Hisham M. Valiuddin, DO; Almir Kalajdzic, DO; James Rosati, DO; Kevin Boehm, DO; Dominique Hill, MD


Western J Emerg Med. 2020;21(6):45-51. 

In This Article

Abstract and Introduction


Severe acute respiratory syndrome coronavirus 2, the source of COVID-19, causes numerous clinical findings including respiratory and gastrointestinal findings. Evidence is now growing for increasing neurological symptoms. This is thought to be from direct in-situ effects in the olfactory bulb caused by the virus. Angiotensin-converting enzyme 2 receptors likely serve as a key receptor for cell entry for most coronaviridae as they are present in multiple organ tissues in the body, notably neurons, and in type 2 alveolar cells in the lung. Hematogenous spread to the nervous system has been described, with viral transmission along neuronal synapses in a retrograde fashion. The penetration of the virus to the central nervous system (CNS) allows for the resulting intracranial cytokine storm, which can result in a myriad of CNS complications. There have been reported cases of associated cerebrovascular accidents with large vessel occlusions, cerebral venous sinus thrombosis, posterior reversible encephalopathy syndrome, meningoencephalitis, acute necrotizing encephalopathy, epilepsy, and myasthenia gravis. Peripheral nervous system effects such as hyposmia, hypogeusia, ophthalmoparesis, Guillain-Barré syndrome, and motor peripheral neuropathy have also been reported. In this review, we update the clinical manifestations of COVID-19 concentrating on the neurological associations that have been described, including broad ranges in both central and peripheral nervous systems.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the source of coronavirus disease 2019 (COVID-19), causes numerous clinical findings including well described respiratory and gastrointestinal findings. While literature on SARS-CoV-2 association with neurological findings was initially sparse, evidence is now rapidly growing for this potentially devastating link. Vigilance is important to recognize all possible sequelae of COVID-19; additionally, early detection and recognition is a mainstay of medicine across any disease.

During the initial outbreak in Wuhan, China, a wide range of clinical presentations was found beyond the typical respiratory symptoms, with close to 50% of patients having gastrointestinal (GI) symptoms, and 7% of patients having no respiratory symptoms.[1] While the US Centers for Disease Control and Prevention (CDC) definition of persons under investigation for COVID-19 has evolved, it generally includes the presence of fever and signs and symptoms of respiratory illness. While this may encompass a large number of cases, it also leaves a big gap in untested patients with minimal to no respiratory symptoms including those with only GI or neurologic symptoms. Earliest reports from Wuhan found that over 36% of patients had some degree of nervous system involvement, the most common being dysfunction of the central nervous system (CNS) with close to 15% of patients having complaints of dizziness or headache.[2] In this article we provide a review of central and peripheral nervous system (PNS) involvement of SARS-CoV-2 (Table 1).