Neurotropic mechanisms in COVID-19 and their potential influence on neuropsychological outcomes in children

Neuropsychological Symptoms and Quality of Life during the COVID-19 Pandemic in Children: A Survey in a Pediatric Population in the Abruzzo Region, Italy

BACKGROUND

The SARS-CoV-2 pandemic has significantly affected the pediatric population. Long-term sequelae (Long COVID-19) may particularly involve the central nervous system, with possible effects on psychological well-being and quality of life (QoL), aspects that were already influenced by the restrictive measures and general social impact of the pandemic.

METHODS

We conducted a cross-sectional survey that aims at investigating the neuropsychological effects and the QoL impairment of SARS-CoV-2 on a cohort of children and adolescents in the Abruzzo region (Italy). A questionnaire was submitted to caregivers with the help of the PEDIATOTEM platform. A control group of healthy subjects was also included to distinguish between the effects of infection from the general influence of the pandemic.

RESULTS

A total of 569 subjects responded: 396 COVID-19 patients (99 of whom had Long COVID-19) and 111 controls. After the pandemic, when compared with the COVID-19 group, the controls reported significantly increased appetite, sleeping habits, and time spent remotely with friends and a reduction in physical activity and time spent in person with friends. A significant higher rate of controls asked for psychological/medical support for emotional problems. On the other hand, the Long COVID-19 group showed more fatigue and emotional instability with respect to non-Long-COVID-19 subjects. No differences in QoL results (EuroQOL) were found between the COVID-19 patients and controls, while the Long-COVID-19 subgroup showed significantly higher rates of pain/discomfort and mood instability, as confirmed by the analysis of variation of responses from the pre-COVID-19 to the post-COVID-19 period.

CONCLUSIONS

Among COVID-19 patients, neuropsychological and QoL impairment was more evident in the Long COVID-19 subgroup, although emotional and relational issues were also reported by uninfected patients, with a growing request for specialist support as a possible consequence of social restriction.

Neuropsychiatric Outcomes and Sleep Dysfunction in COVID-19 Patients: Risk Factors and Mechanisms

The ongoing global health crisis due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has significantly impacted all aspects of life. While the majority of early research following the coronavirus disease caused by SARS-CoV-2 (COVID-19) has focused on the physiological effects of the virus, a substantial body of subsequent studies has shown that the psychological burden of the infection is also considerable. Patients, even without mental illness history, were at increased susceptibility to developing mental health and sleep disturbances during or after the COVID-19 infection. Viral neurotropism and inflammatory storm damaging the blood-brain barrier have been proposed as possible mechanisms for mental health manifestations, along with stressful psychological factors and indirect consequences such as thrombosis and hypoxia. The virus has been found to infect peripheral olfactory neurons and exploit axonal migration pathways, exhibiting metabolic changes in astrocytes that are detrimental to fueling neurons and building neurotransmitters. Patients with COVID-19 present dysregulated and overactive immune responses, resulting in impaired neuronal function and viability, adversely affecting sleep and emotion regulation. Additionally, several risk factors have been associated with the neuropsychiatric sequelae of the infection, such as female sex, age, preexisting neuropathologies, severity of initial disease and sociological status. This review aimed to provide an overview of mental health symptoms and sleep disturbances developed during COVID-19 and to analyze the underlying mechanisms and risk factors of psychological distress and sleep dysfunction.

Preserved perception-action integration in adolescents after a COVID-19 infection

Evidence is accumulating that the Coronavirus disease (COVID-19) can bring forth deficits in executive functioning via alterations in the dopaminergic system. Importantly, dopaminergic pathways have been shown to modulate how actions and perceptions are integrated within the brain. Such alterations in event file binding could thus underlie the cognitive deficits developing after a COVID-19 infection. We examined action-perception integration in a group of young people (11-19 years of age) that had been infected with COVID-19 before study participation (n = 34) and compared them to a group of uninfected healthy controls (n = 29) on the behavioral (i.e., task accuracy, reaction time) and neurophysiological (EEG) level using an established event file binding paradigm. Groups did not differ from each other regarding demographic variables or in reporting psychiatric symptoms. Overall, multiple lines of evidence (behavioral and neurophysiological) suggest that action-perception integration is preserved in adolescents who suffered from COVID-19 prior to study participation. Event file binding processes were intact in both groups on all levels. While cognitive impairments can occur following a COVID-19 infection, the study demonstrates that action-perception integration as one of the basic building blocks of cognition seems to be largely unaffected in adolescents with a rather mild course of the disease.

Neurological symptoms and signs associated with COVID-19 in pediatric patients: a single-center experience

There is insufficient evidence on SARS-CoV-2 induced neurological effects. Studies on CNS involvement during COVID-19 in children are limited. This study aims to identify and manage the neurological signs and symptoms in COVID-19-infected pediatric patients during follow up and plan future follow-ups. Children diagnosed COVID-19 and hospitalized in the pediatric pandemic services, between March 18, 2020, and June 18, 2021, were included in the study. Children with underlying neurological disease were excluded from the study. Patient data retrieved from hospital files and medical records. Children divided into 2 groups, 1 and 2, based on the presence or absence of neurological findings. A total of 243 children received follow-ups in the pandemic wards, 35 (14.4%) of these patients had neurological findings. Major neurological manifestations were headache (n:17, 7%), seizure (n:4, 1.6%), and anosmia/hyposmia (n:17, 7%). The number of boys (n:13, 37.1%) was smaller than the number of girls (n:22, 62.9%) in Group 1. Group 1 showed higher blood leukocyte, lymphocyte, thrombocyte, AST, LDH, d-dimer values. Anosmia/hyposmia occurred more often in girls, anosmia and headache occurred more often over 9 years of age. Pulmonary and hematologic involvement was more common in children with anosmia and headache. Our study is one of the few studies on neurological involvement in COVID-19 in children. To the best of our knowledge, there is limited data on these subjects in the literature.

Neurological effects of COVID-19 in infants and children

Neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children are becoming increasingly apparent as the coronavirus disease (COVID-19) pandemic continues. While children manifest relatively milder features of the disease, accumulating evidence warrants concern that COVID-19 exacts both acute- and long-term effects on the developing central and peripheral nervous systems. This review focuses on the relatively underinvestigated topic of the effects of SARS-CoV-2 on the brain in infancy and childhood, concluding that clinicians should be attentive to both the acute effects and long-term consequences of COVID-19 from a neurological perspective.

SARS-CoV-2 Infection and Possible Neonatal Neurological Outcomes: A Literature Review

The virus responsible for COVID-19 is designated "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2), a highly transmissible and pathogenic coronavirus. Although people of all ages are susceptible to SARS-CoV-2 infection, clinical manifestations may vary with age. The response of neonates to SARS-CoV-2 infection or exposure differs from that of children and adults. Encephalitis due to viral infections in the central nervous system (CNS) and childhood multisystem inflammatory syndrome (MIS-C) are some of the possible neonatal consequences of SARS-CoV-2 infection. This review aims to verify possible neonatal neurological outcomes after SARS-CoV-2 infection. Overall, the cellular and molecular basis of the neurological sequelae of SARS-CoV-2 in neonates remains unclear, and attempts to elucidate the pathophysiology of COVID-19 involve a comparison with the mechanism of other viral diseases. There are a considerable number of case reports in the literature exploring neurological outcomes in the neonatal period. In this review, we present possible effects of SARS-CoV-2 in neonates, emphasizing the importance of monitoring this group. The mechanisms of SARS-CoV-2 entry into the CNS have not yet been fully elucidated, and the potential severity of SARS-CoV-2 infection in neonates, as well as the possible short- and long-term neurological sequelae, remain unclear.

Intermittent Frontal Rhythmic Discharges as an Electroencephalogram Biomarker of Acute SARS-CoV-2 Infection-Associated Encephalopathy in Children

Data on neurological sequelae of COVID-19 infection in children are sparse. Neurotropic and neuroinvasive potentials of the SARS-CoV-2 virus are a matter of ongoing scientific debate and not yet well understood. Most of the reported symptoms are nonspecific including headache, encephalopathy, weakness, and as a part of multisystem inflammatory response syndrome. Few observational studies have reported acute encephalopathy to be one of the neurological manifestations of COVID-19 infection, mostly in adults. A little is known about epileptogenesis or electroencephalogram (EEG) findings in this limited cohort of pediatric patients. We report a 17-year-old female with type 1 diabetes mellitus (DM), who presented with two weeks history of intermittent headaches, followed by a one-day history of acute change in behavior in the form of prolonged staring, decreased speech, confusion, and alternating periods of agitation and sleepiness. No fever or respiratory symptoms. Her blood glucose was normal. Brain MRI was unremarkable. Cerebrospinal fluid (CSF) studies showed 1000 RBCs, no WBCs, normal glucose/protein, negative culture, and negative infectious PCR, and autoimmune panels. She was found to be positive for SARS-CoV-2 PCR with negative IgG. Her EEG showed remarkable background slowing and frequent frontal intermittent rhythmic discharges. She was managed with high-dose steroids with the full clinical recovery of all symptoms at discharge, as well as normalization of subsequent EEG studies. We hypothesize there may be some specific seizure characteristics or EEG patterns in patients with pediatric COVID-19 infection and concomitant acute encephalopathy. It is perhaps reasonable to obtain EEG studies in children who test positive for SARS-CoV-2 and report central neurological symptoms. Long-term follow-up of this cohort of patients will be helpful to understand the clinical significance and implications of such neurophysiological studies.

Studying the neuropsychological sequelae of SARS-CoV-2: lessons learned from 35 years of neuroHIV research

The virology of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and the human immune response to the virus are under vigorous investigation. There are now several reports describing neurological symptoms in individuals who develop coronavirus disease 2019 (COVID-19), the syndrome associated with SARS-CoV-2 infection. The prevalence, incidence, and clinical course of these symptoms will become clearer in the coming months and years through epidemiological studies. However, the long-term neurological and cognitive consequence of SARS-CoV-2 infection will remain conjectural for some time and will likely require the creation of cohort studies that include uninfected individuals. Considering the early evidence for neurological involvement in COVID-19 it may prove helpful to compare SARS-CoV-2 with another endemic and neurovirulent virus, human immunodeficiency virus-1 (HIV-1), when designing such cohort studies and when making predictions about neuropsychological outcomes. In this paper, similarities and differences between SARS-CoV-2 and HIV-1 are reviewed, including routes of neuroinvasion, putative mechanisms of neurovirulence, and factors involved in possible long-term neuropsychological sequelae. Application of the knowledge gained from over three decades of neuroHIV research is discussed, with a focus on alerting researchers and clinicians to the challenges in determining the cause of neurocognitive deficits among long-term survivors.

Environmental Nanoparticles, SARS-CoV-2 Brain Involvement, and Potential Acceleration of Alzheimer's and Parkinson's Diseases in Young Urbanites Exposed to Air Pollution

Alzheimer's and Parkinson's diseases (AD, PD) have a pediatric and young adult onset in Metropolitan Mexico City (MMC). The SARS-CoV-2 neurotropic RNA virus is triggering neurological complications and deep concern regarding acceleration of neuroinflammatory and neurodegenerative processes already in progress. This review, based on our MMC experience, will discuss two major issues: 1) why residents chronically exposed to air pollution are likely to be more susceptible to SARS-CoV-2 systemic and brain effects and 2) why young people with AD and PD already in progress will accelerate neurodegenerative processes. Secondary mental consequences of social distancing and isolation, fear, financial insecurity, violence, poor health support, and lack of understanding of the complex crisis are expected in MMC residents infected or free of SARS-CoV-2. MMC residents with pre-SARS-CoV-2 accumulation of misfolded proteins diagnostic of AD and PD and metal-rich, magnetic nanoparticles damaging key neural organelles are an ideal host for neurotropic SARS-CoV-2 RNA virus invading the body through the same portals damaged by nanoparticles: nasal olfactory epithelium, the gastrointestinal tract, and the alveolar-capillary portal. We urgently need MMC multicenter retrospective-prospective neurological and psychiatric population follow-up and intervention strategies in place in case of acceleration of neurodegenerative processes, increased risk of suicide, and mental disease worsening. Identification of vulnerable populations and continuous effort to lower air pollution ought to be critical steps.

Considerations for educators in supporting student learning in the midst of COVID-19

COVID‐19 has presented a period of unprecedented challenge for schools in the United States. Thousands of school buildings across the country were closed in the spring of 2020 through the end of the school year to slow the spread of the global pandemic. Plans to reopen schools in many states remain uncertain as the virus continues to spread across communities. Current and future challenges are complex, with significant impacts on the global economy, health care system, and overall well‐being. When schools reopen, students will present with a wide variety of academic and social‐emotional needs, and schools will need to mindfully adjust systems and practices to meet the needs of their unique student population. This paper provides educators with suggestions on how to adapt existing multitiered systems of support using a trauma‐informed lens to support students during this unusual time.

COVID-19: Neurological Considerations in Neonates and Children

The ongoing worldwide pandemic of the novel human coronavirus SARS-CoV-2 and the ensuing disease, COVID-19, has presented enormous and unprecedented challenges for all medical specialists. However, to date, children, especially neonates, have been relatively spared from the devastating consequences of this infection. Neurologic involvement is being increasingly recognized among adults with COVID-19, who can develop sensory deficits in smell and taste, delirium, encephalopathy, headaches, strokes, and peripheral nervous system disorders. Among neonates and children, COVID-19-associated neurological manifestations have been relatively rare, yet reports involving neurologic dysfunction in this age range are increasing. As discussed in this review, pediatric neurologists and other pediatric specialists should be alert to potential neurological involvement by this virus, which might have neuroinvasive capability and carry long-term neuropsychiatric and medical consequences.