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" This is a complicated entity that we knew nothing about in
January, " said Dr. Ross Zafonte, chair of the Harvard Medical School
department of physical medicine and rehabilitation at Spaulding,
where he has long specialized in the treatment of brain injuries. " A
lot of progress has already been made in reducing the mortality, but
it's going to take us maybe a couple of years to learn how to combat
the morbidity. "
Long COVID-19 often presents as persistent severe fatigue,
headache and brain fog (mild subjective cognitive impairment) greater
than 4 weeks after an acute illness and may be independent of acute
illness severity (reference 8). More than one quarter of non-hospitalized
patients developed new neurological symptoms after their acute
COVID-19 illness in a study of 70 patients in France (reference 9).

As is often the case with post- or para-infectious syndromes,
especially when viral, treatment to date is supportive and symptomatic. If attention is a major issue, atomoxetine, dextroamphetamine/
amphetamine, methylphenidate or modafinil could be trialed.
Hydration, increased salt intake, compression stockings and meditation
may be of benefit in dysautonomia.
For paresthesia/small fiber neuropathy, any contributing
abnormalities in blood work should be addressed and symptomatic
treatment with gabapentinoids (gabapentin, pregabalin), tricyclic
antidepressants (TCAs), or selective serotonin and norepinephrine
reuptake inhibitors (SNRIs) such as duloxetine or venlafaxine may
be beneficial.

Possible nonpharmacological strategies to treat fatigue include
Neurologists are seeing small fiber neuropathy (paresthesia, dysau- activity pacing or modification, graded exercise therapy (GET) and
tonomic/autonomic neuropathy and fatigue), postural orthostatic cognitive behavioral therapy (CBT).
tachycardia syndrome (POTS) (headaches, fatigue/ generalized
There is no doubt the pandemic was a punch to the gut, and
weakness, orthostasis and tachycardia, paresthesia and brain fog), COVID-19 will be intertwined in the societal fiber for years to come.
*
myalgic encephalomyelitis/chronic fatigue syndrome (MECFS)
(overwhelming fatigue, post-exertional malaise, orthostatic intolerance, Valeriya S. Poukas is associate professor of neurology in the Lewis Katz
School of Medicine at Temple University.
pain, poor sleep and brain fog).
Often a primary role of a neurologist is to rule out serious
neurologic issues, and then to provide a lot of reassurance. Workup
is aimed to look for contributing factors and extensive testing does
not appear to be helpful in vast majority of patients.
Most patients present multiple complaints. Cognitive blunting, or
" brain fog, " appears to be the most common long-term neurological
symptoms of post-COVID-19. Patients report issues with short-term
memory, concentration and word-finding/ speech difficulty. Symptoms
tend to fluctuate in severity from day to day and fluctuations often
correlate with other symptoms, such as fatigue and dysautonomia.

References:
(1) Koy Chong et al. COVID-19, SARS and MERS: A neurological
perspective. Journal of Clinical Neuroscience 77 (2020) 13-16
(2) Mao L et al. Neurologic Manifestations of Hospitalized Patients
With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol.
2020 Jun 1;77(6):683-690
(3) Carlos Manuel Romero-Sanchez et al. Neurologic manifestations
in hospitalized patients with COVID-19: The ALBACOVID registry.
Neurology. 2020 Aug 25;95(8):e1060-e1070.

Headaches are often described as constant pressure fluctuating
in severity, with and without symptoms seen in migraines (nausea, (4) Eric M. Liotta et al. Frequent neurologic manifestations and
photophobia and phonophobia). Paresthesia may be focal, diffuse encephalopathy-associated morbidity in Covid-19 patients. Ann Clin
or alternating in locations.
Transl Neurol 2020 Nov;7(11):2221-2230
A common approach to work up includes a neurological
examination, blood work for contributing reversible causes (such
as B12, thyroid function panel, syphilis and HIV), neuroimaging,
neuropsychological testing, an electroencephalogram (EEG) if
concern for seizures, nerve conduction studies/electromyography
(NCS/EMG) if paresthesia is present, autonomic function and/or
tilt table testing if concern for POTS. MRI brain or vessel imaging
could be considered to investigate positional headaches or headaches
that are acute in onset.
Since many patients experience poor sleep as well as mood
disturbances such as depression, anxiety and even post traumatic
stress disorder (PTSD), sleep and mental health also need to be
addressed in depth.

28 Philadelphia Medicine : Winter-Spring 2021

(5) lberto Vogrig et al. Stroke in patients with COVID-19: Clinical and
neuroimaging characteristics. Neurosci Lett. 2021 Jan 19;743:135564
(6) Sebastian Fridman et al. Stroke risk, phenotypes, and death in
COVID-19: Systematic review and newly reported cases. Neurology.
2020 Dec 15;95(24):e3373-e3385
(7) Wilson F. Abdo et al. Prolonged Unconsciousness
Following Severe COVID-19. Neurology. 2020 Dec 21;10.1212/
WNL.0000000000011355
(8) Greenhalgh et al. Management of post-acute COVID-19 in primary
care. BMJ. 2020 Aug 11;370:m3026.
(9) Salmon-Ceron et al. Clinical, virological and imaging profile in
patients with prolonged forms of COVID-19: A cross-sectional study.
J Infect. 2020 Dec 4;S0163-4453(20)30762-3

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