Document Type : Letter to Editor


1 Klinik Landstrasse, Messerli Institute, Vienna, Austria

2 Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil

3 Programa de Estudos Pós-Graduado em Fonoaudiologia, Pontifícia Universidade Católica de São Paulo (PUC-SP), Brazil

4 Departamento de Fonoaudiologia, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, Brazil



Interested, we read the review article by Assari et al on neurological involvement in coronavirus disease 2019 (COVID-19).1 The authors concluded that the review “can help research, public health, and clinical care of COVID-19 patients and reduce morbidity and mortality as well as the economic pressure of the COVID-19 on patients, health care systems, and the society”.1 We have the following comments and concerns.

The main shortcoming of the study is that several neurological conditions associated with the SARS-CoV-2 infection have not been addressed. Central nervous system abnormalities not included were sinus venous thrombosis, intracerebral bleeding, subarachnoid bleeding, vasoconstriction syndrome, pituitary apoplexia, cerebral vasculitis, encephalitis, acute, haemorrhagic, necrotic encephalopathy, acute demyelinating encephalomyelitis, epilepsy (seizures), and myelitis.2,3 From among the peripheral nervous system abnormalities associated with SARS-CoV-2, the authors did not discuss dysgeusia, polyradiculitis, myasthenic syndrome, myositis and rhabdomyolysis.

A further shortcoming is that neurological disorders due to side effects of the drugs given to treat COVID-19 or complications of the treatment were not addressed. Neurotoxic remedies may induce critical ill neuropathy, critical ill myopathy, polyneuropathy or rhabdomyolysis.4 Neurotoxic drugs frequently applied in the treatment of COVID-19 patients include chloroquine, steroids and azithromycin.4 Long-term pulmonary compromise with or without mechanical ventilation may cause cerebral hypoxia. Nosocomial infections during ICU treatment may trigger sepsis with septic encephalopathy. It is crucial to consider the side effect of drugs applied or complications of treatment as causative for neurological compromise to delineate these secondary abnormalities from direct or indirect primary neurological manifestations of the viral infection with regard to treatment and outcome.

Concerning the therapeutic management of neurological disease in COVID-19 patients, there is only limited discussion on how to manage immunologic neurological disease treated with immunosuppressants, how to manage ischemic stroke due to hypercoagulability, and how to treat newly occurring, so far untreated, immunologic neurological disease (Read more…)