https://doi.org/10.

1590/0004-282X20200121
EDITORIAL

Neurological complications of COVID-19:

from bridesmaid to bride
Complicações neurológicas do COVID-19: de dama de honra à noiva
Avindra NATH1, Bryan SMITH1

A
s we write this editorial, we ask ourselves, why is the description of neurological
1
National Institutes of Health, complications of SARS-CoV-2 newsworthy? The virus causes multiorgan involvement,
National Institute of Neurological so the brain would surely be affected, just like other parts of the body. Yet it comes as
Disorders and Stroke, Section of
Infections of the Nervous System, a surprise to many that so many neurologic issues arise in these patients, and that
Bethesda, Maryland, USA. the complications seen are often severe ones. The SARS-CoV-2 virus is a respiratory pathogen
Avindra NATH https://orcid.
org/0000-0003-0927-5855;
and hence complications affecting the brain could be secondary to hypoxia and metabolic
Bryan SMITH https://orcid. derangements. However, the current paper by Studart-Neto et al.1 finds, and other similar
org/0000-0001-9850-5944
descriptions emerging from around the world show that the vast majority of patients have other
Correspondence: Avindra Nath;
E-mail: natha@ninds.nih.gov types of neurological involvement, some of which can be severe2,3,4,5. While loss of smell and taste
Conflict of interest: There is no is the most common symptom observed, nearly half of the patients hospitalized have some form
conflict of interest to declare.
of encephalopathy and about a fifth of the patients develop strokes6,7.
Received on July 23, 2020
Received in its final form on The current paper provides the most detailed description of the various neurological
July 23, 2020 manifestations in this population. The authors show that even in the acute phase, neurolog-
Accepted on July 24, 2020
ical complications can involve the entire neuraxis, which includes peripheral neuropathies
and rhabdomyolysis (Table 1)8. The number of neurological complications of SARS-CoV-2 is
steadily increasing in their hospital on a daily basis, clearly an ominous sign. These complica-
tions are being recognized in the acute phase of the illness. However, there are additional post-
viral syndromes affecting the nervous system, including dysautonomia9 and persistent fatigue,
exercise intolerance, and malaise that many patients are experiencing months after recover-
ing from the acute illness (Table 1)10,11,12,13,14. Many of these patients had only minimal respira-
tory symptoms. The long-term consequences of these manifestations can have a major impact
on all aspects of health care, with major socioeconomic consequences. Hence, the neurologi-
cal manifestations should be front and center to the disease.
Brazil has faced many major epidemics in the recent past, which include Zika, Dengue,
Chikungunya, and now SARS-CoV-2. Each of these pathogens causes neurological complica-
tions. The country was the first to alert the world about the devastating fetal complications of
Zika virus and has led the field in studying the epidemiology, clinical manifestations, and patho-
physiology of these diseases. But today we all face the biggest challenge of all times. SARS‑CoV-2
has brought the entire healthcare system worldwide to its knees. A respiratory pathogen that can
cause neurological complications is our biggest nightmare. Combined with the rapidity of spread
of this virus and its ability to mutate to alter its pathogenicity has evaded the best of minds

Table 1. Neurological manifestations of COVID-19 caused by SARS-CoV-2.

Acute Post-viral
• Anosmia • Acute disseminated encephalomyelitis
• Myalgia/myositis • Acute necrotizing hemorrhagic encephalopathy
• Encephalopathy • Transverse myelitis
• Stroke • Guillain-Barré syndrome
• Meningitis/encephalitis • Multisystem inflammatory syndrome (Kawasaki’s disease)
• Seizures • Myalgic encephalomyelitis/chronic fatigue syndrome
• Peripheral neuropathy • Dysautonomia
• Rhabdomyolysis

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 and challenged all scientific advancements. Today, we have the treat with anything, despite a lack of science, shows the power
ability to treat the rarest form of genetic illnesses, but we no this virus has on the world’s population.
have effective treatment in sight for the smallest of organisms In multiple visits to Brazil, it has become clear that
that has spread to every corner of the planet. We have treated Brazilians have impressive resilience and tremendous depth
thousands of patients with hydroxychloroquine to the point of knowledge, warmth, and compassion. Brazil will over-
where there is a worldwide shortage of the drug without much come this crisis and emerge stronger than ever. They have a
scientific basis for such treatment. This desperate attempt to bright future.

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