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    2 Comments for this article
    Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China
    Kenneth Lipman, MD | Kaiser Permanente In-Patient Psychiatric Consultant, retired(1/31/2020)
    I have concerns about the conclusions drawn by Mao, Jin, Wang, et al in this article. In my role as a consultation liaison psychiatrist to a busy medical in-patient service, I frequently encountered unusual neurological and psychiatric (delirium) symptoms in very ill medical or post surgical patients. Not infrequently, the source for all or at least some of these symptoms was prescribed medication and their side effects. I was unable to see any data in this article documenting which medications the cited patients were taking. The media and some literature mention the use of the combination of hydroxychloroquine and azithromycin for Coronavirus Disease. I've also seen mention of parenteral corticosteroids. All 3 of these medications have been implicated on occasion as possible sources of most of the CNS and PNS symptoms the authors describe in their article. When we have national TV commentators (Chris Cuomo) publicly describing their own personality changes with hallucinations while experiencing COVID-19, it's important that we know more about the actual source for these symptoms. Only then can the general public be truly informed before consenting to a potentially toxic medication regimen.

    Kenneth Lipman, MD
    A CK level of 200U/L does not always mean muscle injury!
    The authors define skeletal muscle injury as "when a patient had skeletal muscle pain and elevated serum creatine kinase (CK) level greater than 200 U/L". The study conclusions are markedly limited by the lack of proper history, neurological exam and any electrophysiologic studies in their cohort. It may be noted that patients suffering from COVID develop a peripheral neuropathy, at times severe, within the first few days, that may mimic Guillain Barré Syndrome (GBS). Such patents may have significant pain and elevated serum CK. An assumption of muscle disease based on CK levels may lead to erroneous diagnosis and management of such patients. At this time further studies are required to characterize the involvement of the peripheral nervous system during COVID 19 infections.
    Original Investigation
    April 10, 2020

    Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China

    Author Affiliations
    • 1Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
    • 2Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
    • 3Department of Epidemiology and Biostatistics, Key Laboratory for Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
    • 4Neurovascular Division, Department of Neurology, Barrow Neurological Institute, Saint Joseph’s Hospital and Medical Center, Phoenix, Arizona
    JAMA Neurol. 2020;77(6):683-690. doi:10.1001/jamaneurol.2020.1127
    Key Points

    Question  What are neurologic manifestations of patients with coronavirus disease 2019?

    Findings  In a case series of 214 patients with coronavirus disease 2019, neurologic symptoms were seen in 36.4% of patients and were more common in patients with severe infection (45.5%) according to their respiratory status, which included acute cerebrovascular events, impaired consciousness, and muscle injury.

    Meaning  Neurologic symptoms manifest in a notable proportion of patients with coronavirus disease 2019.


    Importance  The outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, is serious and has the potential to become an epidemic worldwide. Several studies have described typical clinical manifestations including fever, cough, diarrhea, and fatigue. However, to our knowledge, it has not been reported that patients with COVID-19 had any neurologic manifestations.

    Objective  To study the neurologic manifestations of patients with COVID-19.

    Design, Setting, and Participants  This is a retrospective, observational case series. Data were collected from January 16, 2020, to February 19, 2020, at 3 designated special care centers for COVID-19 (Main District, West Branch, and Tumor Center) of the Union Hospital of Huazhong University of Science and Technology in Wuhan, China. The study included 214 consecutive hospitalized patients with laboratory-confirmed diagnosis of severe acute respiratory syndrome coronavirus 2 infection.

    Main Outcomes and Measures  Clinical data were extracted from electronic medical records, and data of all neurologic symptoms were checked by 2 trained neurologists. Neurologic manifestations fell into 3 categories: central nervous system manifestations (dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system manifestations (taste impairment, smell impairment, vision impairment, and nerve pain), and skeletal muscular injury manifestations.

    Results  Of 214 patients (mean [SD] age, 52.7 [15.5] years; 87 men [40.7%]) with COVID-19, 126 patients (58.9%) had nonsevere infection and 88 patients (41.1%) had severe infection according to their respiratory status. Overall, 78 patients (36.4%) had neurologic manifestations. Compared with patients with nonsevere infection, patients with severe infection were older, had more underlying disorders, especially hypertension, and showed fewer typical symptoms of COVID-19, such as fever and cough. Patients with more severe infection had neurologic manifestations, such as acute cerebrovascular diseases (5 [5.7%] vs 1 [0.8%]), impaired consciousness (13 [14.8%] vs 3 [2.4%]), and skeletal muscle injury (17 [19.3%] vs 6 [4.8%]).

    Conclusions and Relevance  Patients with COVID-19 commonly have neurologic manifestations. During the epidemic period of COVID-19, when seeing patients with neurologic manifestations, clinicians should suspect severe acute respiratory syndrome coronavirus 2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.