Strokes, seizures, loss of smell and taste and other neurological deficits are showing up in patients critically ill with the coronavirus.

Although the virus is classified as a respiratory disorder and primarily damages the lungs, clinicians are seeing patients with a wide array of symptoms, from seizures to hallucinations, brain inflammation, disorientation, delirium and loss of smell and taste.

I had a patient, a young guy, 48, who attended a party in New Rochelle two weeks before and came in with hallucinations and confusion, said Dr. Pooia Fattahi, regional chair of neurology for Trinity Health Of New England. The patient had no fever and only a slight cough. Still, aware some COVID-19 patients show up at hospitals with seizures, strokes and confusion, Fattahi suspected, correctly, that the patient had COVID-19. Three of those who attended the same New Rochelle party ultimately died of the virus.

A third of COVID-19 patients hospitalized in Wuhan, China, suffered neurological symptoms, according to a Chinese study published April 10. Moreover, many of the patients developed these symptoms early; in some cases, the brain abnormalities were their only symptom. Because of that, study authors encouraged front-line clinicians treating patients with brain deficits to consider COVID-19 to avoid delayed diagnosis or misdiagnosis and prevention of transmission.

Precisely why and how the virus attacks the brain penetrating the protective blood-brain barrier is complex and not well understood, said Dr. Jennifer Moliterno, chief of neurosurgical oncology at Yale Department of Neurosurgery and Yale School of Medicine. Other viruses can similarly affect the brain, so its not completely surprising but it is somewhat surprising, she said.

Moliterno speculates that the brain dysfunction seen in COVID-19 patients could originate in two different responses. First, the hyperactive immune system response that physicians have observed in COVID-19-positive patients known as a cytokine storm could trigger an inflammatory response that could cause widespread clotting throughout the body_ That would explain why hospitals are seeing so many patients who manifest with stroke and later test positive for COVID-19.

Second, experts believe COVID-19 infects cells through ACE2 receptors, which are also present in the specialized endothelial cells that make up a critical part of the neurological netting that comprises the blood-brain barrier.

That can allow the virus to leak into the brain, Moliterno explained.

It is also possible that COVID-19 enters the body through the olfactory system, close to the frontal lobes in the brain, which controls cognitive skills, Fattahi and Moliterno said. Inflammation of those lobes is known as encephalitis, whose symptoms include memory loss, behavioral changes, confusion and irritation.

Fattahi noted that anywhere from 5 to 24 percent of COVID-19 patients experienced a difficulty with smell. We dont know but we suspect there are ACE2 receptors that attach the olfactory nerves, which pass through those nerves into the brain, he said.

Those who present with brain disorders, Moltinero said, have a particularly dangerous infection. These patients are really sick, she said. A lot of the patients with the neurological symptoms have the more severe COVID-19 cases.

In Italy, the neurological damage has been so severe among affected patients that a neurologist at the university of Brescia has opened an 18-bed neuro-COVID-19 unit to treat these patients exclusively. Dr. Alessandro Pezzini, associate professor of neurology at the University of Brescia, has advised U.S. doctors to consider the possibility that these brain events are another effect of the virus.

So is a pronounced loss of smell. In South Korea, China, and Italy, about a third of patients who have tested positive for COVID-19 have reported a loss of smell known as anosmia often as their only symptom. That has led some experts to speculate that those who experience a loss of smell might be unsuspecting carriers of the virus who have unwittingly transmitted it to others.

British researchers recently advised doctors to consider loss of smell among the first symptoms of the virus.

There is potential that if any adult with anosmia but no other symptoms was asked to self-isolate for seven days we might be able to reduce the number of otherwise asymptomatic individuals who continue to act as vectors, not realizing the need to self-isolate, Professor Claire Hopkins, president of British Rhinological Society, said in a joint statement released late last month with the British Association of Otorhinolaryngology. Hopkins noted that because these patients do not have the dry cough, fever or shortness of breath that are hallmarks of the virus, they may not meet criteria for testing or self-isolation, though they could be spreading Covid-19.

Dr. R. Peter Manes, a rhinologist at Yale New Haven Hospital, said it was possible that people who lost their sense of smell in the absence of anything else, it can be one of the first signs of COVID-19.

At Saint Marys, Fattahi said he was perplexed to see a seizure in a relatively young patient. I thought, This is a guy who is not a drinker, has no personal history of seizure, so why is he having seizures?' Fattahi said of his 48-year-old patient. I was worried he was maybe exposed to COVID-19 at a party. Unwilling to wait for lab results, Fattahi said he ordered a CT scan, which confirmed his COVID-19 diagnosis. The patient was treated with a battery of antibiotics, anti-seizure medications and hydroxychloroquine and released.

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WATERBURY Brain malfunction is also a feature of many young, obese patients who are rapidly emerging as at high-risk to contract COVID-19, said Dr. Juan Diego Holguin of Alliance Medical Group.

Once they become infected with the virus, it seems to make their neurological effects more pronounced, Holguin said.

He points to the propensity for the obese to have abnormal pressure of the cerebral spinal fluid. He noted those with a body mass index more than 50 who contract the coronavirus also tend to deteriorate more rapidly.

The progression is unusually fast, Holguin said. We dont know why it progresses so quickly.

Because of the rapid deterioration, he recommends that those younger than 60 with a BMI over 40 should be tested as soon as they develop symptoms: You run the risk of progressing too quickly.

A 6-foot male with a BMI of 50 would weigh 370 pounds. A 54 woman with a BMI of 50 would weigh 290 pounds, Holguin said.

They already have restriction of their thorax from the excess weight. They already have problems getting air to their lungs, he said.

A series of new studies have found obesity may be among the most important predictors in severe COVID-19, particularly among young people. A study from NYU Langone study of patients under age 60 found that those with obesity were twice as likely to be hospitalized. was the second-highest reason why patients were hospitalized with COVID-19.

Tracey OShaughnessy

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Not just the lungs: Some COVID-19 patients show signs of neurological ailments - Waterbury Republican American