Letters to the Editor

Case Report: Need for Vigilance in Recognizing Neurologic Presentations of COVID-19


Am Fam Physician. 2020 Dec 1;102(11):645.

To the Editor: Case reports and clinical studies have suggested neurologic consequences of severe acute respiratory syndrome coronavirus 2 infection—most commonly headache, anosmia, and ageusia—in addition to the more well-recognized respiratory findings. Other manifestations include stroke, impairment of consciousness, coma, seizure, and encephalopathy.1 An early case series from Wuhan, China, identified neurologic features in 78 of 214 patients (36.4%) who were diagnosed with coronavirus disease 2019 (COVID-19),2 and a systematic study in France found neurologic signs in 49 of 58 patients (84.4%), including abnormalities in magnetic resonance imaging (MRI) and cerebrospinal fluid.3 In a case-control study, COVID-19 was implicated as an independent risk factor for acute ischemic stroke (odds ratio [OR] = 3.9).4 Another study demonstrated an association between COVID-19 and large vessel occlusion strokes (OR = 2.4).5

An 88-year-old woman with a history of hypertension, pulmonary embolism (receiving apixaban [Eliquis]), hypothyroidism, and chronic kidney disease presented with three hours of slurred speech, dizziness, and blurred vision. On arrival, her symptoms improved, and she was afebrile. She denied experiencing fever, chills, cough, dyspnea, chest pain, nausea, or vomiting. Computed tomography (CT) of the brain, CT angiography of the head and neck, and an MRI of the brain showed no acute findings. Findings on chest radiography and laboratory tests, including urinalysis, were within normal limits. She was monitored overnight with complete symptom resolution and was diagnosed with a transient ischemic attack.

Seven hours after discharge, she returned to the emergency department with slurred speech, confusion, dizziness, and syncope. Vital signs, including orthostatic vital signs, and test results, including vitamin B12 and folate, were within normal limits. A repeat chest radiograph and CT of the head showed no acute findings. Shortly after arrival, her symptoms returned to baseline. Echocardiography showed a normal ejection fraction. Electroencephalography was normal.

On day 4 after the initial presentation, she developed vomiting. A COVID-19 polymerase chain reaction test was positive. She subsequently developed a temperature of 100.3°F (37.9°C). By day 7, she was afebrile, tolerating food, and was discharged.

In people presenting with neurologic signs and symptoms, COVID-19 may be overlooked as a possible underlying etiology, delaying appropriate treatment and potentially contributing to high-risk exposures for staff and other patients. Twenty-four staff members treated this patient before COVID-19 was diagnosed. However, no viral transmission occurred due to universal precautions (surgical mask and eye covering) among staff, emphasizing the importance of personal protective equipment in treating all patients regardless of symptoms.

Author disclosure: No relevant financial affiliations.


show all references

1. Zubair AS, McAlpine LS, Gardin T, et al. Neuropathogenesis and neurologic manifestations of the coronaviruses in the age of coronavirus disease 2019. JAMA Neurol. 2020;77(8):1018–1027....

2. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683–690.

3. Helms J, Kremer S, Merdji H, et al. Neurologic features in severe SARSCoV-2 infection. N Engl J Med. 2020;382(23):2268–2270.

4. Belani P, Schefflein J, Kihira S, et al. COVID-19 is an independent risk factor for acute ischemic stroke. AJNR Am J Neuroradiol. 2020;41(8):1361–1364.

5. Kihira S, Schefflein J, Mahmoudi K, et al. Association of coronavirus disease (COVID-19) with large vessel occlusion strokes: a case-control study. AJR Am J Roentgenol. 2020;1–6.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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