Covid affects mainly the respiratory system and causes lung disorders and low oxygen saturation. However, we have also seen many patients with neurological problems. Recently, out of the neurological patients that frequent the OPD, a large percentage of them have had Covid or have presented with neurological manifestations of Covid.
Neuropsychological effects of Covid
Many patients who have had covid in the recent past are either quarantined at home, or in the ICU of a hospital. After they recover and come out, they suffer from a variety of neuropsychological problems which include extreme weakness, fatigue, brain fog (inability to think clearly), slowness, sleepiness, lack of energy. Initially, we thought this was because of psychological reasons, home isolation or intensive care treatment. This may be true partly, but also Covid, per se, produces these symptoms .. Therefore, these patients need to be treated for depression, and anxiety, due to which many of them suffer for a long duration of time. This is also called Long Covid.
Besides this, many people including caregivers suffer from severe anxiety and depression, which lasts for a very long time, and needs to be treated because caregivers also suffer.
After experiencing deaths in the family, long ICU stays, tremendous financial or emotional strain, many of these patients also suffer from depression and anxiety. This is not to be dismissed, but rather should be taken very seriously, because this markedly decreases the quality of life. This post covid syndrome and covid consequences in the caregivers is a very important part of treatment of covid.
Neurological effects of Covid
In pure neurological terms, we have seen a number of patients who have been presented with brain stroke, which means their blood vessels (either arteries or veins) get blocked. These patients come to the neurologists with brain symptoms of stroke and headache and blocking of the veins and arteries of the brain. Only when we do the tests, it is detected that they had covid, or they have ongoing covid. So Covid itself produces blockage of blood vessels of the brain, arteries and veins.
Though westerners do not agree, we feel that covid is a risk factor and a trigger for stroke and heart attack. A number of young people in their 20s and 30s who have no other stroke risk factors also suffering from this disorder. This has to be treated aggressively and early only then it can help many patients.
Besides this many patients suffer with a number of cranial nerve palsies especially the facial nerve palsy in which the face becomes crooked and the facial muscles get paralysed, either on one side or both sides. Sometimes, the muscles which enable eye-ball movement also get affected which causes double-vision, difficulty to open and close eyelids, and takes a while to recover with treatment.
Another effect of Covid is patients of Guillain barre syndrome in which all limbs of the patient are totally paralyzed. They have difficulty in swallowing and need to be fed by a tube and in a few cases, they go on a ventilator because their muscles of respiration also have become paralyzed. So, this has to be treated aggressively with various expensive drugs. This is a potentially life threatening condition but with good treatment and ICU care, most of these patients can survive.
Especially in the first wave of Covid, many patients came in with a loss of taste and smell. This was also because of nerves, specifically the involvement of the olfactory cranial nerve and the other cranial nerves affecting the brain. This is also reversible. It can be a presenting symptom of Covid.
Very rarely, as seen in a few cases, the virus gets into the brain. Maybe through the olfactory nerve and produces neuropsychological changes like hallucinations, memory loss. Very rarely it can produce convulsions, unconsciousness and other neurological brain deficits. These are the usual complications of covid.
The Mucormycosis Challenge
In the first wave, and much more in the second wave, we have seen Mucormycosis. Initially, we used to see very few cases . It usually occurred in diabetics who were not treated or who had renal failure, or those who were on immunosuppressive therapy due to cancer and other drugs. However, in this second wave of Covid, the number cases have increased significantly. This particular disorder has a high mortality.. However, with very aggressive treatment many of these patients can be saved if the diagnosis is made early.
How do we make the diagnosis?
The first important thing is early suspicion. Any patient who complains of head and face pain, and numbness on the face should be a suspect of mucormycosis. We need to do an MRI or CT scan quickly to diagnose this condition. Most of these patients have taken steroids which have been given excessively for extended periods of time, sometimes with very poor indication. The blood sugar of these patients is high, they may be in diabetic ketoacidosis, they may have renal failure and they are immunosuppressed. However, there have been few cases where none of these factors existed.
Therefore, various theories were laid that they may have used industrial oxygen, or practiced improper hygiene, or due to overcrowding in the hospital and in the homes. It is uncertain if all these theories are true. But, a major link is that Covid followed by steroids, followed by high blood sugar. This occurs in the majority of cases and with early treatment and various drugs, and early nasal surgery and aggressive treatment, many of these mucormycosis patients can be saved. The mortality can be brought down to 20% as compared to the initial 60-70%. Awareness, early treatment, less steroids, monitoring of sugar, and early diagnosis is the key to survival and treatment of mucormycosis.
Treatment options for brain complications
Strokes are to be treated in the usual way. The problem, however, during this time is that a majority of hospital beds are being taken over by Covid patients. Therefore, there is insufficient availability of ICUs to treat patients with strokes. The stroke treatment has to be done in a few hours and therefore treatment during this was thus challenging in view of these factors. Therefore it is important that we take the patient to a stroke ready hospital.
When GB syndrome occurs, the patient has to be treated either by plasmapheresis (a method of removing blood plasma from the body by withdrawing blood, separating it into plasma and cells, and transfusing the cells back into the bloodstream. It is performed especially to remove antibodies in treating autoimmune conditions..) or by immunoglobulin. These are expensive treatments, but are extremely effective.
When cranial nerve palsies occur, a short course of steroids is given to the patients. Most of them recover quite well.
Patients of neuropsychological problems need a lot of attention, counseling and drug therapy. Most of them, over a period of time, overcome this disorder. However, it may take a few weeks to months to recover completely.
When does the black fungus actually start involving the brain?
The black fungus starts in the sinuses in the surrounding areas of the nose (paranasal sinuses). As the disease progresses, it breaks into the eyeball, and then affects the arteries which affect the brain. Once the arteries are blocked, the brain gets damaged which causes the patient to respond poorly to treatment. The treatment results, in that case, are very poor and most of the patients in such cases do not survive. In most cases like these, it is too late to conduct surgery.
The key to a successful treatment is early diagnosis, and treatment in initial stages before the eye is involved, and before the brain and its blood vessels are affected. It is a disfiguring disorder which requires the removal of large chunks of the bone which has been damaged by mucormycosis. Sometimes, the palate may also get involved in which case the palate is removed and dead tissue is scraped out. This allows the drug to penetrate into the viable tissue and stop the growth of the fungus.
At the same time, the sugar levels have to be controlled properly, and are to be brought down with intensive treatment with insulin and IB fluid. The acidosis that exists in the area should also be treated. This acidosis that occurs due to diabetes and renal failure produces growth of the fungus.
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