Neuropsychiatry of Covid-19

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Neuropsychiatry of Covid-19





Neurological complications of Covid-19 Infection
Chinese investigators studied CNS, PNS, and muscular neurological complications in 214 cases of Covid-19 infection, reporting overall rates of 11% for muscle injury, 7% for altered alertness, 6% for hypogeusia, 5% for hyposmia, and 3% for CVA and/or intracranial hemorrhage. Neurologists in NY, NY also report encountering Covid-related stroke.

This case report indicates that Covid-19 infection can present as encephalopathy.

Clinicians at the Henry Ford Health System in MI report a case of acute necrotizing hemorrhagic encephalitis, most likely a manifestation of cytokine storm.

Chinese clinicians report a single case of apparent acute Guillain-Barré syndrome related to Covid-19 infection.

Five Additional Cases of Guillain–Barré Syndrome Related to Covid-19 Infection
Dr Toscano and colleagues from Italy describe 5 more cases of Guillain–Barré Syndrome appearing typically 5 to 10 days after viral symptom onset, verifying that Covid-19 infection can produce autoimmune reactions in the CNS. Note that other autoimmune CNS reactions to Covid-19 infection are appearing in preliminary case reports.

High Rates of Neurological Features in Covid-19 Cases in ICU
French neurologists describe high rates of agitation, confusion, and corticospinal tract signs with enhanced tendon reflexes, ankle clonus, and bilateral extensor plantar reflexes in 58 Covid-19 ICU patients. In 13 patients with MRI imaging, leptomeningeal enhancement was noted in 8 and CVA in 3. At discharge, 15 of 45 (33%) had a dysexecutive syndrome with inattention, disorientation, or poorly organized movements in response to command.

New Review of Covid-19 Psychopharmacology in Psychosomatics
ACLP members Drs. Anna Kim and Carrie Ernst and others provide an analysis of psychopharmacology in the Covid-19 patient.

More on Psychiatric Sequelae of Covid-19 Infection
Chinese investigators find a 96% incidence of supra-threshold score on a post-traumatic symptom checklist in over 700 hospitalized recovering Covid-19 patients, consistent with other reports emphasizing the likely burden of symptoms in this domain in survivors.

More on Neurological Sequelae of Covid-19 Infection
Dr. Pablo Rábano-Suárez, MD, et al. describe 3 elderly patients with myclonus of the nasopharynx, face, and upper extremities, and Dr. Alireza Radmanesh, MD, et al. describe MRI features of 11 mechanically ventilated ICU patients with Covid-19 infection, with 10 having diffuse leukoencephalopathy and and 7 having juxtacortical/callosal microhemorrhages.

Mental Status Changes in Covid-19 InfectionACLP members Erica Baller, MD, Ana Ivkovic, MD, Elizabeth Madva, MD, Mladen Nisavic, MD, Nathan Praschan, MPH, MD, Scott Beach MD, FACLP, Felicia Smith, MD, and some other physicians review the published literature and the MGH experience, describing a high incidence of delirium in Covid-19 infection. They offer a 5-step algorithm for treatment.

More Evidence for Neurological Presentations of Covid-19
In the most recent issue of the journal General Hospital Psychiatry, ACLP members Drs. Scott R. Beach, MD, FACLP, Nathan C. Praschan, MPH, MD, Flannery Merideth, MD, Nicholas Kontos, MD, FACLP, Gregory L. Fricchione, MD, FACLP, Felicia A. Smith, MD, and two other physicians present 4 cases with combinations of altered mental status, myoclonus, rigidity/cogwheeling, alogia/mutism, or abulia related to Covid-19 infection: only one had significant respiratory symptoms, and only two had fevers (which were mild and transient).

Covid-19 Infection Associated with Toxic Elevation of Serum Clozapine Levels
The authors describe three cases with marked elevations of serum clozapine level induced by Covid-19 infection and note that severe systemic inflammation can increase clozapine levels, perhaps due to cytokine-mediated inhibition of CYP1A2. Clinicians should decrease clozapine dose in patients with Covid-19 infection or consider closely monitoring drug levels.

IgM in CSF Demonstrated in Covid-19 Encephalopathy
Karima Benameur, MD, et al. describe 3 patients with Covid-19 infection, encephalopathy, myoclonus, and other neurological symptoms who were found to have viral anti-S1 IgM in CSF, consistent with brain infection, although only one patient had significantly elevated protein (>200 mg/dl) and pleiocytosis (115 nucleated cells/ml).

ADEM Emerging as Covid-19 Effect
Neurologists in the UK describe 43 consultations for neurological symptoms in 43 adults with Covid-19 infection: 10 with delirium, chiefly reversible; 12 with inflammatory CNS syndromes: 2 encephalitis, 9 acute disseminated encephalomyelitis (ADEM), 1 Isolated myelitis; 8 with ischemic  strokes; 8 with peripheral neurological  disorders: 7 Guillain-Barré  Syndrome (GBS),  1 brachial plexopathy. Of the 12 with autoimmune presentations, 10 were treated with corticosteroids and other immunosuppressants, most making a partial recovery. Strokes and GBS are known complications but this incidence of ADEM is noteworthy.

Psychiatric Aspects of Chloroquine and Hydroxychloroquine Treatment
ACLP members Drs. Brandon S. Hamm, MD, MS, and Lisa J. Rosenthal, MD, FACLP, update us about drug-drug interactions, QT prolongation, and neuropsychiatric effects of these agents in an article in an upcoming issue of Psychosomatics.



Alpha-2 Agonists in Critical Care
This is an excellent discussion of: clonidine, guanfacine, lofexidine, ketamine, and dexmedetomidine in the ICU, from Dr. Josh Farkas, MD, Associate Professor, Pulmonary and Critical Care Medicine, University of Vermont.

Use of Valproate for Agitation in the ICU
As we see valproate used in increasing rates for Covid-19 patients, this interesting study emphasizes the need for adequate dosing of the agent, with median dose of 23 mg/kg/d

Internet Book of Critical Care (IBCC): Covid-19

This is an excellent and continually updated summary of Covid-19 from the intensivist perspective, managed by Dr. Josh Farkas, MD, Associate Professor, Pulmonary and Critical Care Medicine, University of Vermont (whose PulmCrit blog is referenced in an earlier link on this page).

Comments about CAR-T Neurotoxicity and Covid-19 Infection
ACLP member Dr Avram Mack, MD, and his colleague, Dr Hannah-Lise Schofield, PhD, of the Children’s Hospital of Philadelphia have published a letter in Psychosomatics, “Applying (or not?) CAR-T Neurotoxicity Experience to COVID19 Delirium and Agitation.”

More on Treatment of Agitation in Covid Infection
ACLP members Kimberly Yonkers, MD, and Seth Powsner, MD, FACLP, and others pen a commentary on the treatment of agitation in Covid-19 infection.



Neuropsychiatric Sequelae of Viral Infection
Drs Emily Troyer, Jordan Kohn, and Suzi Hong note that previous viral epidemics have been followed by neuropsychiatric sequelae such as insomnia, anxiety, depression, mania, psychosis, suicidality, and delirium. For example, cases of Von Economo encephalitis (encephalitis lethargica), marked by hypersomnolence and catatonia, followed the 1918 viral epidemic. These authors provide a detailed review of viral interaction with the CNS.