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• W3082584088 abstract "Novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the main causative agent of coronavirus disease 2019 (COVID-19).1 Besides, progressive atypical respiratory system involvement, other organ systems including the central nervous system have also been affected due to the discernable affinity of the virus towards the angiotensin-converting enzyme 2 (ACE2) receptors2, 3 that may result in meningitis, encephalitis or stroke. This unique feature of COVID-19 infection is due to the activation of imbalance clotting factors which blocks the vessel and gives rise to ischemia of the brain, even in the young infected patient.4 Reports from the times of the SARS 2003 epidemic in Asia suggested the incidence of similar complications.5 Here, we present the cerebrovascular complication in patients with COVID-19 infection leading to bilateral loss of vision. A 60-year-old male patient presented to the emergency department with complaints of fever, cough, dyspnea, and one episode of loss of consciousness. The patient had no known comorbid. Upon systemic examination, he was found to have nausea, two episodes of vomiting in the previous 24 h, reduced appetite, bilateral loss of vision, and altered mental status. On general physical examination, he was febrile, tachycardiac with a heart rate of 112 per minute, hypoxemic with oxygen saturation of 75% (on 5 L oxygen through a nasal cannula). His blood pressure was within the normal limit (112/80 mm hg). GCS was 11/15 (eye opening = 4, motor response = 5, verbal response = 2). He was started on high flow oxygen through a nonrebreather mask. A chest x-ray was done which revealed the bilateral interstitial infiltrates consistent with atypical pneumonia or COVID-19 infection (Figure 1). Polymerase chain reaction (PCR) was done on a nasal swab that confirmed COVID-19 infection. To investigate the cause of altered mental status computed toography head was ordered which demonstrated bilateral hypodense opacities in occipital lobes consistent with cerebral infarcts (Figure 2). EKG findings were unremarkable. The patient was shifted to the COVID isolation unit where blood workup was done. Lab results are shown in Table 1. As the patient stabilized an ophthalmology consult was taken which confirmed the bilateral vision loss suggesting an embolic event but no other obvious findings were found. Hence, the diagnosis of cortical blindness secondary to occipital lobe stroke was made. Then the patient was evaluated for the administration of thrombolytic medication but due to late presentation, it was differed. To find the source of emboli, echocardiography, and carotid Doppler were done which was unremarkable. The patient was started on broad-spectrum antibiotics including ceftriaxone (75 mg/kg/day in two divided doses) and azithromycin (500 mg/day, once daily), low molecular weight heparin enoxaparin (40 mg/day, single dose, subcutaneous), dexamethasone (intravenous 6 mg/day in a single dose). Vitamin C and Zn supplements were also prescribed. The patient was catheterized and a nasogastric tube was passed for feeding. After 20 days in the isolation unit, his respiratory status (oxygen saturation 95% on 3 L oxygen through a nasal cannula) and mental status improved (GCS 15/15). The patient was weaned off oxygen and finally stopped. He was started on rosuvastatin (oral, 10 mg/day, in a single dose) and coated aspirin (oral 75 mg/day in a single dose). The patient was discharged upon repeated negative COVID PCR. He is now on a follow-up visit with the neurologist and Rehabilitation team. According to the World Health Organization, the current COVID-19 pandemic has infected around three million people globally among 213 countries.1 Various risk factors such as advanced age, obesity, and previous illnesses, that is, cardiovascular, cerebrovascular, and any underlying immunosuppressive condition have been reported as prognosticators of mortality.4 As per initial reports, COVID-19 infection involved with the respiratory system only,4 but over time, with more sub-types recognition and development of several other complications, there is clear evidence that thrombi are a major cause of multisystem organ dysfunction in critical cases of COVID infection.4 The SARS-CoV-2 virus is the seventh known type of coronavirus that pass on a disease to human beings.6 It is a neurotropic virus7, 8 and is genetically similar to SARS-CoV-1.3 It has been reported that SARS-CoV-2 uses the same receptor as SARS-CoV, i.e. membrane-bound ACE II (ACE2), making it the major entry point9, 10 to the central nervous system.3 ACE-2 receptors are found in neurons, endothelial and arterial smooth muscle cells of the brain that possibly allow SARS-CoV-2 to cross the blood-brain barrier (BBB) and detriment the central nervous system.10 Steardo et al., have also suggested several alternative pathways that explain the entry of SARS-CoV-2 into the nervous system via direct injury, hypoxic injury, and immune-related injury to the BBB.7, 8 According to the report, the COVID-19 virus increases the permeability by mutilating the endothelium of the BBB3, 4 that may result in encephalopathy, encephalitis, thrombosis, and hemorrhages.3 A recent study by Klock et al. conducted in Netherland showed that 31% of patients develop thrombotic complications.11 Another study observing the activated partial thromboplastin time-based clot waveform analysis in patients with COVID-19 confirmed that hypercoagulability precedes or concurs with severe COVID-19 illness.11 To our knowledge, this is the first case with PCR confirmed COVID-19 infection presenting with a bilateral occipital stroke leading bilateral vision loss. Our patient, a 60-year-old man with no previous risk factors for the cerebrovascular incident, his sentinel event was preceded by days of fatigue, cough, and malaise. He had one episode of loss of consciousness and presented to our hospital with bilateral loss of vision, altered mental status, and later tested positive for COVID-19 infection. In contrast, the study of Mao et al.,12 where only 5.7% of patients with severe COVID infection developed cerebrovascular complication later in the course of illness while in a study by Li Y et al.,13 the prevalence of stroke in patients with COVID-19 was about 5% with an average age of 71.6 years. These patients had multiple risk factors like hypertension, diabetes, and coronary artery disease13 that may lead to stroke, usually on 12 days of COVID-19 infection diagnosis.13 Similar to our findings, elevated levels of C-reactive protein and d-dimer, directed towards a high inflammatory state and abnormalities with the coagulation cascade.13 This explains the severity of illness that might play a role in the pathophysiology of stroke.9 Similarly, numerous other reports have acknowledged various other coagulation abnormalities with raised d-dimer, thrombocytopenia, and prolonged activated prothrombin time in patients with COVID infection.14 Despite these reports, our patient presented with the cerebrovascular complication in the early stages of his illness with varying levels of inflammatory markers, d-dimers, and Troponin-I with no known previous predisposing factors. As a result, we recommended that stroke teams should be cautious of the fact that patients with COVID-19 can present with cerebrovascular accidents or events. An appropriate approach should be developed to deal with acute cerebrovascular accidents in times of COVID-19 infection. Though, the control of COVID-19 infection should be foremost priority. Further studies are instantly needed for the complete understanding of the neurological pathology of COVID-19 and its upshots on the nervous system." @default.
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• W3082584088 date "2020-09-29" @default.
• W3082584088 modified "2023-09-27" @default.
• W3082584088 title "Ischemic stroke leading to bilateral vision loss in COVID‐19 patient—A rare case report" @default.
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• W3082584088 doi "https://doi.org/10.1002/jmv.26484" @default.
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