Mental compromise in SARS-CoV-2 infected patients is multicausal, organic or inorganic

Abstract

With interest, we read the review article by Meier et al. about the neurological and mental health consequences of COVID-19 [1]. It was concluded that future medication for COVID-19 may keep labour force healthy and may be also beneficial for Alzheimer’s disease or other types of dementia [1]. The review is appealing but raises concerns and comments. Mental complications of SARS-CoV-2 infections may either originate from the impact of the infection on the individual or collective psycho-social status causing uncertainty, fear, mood disorder or psychosis, or from neurological disease as a complication of the viral infection. It is well established that SARS-CoV-2 may not only affect the lungs but generally all organs/tissues, including the central nervous system [2]. Central nervous system disease triggered by the virus includes viral or immune encephalitis, myelitis, acute, haemorrhagic, necrotizing encephalitis, diffuse leukoencephalopathy, acute disseminated encephalomyelitis, ischaemic stroke, intracerebral bleeding, subarachnoid bleeding, venous sinus thrombosis, posterior reversible encephalopathy syndrome, cerebral vasculitis, cerebral vasoconstriction syndrome or neuroleptic malignant syndrome [2]. Most of these conditions can go along with psychiatric or mental abnormalities. Not addressed in the review, for example, were viral and immune encephalitis, both having been reported as complications of SARS-CoV-2 infections [3]. Encephalitis may manifest as abnormal behaviour or delirium [3]. Patients with SARS-CoV-2 associated encephalitis may also present with confusion in addition to focal neurological deficits [4]. Single patients with encephalitis and mania have been reported. Such patients may favourably respond to steroids or intravenous immunoglobulins, not only with regard to encephalitis but also with regard to the mental condition. Since mental disease in patients with SARS-CoV-2 infections may have a neurological origin, it is crucial that patients with mental compromise are thoroughly investigated for neurological causes of the psychological compromise. Work-up for neurological disease should not only include a profound individual and family history and a clinical neurologic exam but also imaging of the central nervous system and the vascular supply with contrast medium, EEG, and eventually investigations of the cerebro-spinal fluid. Assuming that SARS-CoV-2 infections are associated with neuronal or glial death, it is recommended that COVID-19 patients undergo appropriate neuropsychological testing on admission and on dismissal from the hospital. An issue not addressed in the review is that the antiCOVID-19 medication may be neurotoxic and may be responsible for long-term mental impairment in patients experiencing a SARS-CoV-2 infection. Particularly, from chloroquine it is known that it can cause severe psychiatric disease and some patients may even commit suicide [5]. In a single patient with COVID-19 the loading dose of favipiravir triggered an acute psychosis [6]. In a study on the side effects of tocilizumab given prior to haematopoetic stem cell transplantation, the prevalence of depression was significantly increased compared to controls [7].