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.