brain MRI with 3D VBM at median time of 85 days following laboratory confirmation. All patients had relatively mild respiratory symptoms not requiring oxygen supplementation, hospitalization, or assisted ventilation. 3D VBM was obtained for whole brain and forebrain parenchyma, cortical grey matter (CGM), hippocampus, and thalamus. RESULTS The results demonstrate a statistically significant depletion of CGM volume in 24 COVID-19 infected patients. Reduced CGM volume likely influences their long term neurological sequelae and may impair post COVID-19 patient's quality of life and productivity. CONCLUSION This study contributes to understanding effects of COVID-19 infection on patient's neurocognitive and neurological function, with potential for producing serious long term personal and economic consequences, and ongoing challenges to public health systems.
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Affiliation(s)
- Ted L. Rothstein
- grid.253615.60000 0004 1936 9510Department of Neurology, George Washington University, Washington, DC USA
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Abstract
COVID-19 illness is associated with diverse neurological manifestations. Its exceptionally high prevalence results from unprecedented genetic diversity, genomic recombination, and superspreading. With each new mutation and variant, there are foreseeable risks of rising fatality and novel neurological motor complications in childhood and adult cases. This chapter provides an extensive review of COVID-19 neurological illness, notably the motor manifestations. Innovative treatments have been developed to stem the spread of infectious contagious illness, and attenuate the resultant cytokine storm and other postinfectious immune aspects responsible for postacute COVID-19 syndrome due to the multiplier effect of infection, immunity, and inflammation, termed I3.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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24
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Younger DS. Critical illness-associated weakness and related motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:707-777. [PMID: 37562893 DOI: 10.1016/b978-0-323-98818-6.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Thapaliya K, Marshall-Gradisnik S, Barth M, Eaton-Fitch N, Barnden L. Brainstem volume changes in myalgic encephalomyelitis/chronic fatigue syndrome and long COVID patients. Front Neurosci 2023; 17:1125208. [PMID: 36937672 PMCID: PMC10017877 DOI: 10.3389/fnins.2023.1125208] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and long COVID patients have overlapping neurological, autonomic, pain, and post-exertional symptoms. We compared volumes of brainstem regions for 10 ME/CFS (CCC or ICC criteria), 8 long COVID (WHO Delphi consensus), and 10 healthy control (HC) subjects on 3D, T1-weighted MRI images acquired using sub-millimeter isotropic resolution using an ultra-high field strength of 7 Tesla. Group comparisons with HC detected significantly larger volumes in ME/CFS for pons (p = 0.004) and whole brainstem (p = 0.01), and in long COVID for pons (p = 0.003), superior cerebellar peduncle (p = 0.009), and whole brainstem (p = 0.005). No significant differences were found between ME/CFS and long COVID volumes. In ME/CFS, we detected positive correlations between the pons and whole brainstem volumes with "pain" and negative correlations between the midbrain and whole brainstem volumes with "breathing difficulty." In long COVID patients a strong negative relationship was detected between midbrain volume and "breathing difficulty." Our study demonstrated an abnormal brainstem volume in both ME/CFS and long COVID consistent with the overlapping symptoms.
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Affiliation(s)
- Kiran Thapaliya
- National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia
- *Correspondence: Kiran Thapaliya,
| | - Sonya Marshall-Gradisnik
- National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Markus Barth
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia
| | - Natalie Eaton-Fitch
- National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Leighton Barnden
- National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
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26
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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27
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Eschbacher KL, Larsen RA, Moyer AM, Majumdar R, Reichard RR. Neuropathological findings in COVID-19: an autopsy cohort. J Neuropathol Exp Neurol 2022; 82:21-28. [PMID: 36355625 DOI: 10.1093/jnen/nlac101] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The literature regarding the neuropathological findings in cases of SARS-CoV-2 infection, which causes coronavirus disease 2019 (COVID-19), is expanding. We identified 72 patients who died of COVID-19 (n = 48) or had recovered shortly before death (n = 24) and had autopsies performed at our institution (49 males, 23 females; median age at death 76.4 years, range: 0.0-95.0 years). Droplet digital polymerase chain reaction (ddPCR) for the detection of SARS-CoV-2 was performed (n = 58) in multiple brain regions. In cases the assay was successfully completed (n = 50), 98.0% were negative (n = 49) and 2% were indeterminate (n = 1). Most histologic findings were typical of the patient age demographic, such as neurodegenerative disease and arteriolosclerosis. A subset of cases demonstrated findings which may be associated with sequelae of critical illness. We identified 3 cases with destructive perivascular lesions with axonal injury, one of which also harbored perivascular demyelinating lesions. These rare cases may represent a parainfectious process versus sequelae of vascular injury. The lack of detectable SARS-CoV-2 by ddPCR or significant histologic evidence of direct infection suggests that active encephalitis is not a feature of COVID-19.
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Affiliation(s)
- Kathryn L Eschbacher
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rachel A Larsen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramanath Majumdar
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert Ross Reichard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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28
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[Clinical features of children with coronavirus disease 2019 complicated by acute encephalitis and related research advances]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:1301-1306. [PMID: 36544407 PMCID: PMC9785077 DOI: 10.7499/j.issn.1008-8830.2208033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Coronavirus disease 2019 (COVID-19) has become a worldwide pandemic since the end of 2019. There is an increasing number of reports on nervous system symptoms, among which encephalitis is considered a serious neurological complication of COVID-19, but there are few reports of this complication in China. Acute encephalitis has severe symptoms. If it is not identified early and treated in time, the mortality is high and the prognosis is poor. During the current global epidemic, it is necessary to pay attention to the severe nervous system symptoms of COVID-19. Therefore, this article summarizes the clinical features of COVID-19 complicated by acute encephalitis through literature review and a detailed analysis of medical records, so as to provide a reference for clinicians to deal with the cases of COVID-19 complicated by acute encephalitis.
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29
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Yepes M. Neurological Complications of SARS-CoV-2 Infection and COVID-19 Vaccines: From Molecular Mechanisms to Clinical Manifestations. Curr Drug Targets 2022; 23:1620-1638. [PMID: 36121081 DOI: 10.2174/1389450123666220919123029] [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: 02/04/2022] [Revised: 05/31/2022] [Accepted: 07/26/2022] [Indexed: 01/25/2023]
Abstract
Coronavirus Disease 2019 (COVID-19) is an infectious disease, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), that reached pandemic proportions in 2020. Despite the fact that it was initially characterized by pneumonia and acute respiratory distress syndrome, it is now clear that the nervous system is also compromised in one third of these patients. Indeed, a significant proportion of COVID-19 patients suffer nervous system damage via a plethora of mechanisms including hypoxia, coagulopathy, immune response to the virus, and the direct effect of SARS-CoV-2 on endothelial cells, neurons, astrocytes, pericytes and microglia. Additionally, a low number of previously healthy individuals develop a variety of neurological complications after receiving COVID-19 vaccines and a large proportion of COVID-19 survivors experience longlasting neuropsychiatric symptoms. In conclusion, COVID-19 is also a neurological disease, and the direct and indirect effects of the virus on the nervous system have a significant impact on the morbidity and mortality of these patients. Here we will use the concept of the neurovascular unit, assembled by endothelial cells, basement membrane, perivascular astrocytes, neurons and microglia, to review the effects of SARS-CoV-2 in the nervous system. We will then use this information to review data published to this date on the neurological manifestations of COVID-19, the post- COVID syndrome and COVID-19 vaccines.
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Affiliation(s)
- Manuel Yepes
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA.,Department of Neurology & Center for Neurodegenerative Disease, Emory University School of Medicine, Atlanta, GA, USA.,Department of Neurology, Veterans Affairs Medical Center, Atlanta, GA, USA
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30
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Etter MM, Martins TA, Kulsvehagen L, Pössnecker E, Duchemin W, Hogan S, Sanabria-Diaz G, Müller J, Chiappini A, Rychen J, Eberhard N, Guzman R, Mariani L, Melie-Garcia L, Keller E, Jelcic I, Pargger H, Siegemund M, Kuhle J, Oechtering J, Eich C, Tzankov A, Matter MS, Uzun S, Yaldizli Ö, Lieb JM, Psychogios MN, Leuzinger K, Hirsch HH, Granziera C, Pröbstel AK, Hutter G. Severe Neuro-COVID is associated with peripheral immune signatures, autoimmunity and neurodegeneration: a prospective cross-sectional study. Nat Commun 2022; 13:6777. [DOI: 10.1038/s41467-022-34068-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractGrowing evidence links COVID-19 with acute and long-term neurological dysfunction. However, the pathophysiological mechanisms resulting in central nervous system involvement remain unclear, posing both diagnostic and therapeutic challenges. Here we show outcomes of a cross-sectional clinical study (NCT04472013) including clinical and imaging data and corresponding multidimensional characterization of immune mediators in the cerebrospinal fluid (CSF) and plasma of patients belonging to different Neuro-COVID severity classes. The most prominent signs of severe Neuro-COVID are blood-brain barrier (BBB) impairment, elevated microglia activation markers and a polyclonal B cell response targeting self-antigens and non-self-antigens. COVID-19 patients show decreased regional brain volumes associating with specific CSF parameters, however, COVID-19 patients characterized by plasma cytokine storm are presenting with a non-inflammatory CSF profile. Post-acute COVID-19 syndrome strongly associates with a distinctive set of CSF and plasma mediators. Collectively, we identify several potentially actionable targets to prevent or intervene with the neurological consequences of SARS-CoV-2 infection.
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31
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Poloni TE, Moretti M, Medici V, Turturici E, Belli G, Cavriani E, Visonà SD, Rossi M, Fantini V, Ferrari RR, Carlos AF, Gagliardi S, Tronconi L, Guaita A, Ceroni M. COVID-19 Pathology in the Lung, Kidney, Heart and Brain: The Different Roles of T-Cells, Macrophages, and Microthrombosis. Cells 2022; 11:3124. [PMID: 36231087 PMCID: PMC9563269 DOI: 10.3390/cells11193124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 12/03/2022] Open
Abstract
Here, we aim to describe COVID-19 pathology across different tissues to clarify the disease's pathophysiology. Lungs, kidneys, hearts, and brains from nine COVID-19 autopsies were compared by using antibodies against SARS-CoV-2, macrophages-microglia, T-lymphocytes, B-lymphocytes, and activated platelets. Alzheimer's Disease pathology was also assessed. PCR techniques were used to verify the presence of viral RNA. COVID-19 cases had a short clinical course (0-32 days) and their mean age was 77.4 y/o. Hypoxic changes and inflammatory infiltrates were present across all tissues. The lymphocytic component in the lungs and kidneys was predominant over that of other tissues (p < 0.001), with a significantly greater presence of T-lymphocytes in the lungs (p = 0.020), which showed the greatest presence of viral antigens. The heart showed scant SARS-CoV-2 traces in the endothelium-endocardium, foci of activated macrophages, and rare lymphocytes. The brain showed scarce SARS-CoV-2 traces, prominent microglial activation, and rare lymphocytes. The pons exhibited the highest microglial activation (p = 0.017). Microthrombosis was significantly higher in COVID-19 lungs (p = 0.023) compared with controls. The most characteristic pathological features of COVID-19 were an abundance of T-lymphocytes and microthrombosis in the lung and relevant microglial hyperactivation in the brainstem. This study suggests that the long-term sequelae of COVID-19 derive from persistent inflammation, rather than persistent viral replication.
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Affiliation(s)
- Tino Emanuele Poloni
- Department of Neurology and Neuropathology, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
- Department of Rehabilitation, ASP Golgi-Redaelli, Abbiategrasso, 20081 Milan, Italy
| | - Matteo Moretti
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Valentina Medici
- Department of Neurology and Neuropathology, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
| | - Elvira Turturici
- Department of Neurology and Neuropathology, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
| | - Giacomo Belli
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Elena Cavriani
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Silvia Damiana Visonà
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Michele Rossi
- Unit of Biostatistics, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
| | - Valentina Fantini
- Laboratory of Neurobiology and Neurogenetic, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
| | - Riccardo Rocco Ferrari
- Laboratory of Neurobiology and Neurogenetic, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
| | - Arenn Faye Carlos
- Department of Neurology and Neuropathology, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
| | - Stella Gagliardi
- Unit of Molecular Biology and Transcriptomics IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Livio Tronconi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
- Department of Forensic Medicine, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Antonio Guaita
- Department of Neurology and Neuropathology, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
- Unit of Biostatistics, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
- Laboratory of Neurobiology and Neurogenetic, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
| | - Mauro Ceroni
- Department of Neurology and Neuropathology, Golgi-Cenci Foundation, Abbiategrasso, 20081 Milan, Italy
- Unit of Molecular Biology and Transcriptomics IRCCS Mondino Foundation, 27100 Pavia, Italy
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Latorre D. Autoimmunity and SARS-CoV-2 infection: Unraveling the link in neurological disorders. Eur J Immunol 2022; 52:1561-1571. [PMID: 35833748 PMCID: PMC9350097 DOI: 10.1002/eji.202149475] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/14/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022]
Abstract
According to the World Health Organization, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has already infected more than 400 million people and caused over 5 million deaths globally. The infection is associated with a wide spectrum of clinical manifestations, ranging from no signs of illness to severe pathological complications that go beyond the typical respiratory symptoms. On this note, new-onset neurological and neuropsychiatric syndromes have been increasingly reported in a large fraction of COVID-19 patients, thus potentially representing a significant public health threat. Although the underlying pathophysiological mechanisms remain elusive, a growing body of evidence suggests that SARS-CoV-2 infection may trigger an autoimmune response, which could potentially contribute to the establishment and/or exacerbation of neurological disorders in COVID-19 patients. Shedding light on this aspect is urgently needed for the development of effective therapeutic intervention. This review highlights the current knowledge of the immune responses occurring in Neuro-COVID patients and discusses potential immune-mediated mechanisms by which SARS-CoV-2 infection may trigger neurological complications.
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Solimando AG, Marziliano D, Ribatti D. SARS-CoV-2 and Endothelial Cells: Vascular Changes, Intussusceptive Microvascular Growth and Novel Therapeutic Windows. Biomedicines 2022; 10:2242. [PMID: 36140343 PMCID: PMC9496230 DOI: 10.3390/biomedicines10092242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022] Open
Abstract
Endothelial activation in infectious diseases plays a crucial role in understanding and predicting the outcomes and future treatments of several clinical conditions. COVID-19 is no exception. Moving from basic principles to novel approaches, an evolving view of endothelial activation provides insights into a better knowledge of the upstream actors in COVID-19 as a crucial future direction for managing SARS-CoV-2 and other infections. Assessing the function of resting and damaged endothelial cells in infection, particularly in COVID-19, five critical processes emerged controlling thrombo-resistance: vascular integrity, blood flow regulation, immune cell trafficking, angiogenesis and intussusceptive microvascular growth. Endothelial cell injury is associated with thrombosis, increased vessel contraction and a crucial phenomenon identified as intussusceptive microvascular growth, an unprecedented event of vessel splitting into two lumens through the integration of circulating pro-angiogenic cells. An essential awareness of endothelial cells and their phenotypic changes in COVID-19 inflammation is pivotal to understanding the vascular biology of infections and may offer crucial new therapeutic windows.
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Affiliation(s)
- Antonio Giovanni Solimando
- Guido Baccelli Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, 70124 Bari, Italy
| | - Donatello Marziliano
- Guido Baccelli Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, 70124 Bari, Italy
| | - Domenico Ribatti
- Department of Basic Medical Sciences, Neurosciences, and Sensory Organs, University of Bari Medical School, 70124 Bari, Italy
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Lachén-Montes M, Mendizuri N, Ausín K, Echaide M, Blanco E, Chocarro L, de Toro M, Escors D, Fernández-Irigoyen J, Kochan G, Santamaría E. Metabolic dyshomeostasis induced by SARS-CoV-2 structural proteins reveals immunological insights into viral olfactory interactions. Front Immunol 2022; 13:866564. [PMID: 36159830 PMCID: PMC9492993 DOI: 10.3389/fimmu.2022.866564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
One of the most common symptoms in COVID-19 is a sudden loss of smell. SARS-CoV-2 has been detected in the olfactory bulb (OB) from animal models and sporadically in COVID-19 patients. To decipher the specific role over the SARS-CoV-2 proteome at olfactory level, we characterized the in-depth molecular imbalance induced by the expression of GFP-tagged SARS-CoV-2 structural proteins (M, N, E, S) on mouse OB cells. Transcriptomic and proteomic trajectories uncovered a widespread metabolic remodeling commonly converging in extracellular matrix organization, lipid metabolism and signaling by receptor tyrosine kinases. The molecular singularities and specific interactome expression modules were also characterized for each viral structural factor. The intracellular molecular imbalance induced by each SARS-CoV-2 structural protein was accompanied by differential activation dynamics in survival and immunological routes in parallel with a differentiated secretion profile of chemokines in OB cells. Machine learning through a proteotranscriptomic data integration uncovered TGF-beta signaling as a confluent activation node by the SARS-CoV-2 structural proteome. Taken together, these data provide important avenues for understanding the multifunctional immunomodulatory properties of SARS-CoV-2 M, N, S and E proteins beyond their intrinsic role in virion formation, deciphering mechanistic clues to the olfactory inflammation observed in COVID-19 patients.
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Affiliation(s)
- Mercedes Lachén-Montes
- Clinical Neuroproteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
| | - Naroa Mendizuri
- Clinical Neuroproteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
| | - Karina Ausín
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
- Proteomics Platform, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Miriam Echaide
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
- Oncoimmunology Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Ester Blanco
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
- Oncoimmunology Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Luisa Chocarro
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
- Oncoimmunology Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - María de Toro
- Genomics and Bioinformatics Platform, Centro de Investigación Biomédica de La Rioja (CIBIR), Logroño, Spain
| | - David Escors
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
- Oncoimmunology Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Joaquín Fernández-Irigoyen
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
- Proteomics Platform, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Grazyna Kochan
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
- Oncoimmunology Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| | - Enrique Santamaría
- Clinical Neuroproteomics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
- IdiSNA. Navarra Institute for Health Research, Pamplona, Spain
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Graham EL, Koralnik IJ, Liotta EM. Therapeutic Approaches to the Neurologic Manifestations of COVID-19. Neurotherapeutics 2022; 19:1435-1466. [PMID: 35861926 PMCID: PMC9302225 DOI: 10.1007/s13311-022-01267-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 02/07/2023] Open
Abstract
As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.
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Affiliation(s)
- Edith L Graham
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Igor J Koralnik
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA
| | - Eric M Liotta
- The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave Suite 1150, Chicago, IL, 60611, USA.
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Serrano GE, Walker JE, Tremblay C, Piras IS, Huentelman MJ, Belden CM, Goldfarb D, Shprecher D, Atri A, Adler CH, Shill HA, Driver-Dunckley E, Mehta SH, Caselli R, Woodruff BK, Haarer CF, Ruhlen T, Torres M, Nguyen S, Schmitt D, Rapscak SZ, Bime C, Peters JL, Alevritis E, Arce RA, Glass MJ, Vargas D, Sue LI, Intorcia AJ, Nelson CM, Oliver J, Russell A, Suszczewicz KE, Borja CI, Cline MP, Hemmingsen SJ, Qiji S, Hobgood HM, Mizgerd JP, Sahoo MK, Zhang H, Solis D, Montine TJ, Berry GJ, Reiman EM, Röltgen K, Boyd SD, Pinsky BA, Zehnder JL, Talbot P, Desforges M, DeTure M, Dickson DW, Beach TG. SARS-CoV-2 Brain Regional Detection, Histopathology, Gene Expression, and Immunomodulatory Changes in Decedents with COVID-19. J Neuropathol Exp Neurol 2022; 81:666-695. [PMID: 35818336 PMCID: PMC9278252 DOI: 10.1093/jnen/nlac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Brains of 42 COVID-19 decedents and 107 non-COVID-19 controls were studied. RT-PCR screening of 16 regions from 20 COVID-19 autopsies found SARS-CoV-2 E gene viral sequences in 7 regions (2.5% of 320 samples), concentrated in 4/20 subjects (20%). Additional screening of olfactory bulb (OB), amygdala (AMY) and entorhinal area for E, N1, N2, RNA-dependent RNA polymerase, and S gene sequences detected one or more of these in OB in 8/21 subjects (38%). It is uncertain whether these RNA sequences represent viable virus. Significant histopathology was limited to 2/42 cases (4.8%), one with a large acute cerebral infarct and one with hemorrhagic encephalitis. Case-control RNAseq in OB and AMY found more than 5000 and 700 differentially expressed genes, respectively, unrelated to RT-PCR results; these involved immune response, neuronal constituents, and olfactory/taste receptor genes. Olfactory marker protein-1 reduction indicated COVID-19-related loss of OB olfactory mucosa afferents. Iba-1-immunoreactive microglia had reduced area fractions in cerebellar cortex and AMY, and cytokine arrays showed generalized downregulation in AMY and upregulation in blood serum in COVID-19 cases. Although OB is a major brain portal for SARS-CoV-2, COVID-19 brain changes are more likely due to blood-borne immune mediators and trans-synaptic gene expression changes arising from OB deafferentation.
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Affiliation(s)
- Geidy E Serrano
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Jessica E Walker
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Cécilia Tremblay
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Ignazio S Piras
- Neurogenomics Division, Translational Genomics Research Institute, Phoenix, Arizona, USA
| | - Matthew J Huentelman
- Neurogenomics Division, Translational Genomics Research Institute, Phoenix, Arizona, USA
| | | | - Danielle Goldfarb
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - David Shprecher
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Alireza Atri
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Charles H Adler
- Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Holly A Shill
- Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Shyamal H Mehta
- Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Richard Caselli
- Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Bryan K Woodruff
- Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | - Thomas Ruhlen
- Banner Boswell Medical Center, Sun City, Arizona, USA
| | - Maria Torres
- Banner Boswell Medical Center, Sun City, Arizona, USA
| | - Steve Nguyen
- Banner Boswell Medical Center, Sun City, Arizona, USA
| | - Dasan Schmitt
- Banner Boswell Medical Center, Sun City, Arizona, USA
| | | | | | | | | | - Richard A Arce
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Michael J Glass
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Daisy Vargas
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Lucia I Sue
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | | | - Courtney M Nelson
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Javon Oliver
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Aryck Russell
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA (AR)
| | | | - Claryssa I Borja
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Madison P Cline
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | | | - Sanaria Qiji
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Holly M Hobgood
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
| | - Joseph P Mizgerd
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Malaya K Sahoo
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Haiyu Zhang
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Daniel Solis
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Thomas J Montine
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Gerald J Berry
- Department of Pathology, Stanford University, Stanford, California, USA
| | | | - Katharina Röltgen
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Scott D Boyd
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Benjamin A Pinsky
- Department of Pathology, Stanford University, Stanford, California, USA
- Division of Infectious Disease & Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - James L Zehnder
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Pierre Talbot
- Laboratory of Neuroimmunology, Centre Armand-Frappier Santé Biotechnologie, Institut National de la Recherche Scientifique, Laval, Quebec, Canada
| | - Marc Desforges
- Mayo Clinic College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
- Laboratory of Virology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Quebec, Canada
| | - Michael DeTure
- Département de microbiologie, infectiologie et Immunologie, Université de Montréal, Montréal, Quebec, Canada
| | - Dennis W Dickson
- Mayo Clinic College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Thomas G Beach
- From the Banner Sun Health Research Institute, Sun City, Arizona, USA
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Assessing and improving the validity of COVID-19 autopsy studies - A multicentre approach to establish essential standards for immunohistochemical and ultrastructural analyses. EBioMedicine 2022; 83:104193. [PMID: 35930888 PMCID: PMC9344879 DOI: 10.1016/j.ebiom.2022.104193] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 12/26/2022] Open
Abstract
Background Autopsy studies have provided valuable insights into the pathophysiology of COVID-19. Controversies remain about whether the clinical presentation is due to direct organ damage by SARS-CoV-2 or secondary effects, such as overshooting immune response. SARS-CoV-2 detection in tissues by RT-qPCR and immunohistochemistry (IHC) or electron microscopy (EM) can help answer these questions, but a comprehensive evaluation of these applications is missing. Methods We assessed publications using IHC and EM for SARS-CoV-2 detection in autopsy tissues. We systematically evaluated commercially available antibodies against the SARS-CoV-2 proteins in cultured cell lines and COVID-19 autopsy tissues. In a multicentre study, we evaluated specificity, reproducibility, and inter-observer variability of SARS-CoV-2 IHC. We correlated RT-qPCR viral tissue loads with semiquantitative IHC scoring. We used qualitative and quantitative EM analyses to refine criteria for ultrastructural identification of SARS-CoV-2. Findings Publications show high variability in detection and interpretation of SARS-CoV-2 abundance in autopsy tissues by IHC or EM. We show that IHC using antibodies against SARS-CoV-2 nucleocapsid yields the highest sensitivity and specificity. We found a positive correlation between presence of viral proteins by IHC and RT-qPCR-determined SARS-CoV-2 viral RNA load (N= 35; r=-0.83, p-value <0.0001). For EM, we refined criteria for virus identification and provide recommendations for optimized sampling and analysis. 135 of 144 publications misinterpret cellular structures as virus using EM or show only insufficient data. We provide publicly accessible digitized EM sections as a reference and for training purposes. Interpretation Since detection of SARS-CoV-2 in human autopsy tissues by IHC and EM is difficult and frequently incorrect, we propose criteria for a re-evaluation of available data and guidance for further investigations of direct organ effects by SARS-CoV-2. Funding German Federal Ministry of Health, German Federal Ministry of Education and Research, Berlin University Alliance, German Research Foundation, German Center for Infectious Research.
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38
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Jonigk D, Werlein C, Acker T, Aepfelbacher M, Amann KU, Baretton G, Barth P, Bohle RM, Büttner A, Büttner R, Dettmeyer R, Eichhorn P, Elezkurtaj S, Esposito I, Evert K, Evert M, Fend F, Gaßler N, Gattenlöhner S, Glatzel M, Göbel H, Gradhand E, Hansen T, Hartmann A, Heinemann A, Heppner FL, Hilsenbeck J, Horst D, Kamp JC, Mall G, Märkl B, Ondruschka B, Pablik J, Pfefferle S, Quaas A, Radbruch H, Röcken C, Rosenwald A, Roth W, Rudelius M, Schirmacher P, Slotta-Huspenina J, Smith K, Sommer L, Stock K, Ströbel P, Strobl S, Titze U, Weirich G, Weis J, Werner M, Wickenhauser C, Wiech T, Wild P, Welte T, von Stillfried S, Boor P. Organ manifestations of COVID-19: what have we learned so far (not only) from autopsies? Virchows Arch 2022; 481:139-159. [PMID: 35364700 PMCID: PMC8975445 DOI: 10.1007/s00428-022-03319-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 01/08/2023]
Abstract
The use of autopsies in medicine has been declining. The COVID-19 pandemic has documented and rejuvenated the importance of autopsies as a tool of modern medicine. In this review, we discuss the various autopsy techniques, the applicability of modern analytical methods to understand the pathophysiology of COVID-19, the major pathological organ findings, limitations or current studies, and open questions. This article summarizes published literature and the consented experience of the nationwide network of clinical, neuro-, and forensic pathologists from 27 German autopsy centers with more than 1200 COVID-19 autopsies. The autopsy tissues revealed that SARS-CoV-2 can be found in virtually all human organs and tissues, and the majority of cells. Autopsies have revealed the organ and tissue tropism of SARS-CoV-2, and the morphological features of COVID-19. This is characterized by diffuse alveolar damage, combined with angiocentric disease, which in turn is characterized by endothelial dysfunction, vascular inflammation, (micro-) thrombosis, vasoconstriction, and intussusceptive angiogenesis. These findings explained the increased pulmonary resistance in COVID-19 and supported the recommendations for antithrombotic treatment in COVID-19. In contrast, in extra-respiratory organs, pathological changes are often nonspecific and unclear to which extent these changes are due to direct infection vs. indirect/secondary mechanisms of organ injury, or a combination thereof. Ongoing research using autopsies aims at answering questions on disease mechanisms, e.g., focusing on variants of concern, and future challenges, such as post-COVID conditions. Autopsies are an invaluable tool in medicine and national and international interdisciplinary collaborative autopsy-based research initiatives are essential.
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Affiliation(s)
- Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany.
| | | | - Till Acker
- Institute of Neuropathology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Martin Aepfelbacher
- Institute of Medical Microbiology, Virology, and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kerstin U Amann
- Department of Nephropathology, University Hospital Erlangen-Nürnberg, Erlangen, Germany
| | - Gustavo Baretton
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - Peter Barth
- Gerhard Domagk Institute of Pathology, University Hospital Münster, Münster, Germany
| | - Rainer M Bohle
- Department of Pathology, University Hospital Saarland Homburg, Homburg, Germany
| | - Andreas Büttner
- Institute of Forensic Medicine, University Medical Center Rostock, Rostock, Germany
| | - Reinhard Büttner
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Reinhard Dettmeyer
- Department of Legal Medicine, University Hospital Giessen and Marburg, Giessen, Germany
| | - Philip Eichhorn
- Department of Pathology, University Hospital Erlangen-Nürnberg, Erlangen, Germany
| | - Sefer Elezkurtaj
- Department of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Irene Esposito
- Department of Pathology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Katja Evert
- Department of Pathology, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Evert
- Department of Pathology, University Hospital Regensburg, Regensburg, Germany
| | - Falko Fend
- Department of Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Nikolaus Gaßler
- Department of Pathology, University Hospital Jena, Jena, Germany
| | - Stefan Gattenlöhner
- Department of Pathology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heike Göbel
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Elise Gradhand
- Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany
| | - Torsten Hansen
- Department of Pathology, University Hospital OWL of the Bielefeld University, Campus Lippe, Detmold, Germany
| | - Arndt Hartmann
- Department of Pathology, University Hospital Erlangen-Nürnberg, Erlangen, Germany
| | - Axel Heinemann
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank L Heppner
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
- Cluster of Excellence, NeuroCure, Berlin, Germany
| | - Julia Hilsenbeck
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - David Horst
- Department of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan C Kamp
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Gita Mall
- Department of Legal Medicine, University Hospital Jena, Jena, Germany
| | - Bruno Märkl
- General Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jessica Pablik
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - Susanne Pfefferle
- Institute of Medical Microbiology, Virology, and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Quaas
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Helena Radbruch
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christoph Röcken
- Department of Pathology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Wilfried Roth
- Department of Pathology, University Medical Center Mainz, Mainz, Germany
| | - Martina Rudelius
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Peter Schirmacher
- Department of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Slotta-Huspenina
- Department of Pathology, TUM School of Medicine of Technical University of Munich, Munich, Germany
| | - Kevin Smith
- Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany
| | - Linna Sommer
- Department of Pathology, University Hospital Dresden, Dresden, Germany
| | - Konrad Stock
- Department of Nephrology, TUM School of Medicine of Technical University of Munich, Munich, Germany
| | - Philipp Ströbel
- Department of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Stephanie Strobl
- Department of Pathology, University Medical Center Mainz, Mainz, Germany
| | - Ulf Titze
- Department of Pathology, University Hospital OWL of the Bielefeld University, Campus Lippe, Detmold, Germany
| | - Gregor Weirich
- Department of Pathology, TUM School of Medicine of Technical University of Munich, Munich, Germany
| | - Joachim Weis
- Department of Neuropathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Werner
- Institute for Surgical Pathology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Claudia Wickenhauser
- Department of Pathology, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Thorsten Wiech
- Department of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Wild
- Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | | | - Peter Boor
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany.
- Department of Nephrology and Immunology, University Hospital RWTH Aachen, Aachen, Germany.
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COVID-19 and Parkinsonism: A Critical Appraisal. Biomolecules 2022; 12:biom12070970. [PMID: 35883526 PMCID: PMC9313170 DOI: 10.3390/biom12070970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
A few cases of parkinsonism linked to COVID-19 infection have been reported so far, raising the possibility of a post-viral parkinsonian syndrome. The objective of this review is to summarize the clinical, biological, and neuroimaging features of published cases describing COVID-19-related parkinsonism and to discuss the possible pathophysiological mechanisms. A comprehensive literature search was performed using NCBI’s PubMed database and standardized search terms. Thirteen cases of COVID-19-related parkinsonism were included (7 males; mean age: 51 years ± 14.51, range 31–73). Patients were classified based on the possible mechanisms of post-COVID-19 parkinsonism: extensive inflammation or hypoxic brain injury within the context of encephalopathy (n = 5); unmasking of underlying still non-symptomatic Parkinson’s Disease (PD) (n = 5), and structural and functional basal ganglia damage (n = 3). The various clinical scenarios show different outcomes and responses to dopaminergic treatment. Different mechanisms may play a role, including vascular damage, neuroinflammation, SARS-CoV-2 neuroinvasive potential, and the impact of SARS-CoV-2 on α-synuclein. Our results confirm that the appearance of parkinsonism during or immediately after COVID-19 infection represents a very rare event. Future long-term observational studies are needed to evaluate the possible role of SARS-CoV-2 infection as a trigger for the development of PD in the long term.
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40
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Yang RC, Huang K, Zhang HP, Li L, Tan C, Chen HC, Jin ML, Wang XR. Transcriptional landscape of human neuroblastoma cells in response to SARS-CoV-2. BMC Neurosci 2022; 23:43. [PMID: 35794518 PMCID: PMC9258770 DOI: 10.1186/s12868-022-00728-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022] Open
Abstract
Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly contagious, and the neurological symptoms of SARS-CoV-2 infection have already been reported. However, the mechanisms underlying the effect of SARS-CoV-2 infection on patients with central nervous system injuries remain unclear. Methods The high-throughput RNA sequencing was applied to analyze the transcriptomic changes in SK-N-SH cells after SARS-CoV-2 infection. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses were performed to identify the functions of differentially expressed genes and related pathways. Results A total of 820 mRNAs were significantly altered, including 671 upregulated and 149 downregulated mRNAs (showing an increase of ≥ 2-fold or decrease to ≤ 0.5-fold, respectively; p ≤ 0.05). Moreover, we verified the significant induction of cytokines, chemokines, and their receptors, as well as the activation of NF-κB, p38, and Akt signaling pathways, in SK-N-SH by SARS-CoV-2. Conclusions To our knowledge, this is the first time the transcriptional profiles of the host mRNAs involved in SARS-CoV-2 infection of SK-N-SH cells have been reported. These findings provide novel insight into the pathogenic mechanism of SARS-CoV-2 and might constitute a new approach for future prevention and treatment of SARS-CoV-2-induced central nervous system infection. Supplementary Information The online version contains supplementary material available at 10.1186/s12868-022-00728-6.
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Affiliation(s)
- Rui-Cheng Yang
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China.,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China
| | - Kun Huang
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China.,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China
| | - Hui-Peng Zhang
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China.,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China
| | - Liang Li
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China.,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China
| | - Chen Tan
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China.,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China
| | - Huan-Chun Chen
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China.,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China
| | - Mei-Lin Jin
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China.,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China
| | - Xiang-Ru Wang
- State Key Laboratory of Agricultural Microbiology, The Cooperative Innovation Center for Sustainable Pig Production, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, 430070, China. .,Key Laboratory of Preventive Veterinary Medicine in Hubei Province, Wuhan, Hubei, 430070, China.
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41
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Matschke J, Lahann H, Krasemann S, Altmeppen H, Pfefferle S, Galliciotti G, Fitzek A, Sperhake JP, Ondruschka B, Busch M, Rotermund N, Schulz K, Lohr C, Dottermusch M, Glatzel M. Young COVID-19 Patients Show a Higher Degree of Microglial Activation When Compared to Controls. Front Neurol 2022; 13:908081. [PMID: 35785352 PMCID: PMC9243237 DOI: 10.3389/fneur.2022.908081] [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: 03/30/2022] [Accepted: 05/20/2022] [Indexed: 11/20/2022] Open
Abstract
The severe acute respiratory syndrome-corona virus type 2 (SARS-CoV-2) is the cause of human coronavirus disease 2019 (COVID-19). Since its identification in late 2019 SARS-CoV-2 has spread rapidly around the world creating a global pandemic. Although considered mainly a respiratory disease, COVID-19 also encompasses a variety of neuropsychiatric symptoms. How infection with SARS-CoV-2 leads to brain damage has remained largely elusive so far. In particular, it has remained unclear, whether signs of immune cell and / or innate immune and reactive astrogliosis are due to direct effects of the virus or may be an expression of a non-specific reaction of the brain to a severe life-threatening disease with a considerable proportion of patients requiring intensive care and invasive ventilation activation. Therefore, we designed a case-control-study of ten patients who died of COVID-19 and ten age-matched non-COVID-19-controls to quantitatively assess microglial and astroglial response. To minimize possible effects of severe systemic inflammation and / or invasive therapeutic measures we included only patients without any clinical or pathomorphological indication of sepsis and who had not been subjected to invasive intensive care treatment. Our results show a significantly higher degree of microglia activation in younger COVID-19 patients, while the difference was less and not significant for older COVID-19 patients. The difference in the degree of reactive gliosis increased with age but was not influenced by COVID-19. These preliminary data warrants further investigation of larger patient cohorts using additional immunohistochemical markers for different microglial phenotypes.
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Affiliation(s)
- Jakob Matschke
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Jakob Matschke
| | - Henri Lahann
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Krasemann
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Altmeppen
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Pfefferle
- Institute of Medical Microbiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giovanna Galliciotti
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antonia Fitzek
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Peter Sperhake
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Busch
- Institute of Cell and Systems Biology of Animals, University of Hamburg, Hamburg, Germany
| | - Natalie Rotermund
- Institute of Cell and Systems Biology of Animals, University of Hamburg, Hamburg, Germany
| | - Kristina Schulz
- Institute of Cell and Systems Biology of Animals, University of Hamburg, Hamburg, Germany
| | - Christian Lohr
- Institute of Cell and Systems Biology of Animals, University of Hamburg, Hamburg, Germany
| | - Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Eskandarian Boroujeni M, Sekrecka A, Antonczyk A, Hassani S, Sekrecki M, Nowicka H, Lopacinska N, Olya A, Kluzek K, Wesoly J, Bluyssen HAR. Dysregulated Interferon Response and Immune Hyperactivation in Severe COVID-19: Targeting STATs as a Novel Therapeutic Strategy. Front Immunol 2022; 13:888897. [PMID: 35663932 PMCID: PMC9156796 DOI: 10.3389/fimmu.2022.888897] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/13/2022] [Indexed: 01/08/2023] Open
Abstract
A disease outbreak in December 2019, caused by a novel coronavirus SARS-CoV-2, was named COVID-19. SARS-CoV-2 infects cells from the upper and lower respiratory tract system and is transmitted by inhalation or contact with infected droplets. Common clinical symptoms include fatigue, fever, and cough, but also shortness of breath and lung abnormalities. Still, some 5% of SARS-CoV-2 infections progress to severe pneumonia and acute respiratory distress syndrome (ARDS), with pulmonary edema, acute kidney injury, and/or multiple organ failure as important consequences, which can lead to death. The innate immune system recognizes viral RNAs and triggers the expression of interferons (IFN). IFNs activate anti-viral effectors and components of the adaptive immune system by activating members of the STAT and IRF families that induce the expression of IFN-stimulated genes (ISG)s. Among other coronaviruses, such as Middle East respiratory syndrome coronavirus (MERS-CoV) and SARS-CoV, common strategies have been identified to antagonize IFN signaling. This typically coincides with hyperactive inflammatory host responses known as the “cytokine storm” that mediate severe lung damage. Likewise, SARS-CoV-2 infection combines a dysregulated IFN response with excessive production of inflammatory cytokines in the lungs. This excessive inflammatory response in the lungs is associated with the local recruitment of immune cells that create a pathogenic inflammatory loop. Together, it causes severe lung pathology, including ARDS, as well as damage to other vulnerable organs, like the heart, spleen, lymph nodes, and kidney, as well as the brain. This can rapidly progress to multiple organ exhaustion and correlates with a poor prognosis in COVID-19 patients. In this review, we focus on the crucial role of different types of IFN that underlies the progression of SARS-CoV-2 infection and leads to immune cell hyper-activation in the lungs, exuberant systemic inflammation, and multiple organ damage. Consequently, to protect from systemic inflammation, it will be critical to interfere with signaling cascades activated by IFNs and other inflammatory cytokines. Targeting members of the STAT family could therefore be proposed as a novel therapeutic strategy in patients with severe COVID-19.
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Affiliation(s)
- Mahdi Eskandarian Boroujeni
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Agata Sekrecka
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Aleksandra Antonczyk
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Sanaz Hassani
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Michal Sekrecki
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Hanna Nowicka
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Natalia Lopacinska
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Arta Olya
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Katarzyna Kluzek
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Joanna Wesoly
- Laboratory of High Throughput Technologies, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
| | - Hans A R Bluyssen
- Laboratory of Human Molecular Genetics, Institute of Molecular Biology and Biotechnology, Faculty of Biology, Adam Mickiewicz University, Poznań, Poland
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43
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Aschman T, Mothes R, Heppner FL, Radbruch H. What SARS-CoV-2 does to our brains. Immunity 2022; 55:1159-1172. [PMID: 35777361 PMCID: PMC9212726 DOI: 10.1016/j.immuni.2022.06.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/22/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Abstract
Neurological symptoms in SARS-CoV-2-infected patients have been reported, but their cause remains unclear. In theory, the neurological symptoms observed after SARS-CoV-2 infection could be (1) directly caused by the virus infecting brain cells, (2) indirectly by our body’s local or systemic immune response toward the virus, (3) by coincidental phenomena, or (4) a combination of these factors. As indisputable evidence of intact and replicating SARS-CoV-2 particles in the central nervous system (CNS) is currently lacking, we suggest focusing on the host’s immune reaction when trying to understand the neurocognitive symptoms associated with SARS-CoV-2 infection. In this perspective, we discuss the possible immune-mediated mechanisms causing functional or structural CNS alterations during acute infection as well as in the post-infectious context. We also review the available literature on CNS affection in the context of COVID-19 infection, as well as observations from animal studies on the molecular pathways involved in sickness behavior.
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Seehusen F, Clark JJ, Sharma P, Bentley EG, Kirby A, Subramaniam K, Wunderlin-Giuliani S, Hughes GL, Patterson EI, Michael BD, Owen A, Hiscox JA, Stewart JP, Kipar A. Neuroinvasion and Neurotropism by SARS-CoV-2 Variants in the K18-hACE2 Mouse. Viruses 2022; 14:1020. [PMID: 35632761 PMCID: PMC9146514 DOI: 10.3390/v14051020] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) not only affects the respiratory tract but also causes neurological symptoms such as loss of smell and taste, headache, fatigue or severe cerebrovascular complications. Using transgenic mice expressing human angiotensin-converting enzyme 2 (hACE2), we investigated the spatiotemporal distribution and pathomorphological features in the CNS following intranasal infection with SARS-CoV-2 variants, as well as after prior influenza A virus infection. Apart from Omicron, we found all variants to frequently spread to and within the CNS. Infection was restricted to neurons and appeared to spread from the olfactory bulb mainly in basally oriented regions in the brain and into the spinal cord, independent of ACE2 expression and without evidence of neuronal cell death, axonal damage or demyelination. However, microglial activation, microgliosis and a mild macrophage and T cell dominated inflammatory response was consistently observed, accompanied by apoptotic death of endothelial, microglial and immune cells, without their apparent infection. Microgliosis and immune cell apoptosis indicate a potential role of microglia for pathogenesis and viral effect in COVID-19 and the possible impairment of neurological functions, especially in long COVID. These data may also be informative for the selection of therapeutic candidates and broadly support the investigation of agents with adequate penetration into relevant regions of the CNS.
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Affiliation(s)
- Frauke Seehusen
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (F.S.); (S.W.-G.)
| | - Jordan J. Clark
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
| | - Parul Sharma
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
| | - Eleanor G. Bentley
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
| | - Adam Kirby
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
| | - Krishanthi Subramaniam
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
| | - Sabina Wunderlin-Giuliani
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (F.S.); (S.W.-G.)
| | - Grant L. Hughes
- Departments of Vector Biology and Tropical Disease Biology, Centre for Neglected Tropical Disease, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; (G.L.H.); (E.I.P.)
| | - Edward I. Patterson
- Departments of Vector Biology and Tropical Disease Biology, Centre for Neglected Tropical Disease, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; (G.L.H.); (E.I.P.)
| | - Benedict D. Michael
- Department of Clinical Infection Microbiology and Immunology and NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool L69 7BE, UK;
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool L9 7AL, UK
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, Centre of Excellence in Long-Acting Therapeutics (CELT), University of Liverpool, Liverpool L3 3NY, UK;
| | - Julian A. Hiscox
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
| | - James P. Stewart
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
| | - Anja Kipar
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (F.S.); (S.W.-G.)
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L3 5RF, UK; (J.J.C.); (P.S.); (E.G.B.); (A.K.); (K.S.); (J.A.H.); (J.P.S.)
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Käufer C, Schreiber CS, Hartke AS, Denden I, Stanelle-Bertram S, Beck S, Kouassi NM, Beythien G, Becker K, Schreiner T, Schaumburg B, Beineke A, Baumgärtner W, Gabriel G, Richter F. Microgliosis and neuronal proteinopathy in brain persist beyond viral clearance in SARS-CoV-2 hamster model. EBioMedicine 2022; 79:103999. [PMID: 35439679 PMCID: PMC9013202 DOI: 10.1016/j.ebiom.2022.103999] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Neurological symptoms such as cognitive decline and depression contribute substantially to post-COVID-19 syndrome, defined as lasting symptoms several weeks after initial SARS-CoV-2 infection. The pathogenesis is still elusive, which hampers appropriate treatment. Neuroinflammatory responses and neurodegenerative processes may occur in absence of overt neuroinvasion. METHODS Here we determined whether intranasal SARS-CoV-2 infection in male and female syrian golden hamsters results in persistent brain pathology. Brains 3 (symptomatic) or 14 days (viral clearance) post infection versus mock (n = 10 each) were immunohistochemically analyzed for viral protein, neuroinflammatory response and accumulation of tau, hyperphosphorylated tau and alpha-synuclein protein. FINDINGS Viral protein in the nasal cavity led to pronounced microglia activation in the olfactory bulb beyond viral clearance. Cortical but not hippocampal neurons accumulated hyperphosphorylated tau and alpha-synuclein, in the absence of overt inflammation and neurodegeneration. Importantly, not all brain regions were affected, which is in line with selective vulnerability. INTERPRETATION Thus, despite the absence of virus in brain, neurons develop signatures of proteinopathies that may contribute to progressive neuronal dysfunction. Further in depth analysis of this important mechanism is required. FUNDING Federal Ministry of Health (BMG; ZMV I 1-2520COR501), Federal Ministry of Education and Research (BMBF 01KI1723G), Ministry of Science and Culture of Lower Saxony in Germany (14 - 76103-184 CORONA-15/20), German Research Foundation (DFG; 398066876/GRK 2485/1), Luxemburgish National Research Fund (FNR, Project Reference: 15686728, EU SC1-PHE-CORONAVIRUS-2020 MANCO, no > 101003651).
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Affiliation(s)
- Christopher Käufer
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Cara S Schreiber
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany
| | - Anna-Sophia Hartke
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany
| | - Ivo Denden
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | | | - Sebastian Beck
- Leibniz Institute for Experimental Virology, Hamburg, Germany
| | | | - Georg Beythien
- Department of Pathology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Kathrin Becker
- Department of Pathology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Tom Schreiner
- Department of Pathology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany
| | | | - Andreas Beineke
- Department of Pathology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany
| | - Wolfgang Baumgärtner
- Department of Pathology, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany
| | - Gülsah Gabriel
- Leibniz Institute for Experimental Virology, Hamburg, Germany; Institute for Virology, University for Veterinary Medicine Hannover, 30559 Hannover, Germany
| | - Franziska Richter
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, Hannover, Germany.
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COVID-19 and the Brain: The Neuropathological Italian Experience on 33 Adult Autopsies. Biomolecules 2022; 12:biom12050629. [PMID: 35625558 PMCID: PMC9138268 DOI: 10.3390/biom12050629] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/16/2022] [Accepted: 04/22/2022] [Indexed: 02/04/2023] Open
Abstract
Neurological symptoms are increasingly recognized in SARS-CoV-2 infected individuals. However, the neuropathogenesis remains unclear and it is not possible to define a specific damage pattern due to brain virus infection. In the present study, 33 cases of brain autopsies performed during the first (February–April 2020) and the second/third (November 2020–April 2021) pandemic waves are described. In all the cases, SARS-CoV-2 RNA was searched. Pathological findings are described and compared with those presently published.
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47
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Morowitz JM, Pogson KB, Roque DA, Church FC. Role of SARS-CoV-2 in Modifying Neurodegenerative Processes in Parkinson's Disease: A Narrative Review. Brain Sci 2022; 12:536. [PMID: 35624923 PMCID: PMC9139310 DOI: 10.3390/brainsci12050536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/12/2022] [Accepted: 04/21/2022] [Indexed: 12/12/2022] Open
Abstract
The COVID-19 pandemic, caused by SARS-CoV-2, continues to impact global health regarding both morbidity and mortality. Although SARS-CoV-2 primarily causes acute respiratory distress syndrome (ARDS), the virus interacts with and influences other organs and tissues, including blood vessel endothelium, heart, gastrointestinal tract, and brain. We are learning much about the pathophysiology of SARS-CoV-2 infection; however, we are just beginning to study and understand the long-term and chronic health consequences. Since the pandemic's beginning in late 2019, older adults, those with pre-existing illnesses, or both, have an increased risk of contracting COVID-19 and developing severe COVID-19. Furthermore, older adults are also more likely to develop the neurodegenerative disorder Parkinson's disease (PD), with advanced age as the most significant risk factor. Thus, does SARS-CoV-2 potentially influence, promote, or accelerate the development of PD in older adults? Our initial focus was aimed at understanding SARS-CoV-2 pathophysiology and the connection to neurodegenerative disorders. We then completed a literature review to assess the relationship between PD and COVID-19. We described potential molecular and cellular pathways that indicate dopaminergic neurons are susceptible, both directly and indirectly, to SARS-CoV-2 infection. We concluded that under certain pathological circumstances, in vulnerable persons-with-Parkinson's disease (PwP), SARS-CoV-2 acts as a neurodegenerative enhancer to potentially support the development or progression of PD and its related motor and non-motor symptoms.
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Affiliation(s)
- Jeremy M. Morowitz
- Developmental and Stem Cell Biology Program, Duke University, Durham, NC 27708, USA;
| | - Kaylyn B. Pogson
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Daniel A. Roque
- Department of Neurology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599, USA;
| | - Frank C. Church
- Department of Pathology and Laboratory Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599, USA
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48
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Neuropathology and virus in brain of SARS-CoV-2 infected non-human primates. Nat Commun 2022; 13:1745. [PMID: 35365631 PMCID: PMC8975902 DOI: 10.1038/s41467-022-29440-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/12/2022] [Indexed: 12/14/2022] Open
Abstract
Neurological manifestations are a significant complication of coronavirus disease (COVID-19), but underlying mechanisms aren’t well understood. The development of animal models that recapitulate the neuropathological findings of autopsied brain tissue from patients who died from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are critical for elucidating the neuropathogenesis of infection and disease. Here, we show neuroinflammation, microhemorrhages, brain hypoxia, and neuropathology that is consistent with hypoxic-ischemic injury in SARS-CoV-2 infected non-human primates (NHPs), including evidence of neuron degeneration and apoptosis. Importantly, this is seen among infected animals that do not develop severe respiratory disease, which may provide insight into neurological symptoms associated with “long COVID”. Sparse virus is detected in brain endothelial cells but does not associate with the severity of central nervous system (CNS) injury. We anticipate our findings will advance our current understanding of the neuropathogenesis of SARS-CoV-2 infection and demonstrate SARS-CoV-2 infected NHPs are a highly relevant animal model for investigating COVID-19 neuropathogenesis among human subjects. COVID-19 can result in neurological manifestations and animal models could provide insights into the mechanisms. Here, the authors describe neuroinflammation, microhemorrhages and brain hypoxia in SARS-CoV-2 infected non-human primates, including in animals that don’t develop severe respiratory disease.
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49
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Putative Role of the Lung-Brain Axis in the Pathogenesis of COVID-19-Associated Respiratory Failure: A Systematic Review. Biomedicines 2022; 10:biomedicines10030729. [PMID: 35327531 PMCID: PMC8944980 DOI: 10.3390/biomedicines10030729] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 01/08/2023] Open
Abstract
The emergence of SARS-CoV-2 and its related disease caused by coronavirus (COVID-19) has posed a huge threat to the global population, with millions of deaths and the creation of enormous social and healthcare pressure. Several studies have shown that besides respiratory illness, other organs may be damaged as well, including the heart, kidneys, and brain. Current evidence reports a high frequency of neurological manifestations in COVID-19, with significant prognostic implications. Importantly, emerging literature is showing that the virus may spread to the central nervous system through neuronal routes, hitting the brainstem and cardiorespiratory centers, potentially exacerbating the respiratory illness. In this systematic review, we searched public databases for all available evidence and discuss current clinical and pre-clinical data on the relationship between the lung and brain during COVID-19. Acknowledging the involvement of these primordial brain areas in the pathogenesis of the disease may fuel research on the topic and allow the development of new therapeutic strategies.
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50
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Emmi A, Boura I, Raeder V, Mathew D, Sulzer D, Goldman JE, Leta V. Covid-19, nervous system pathology, and Parkinson's disease: Bench to bedside. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 165:17-34. [PMID: 36208899 PMCID: PMC9361071 DOI: 10.1016/bs.irn.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Coronavirus disease 2019 (Covid-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is primarily regarded as a respiratory disease; however, multisystemic involvement accompanied by a variety of clinical manifestations, including neurological symptoms, are commonly observed. There is, however, little evidence supporting SARS-CoV-2 infection of central nervous system cells, and neurological symptoms for the most part appear to be due to damage mediated by hypoxic/ischemic and/or inflammatory insults. In this chapter, we report evidence on candidate neuropathological mechanisms underlying neurological manifestations in Covid-19, suggesting that while there is mostly evidence against SARS-CoV-2 entry into brain parenchymal cells as a mechanism that may trigger Parkinson's disease and parkinsonism, that there are multiple means by which the virus may cause neurological symptoms.
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Affiliation(s)
- Aron Emmi
- Institute of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy
| | - Iro Boura
- Department of Neurology, University Hospital of Heraklion, Crete, Greece
| | - Vanessa Raeder
- Parkinson's Foundation Centre of Excellence, King's College Hospital NHS Foundation Trust, London, United Kingdom; Department of Neurology, Technical University Dresden, Dresden, Germany; Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Donna Mathew
- Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - David Sulzer
- Departments of Psychiatry, Neurology, Pharmacology, Columbia University Medical Center, New York State Psychiatric Institute, New York, United States
| | - James E Goldman
- Department of Pathology and Cell Biology, and the Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Vagelos College of Physicians and Surgeons, Columbia University and the New York Presbyterian Hospital, New York, NY, United States
| | - Valentina Leta
- Parkinson's Foundation Centre of Excellence, King's College Hospital NHS Foundation Trust, London, United Kingdom; Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.
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