An Elderly Woman with SARS-CoV-2 Infection and Neuropsychiatric Disorders

Citation: Nnaji M, Rosada A, Wilke S, Wirsching I, Schurig J, et al. (2021) An Elderly Woman with SARSCoV-2 Infection and Neuropsychiatric Disorders. J Geriatr Med Gerontol 7:113. doi.org/10.23937/24695858/1510113 Accepted: June 17, 2021: Published: June 19, 2021 Copyright: © 2021 Nnaji M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Open Access ISSN: 2469-5858


Introduction
The SARS-CoV-2 pandemic has placed a considerable strain on public health services worldwide. According to the Johns Hopkins COVID-19 Dashboard (https://coronavirus.jhu.edu/map.html), as of April 2021 over 150 million cases had been recorded worldwide with a global death toll of over 3 million. Most efforts in delineating the effects of SARS-CoV-2 infection have focused largely on the pulmonary, digestive and nephrological organ involvement as well as thromboembolic complications.
There is however growing evidence that there may be significant nervous system involvement in the context of SARS-CoV-2 infection [1].
Generally, the geriatric population has been disproportionately affected by the SARS-CoV-2 infection and the protean manifestations of COVID-19-related disease. The full extent of the potential sequelae of COVID-19 disease is yet to be known.
In this case presentation, we report of an elderly patient with SARS-CoV-2 infection with neuropsychiatric disorders. We present clinical, laboratory, imaging, neuropsychiatric test findings and electrophysiological evidence to underscore the potential of the neuropsy-tilated with the blood gas analyses showing an impaired gas exchange with global respiratory insufficiency. On examination her pupils were isocor and reactive to light. On the third hospital day, she was extubated and weaned off mechanical ventilation.
Diuretic therapy with furosemide and haemodialysis were initiated after consultation with a nephrologist.
Meanwhile blood and urine cultures remained sterile. The antibiotic therapy was discontinued on the 8 th hospital day following improvement in the patient's clinical condition, laboratory and vital parameters. Subsequent RT-PCR tests for SARS-CoV-2 from nasopharyngeal samples returned negative.
After further stabilization, she was transferred to the geriatric department of our hospital for further treatment and rehabilitation. She still required 4 litres of oxygen administered through nasal cannula. On examination, she displayed psychomotor sluggishness and was unable to sit or stand, let alone walk alone. The remainder of the physical examination was otherwise unremarkable.
A Computed Tomographic (CT) scan of the brain showed no acute pathologies. A CT scan of the chest and abdomen with contrast material (Figure 1) showed pulmonary infiltrates in the dorsobasal aspects as well as bilateral ground-glass opacities and consolidations, features that were suggestive of COVID-19 pneumonia [2].
There was no evidence of pulmonary embolism, trauma or abdominal infection. While undergoing the imaging diagnostic procedure, she again experienced cardiorespiratory arrest and was successfully resuscitated (ROSC 2 minutes) and required continuous vasopressor support. A reverse transcriptase PCR (RT-PCR) test for the SARS-CoV-2 virus from nasopharyngeal samples returned positive.
She was subsequently transferred to the intensive care unit (ICU) for further treatment. On arrival on the ICU she was sedated (Richmond Agitation Scale -2, indicating light sedation), intubated and mechanically ven- In the meantime, the initially abnormal laboratory findings returned largely to within normal values. The electrolyte levels, HbA1C, folic acid and vitamin B12 were within normal limits. She was successfully weaned off dialysis. Following intensive physical therapy and respiratory training, her functional independence improved somewhat (Barthel index 35/100). There were no longer any signs of delirium and risperidone was discontinued; she however still showed signs of cognitive impairment in repeat neuropsychological testings, with deficits in verbal and figurative memory. She was transitioned to a phase B rehabilitation centre for further treatment and care.

Discussion
Severe SARS-CoV-2 infections typically tend to manifest in the respiratory system, causing acute respiratory distress syndrome (ARDS) requiring intensive care potentially leading to multiorgan failure. The present case, however, seeks to corroborate growing evidence suggesting severe neuropsychiatric involvement in the setting of the COVID-19 disease. In summary, our patient was diagnosed with acute SARS-CoV-2 infection which initially involved the cardiopulmonary system, although -against the backdrop of the syncope she experienced -neurologic involvement might well have been present from the onset especially given the stretch synergism that was present. The course was further complicated by multi organ failure, the need for intubation and mechanical intubation due to respiratory failure and dialysis for acute renal failure accompanied metabolic derangement. Before hospitalization, the patient had been otherwise healthy and functionally independent with a medical history of well-controlled asthma and hypertension.
Strikingly, although she was intubated and mechanically ventilated for only 3 days, she showed clinical signs of polyneuropathy which were subsequently confirmed by electrophysiogical studies which demonstrated features consistent with critical illness polyneuropathy, using the The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test battery showed deficiencies in mental flexibility, processing speed and memory. A neurological examination performed by a trained neurologist was notable for her reduced reflexes and strength in the lower extremities as well as pallhypaesthesia of the malleolar joints. She showed hyporeflexia of the Achilles tendon, especially on the right side. She also displayed truncal instability and was unable to stand or walk on her own. Dialysis was still ongoing. Pulmonary function tests were inconclusive because the patient was physically week and mentally impaired to follow instructions. However, the patient had no shortness of breath and the oxygen saturation levels were satisfactory while she was breathing ambient air.
In our dedicated virology laboratory, neither SARS-CoV-2 viral loads nor antibodies were detected in the Cerebrospinal Fluid (CSF). In addition, analysis of the Cerebrospinal Fluid (CSF) showed no evidence of a co-infection with Borrelia burgdorferi, varizella zoster or herpes simplex virus. Furthermore, antibodies against SARS-CoV-2 were not detected in the CSF. However, in indirect immunofluorescence studies, high levels of IgG binding to intracellular structures (among others ANA) were detected.
Despite intensive physiotherapy, no significant improvement was initially observed in the ambulation or functional independence in our patient (Barthel index 15/100). Hence further diagnostic work-up was performed to rule out possible nervous system involvement. An MRI scan of the brain showed hippocampal atrophy, reduced brain volume, findings that are otherwise consistent with Alzheimer's disease. There was no clear evidence of spinal cord injury on MRI studies.
Electrophysiological studies then showed changes consistent with polyneuropathy analogous to critical illness polyneuropathy (CIP) (see Figure 2). The transient nature of her recovery and the absence of substantial neuropsychiatric sequelae argue against significant hypoxic brain damage, tipping the scales towards direct potential CNS damage by an autoimmune response. Interestingly, detection of the SARS-CoV-2 viral antigen or antibodies directed against it -as seen in this case -do not appear to be preconditions for neurologic involvement.
The disturbed mentation was ascribed to pre-existing (latent) underlying mild cognitive impairment (MCI) which was accentuated by the SARS-CoV-2 infection.
With this investigation, we wish to draw attention to the genuine probability of neuropsychiatric involvement in the context of SARS-CoV-2 infection. In the light of this and other clinical observations published elsewhere, it is easy to envisage a situation where elderly frail patients also present with neuropsychiatric symptoms. Physicians and caregivers should accordingly raise their suspicion index for neurological and mental health issues in geriatric patients with ongoing or antecedent SARS-CoV-2 infection. This would help in early diagnosis and the institution of adequate therapy (in this case intensive physical and cognitive therapies).
This case also highlights the importance of a multidisciplinary approach (in this case medical, laboratory, neurocognitive and physical therapy expertise) in the management of the fall-out from SARS-CoV-2 infection with a view to ameliorating the public health burden associated with this novel human virus. This report also throws a searchlight on the potential manifold manifestations of SARS-CoV-2 infection as we await further clinical, laboratory and epidemiological findings in the efforts to fully understand this novel disease entity.