complicating COVID-19
Dear editor,
We are still fighting the new coronavirus disease (COVID-19) worldwide. Some patients with the COVID-19 develop neurological symptoms.1Recent studies reported that the virus invades the central or peripheral nervous system by various mechanisms including angiotensin converting enzyme-2 receptors, blood-brain barrier injury, and immune injury.2 Ischemic stroke can occur, as a result of the virus penetrating the central nervous system. The average time of stroke after COVID-19 is about 12 days.3 The etiology of stroke after COVID-19 diagnosis are diverse. Recent studies found that COVID-19 was associated with large vessel stroke.4 I have experienced a strong association between multiple thromboembolic stroke and COVID-19.5An 82-year-old woman with known diabetes mellitus and hypertension was admitted to a tertiary hospital with fever (38.0°C), cough, and diarrhea for two days. One week before hospitalization, her daughter was diagnosed with COVID-19. At admission, her chest X-ray showed multifocal infiltrates in both lungs, and chest computed tomography (CT) showed peripherally distributed patchy ground-glass opacification. Nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 on real-time reverse transcription-polymerase chain reaction assay. Laboratory findings revealed elevated C reactive protein (3.76 mg/dL; normal 0.0-0.5 mg/dl), elevated D-dimer (16.67 mg/mL; normal 0.0-0.5 μg/ml), normal leukocyte count (7420/mm3; normal 4.0x103-10.0x103/㎕), and normal prothrombin time (12.7s; normal 11.0-15.0s). Initial treatment involved oral lopinavir/ritonavir (200mg/500mg, 2 tablets, every day) and hydroxyquinine (200mg, 1 tablet, two times a day) and subcutaneous low molecular weight heparin (40mg, every day). However, fever persisted, and her chest X-ray findings worsened. Intravenous immunoglobulin (0.3g/kg) was added, including oxygen (2L/min) through nasal prongs. On the 8th day of hospitalization (11 days after COVID-19), the patient abruptly complained of weakness and numbness in the right arm. The initial National Institutes of Health Stroke Scale score was 2, with power grade 4+ and decreased sensation in the right arm. The other neurological examination were normal. Brain CT showed a focal low-density lesion in the right cerebellum (Figure 1). The patient’s symptoms were mild, and no intravenous alteplase was administered. Brain magnetic resonance image showed multiple high signal intensity lesions with low apparent diffusion coefficient value in the right cerebellum (Figure 2), left precentral gyrus (Figure 3), and left fronto-parietal cortex (Figure 4). Brain magnetic resonance angiography showed no steno-occlusive lesions (Figure 5). The main lesion of the left precentral gyrus caused weakness and numbness of the right arm. The medicine was added to aspirin, clopidogrel, and statin. Trans-thoracic echocardiography and 24h Holter monitoring was normal. The patient’s neurological symptoms improved accompanied by rapid diagnosis, medication, and rehabilitation. Elevated CRP and D-dimer may be the main cause of stroke in COVID-19,6 as they represent an active inflammatory state and abnormalities of the coagulation pathway.7,8 Our patient elevated CRP and D-dimer, and was no clear abnormalities in other test for stroke mechanism. Focal neurological symptoms occurred after our patient had been managed for COVID-19 for 11 days. If the COVID-19 patient occur neurological symptoms with high D-dimer and an inflammatory maker, clinician be aware of stroke occurrence.