ABSTRACT
Introduction: Since the coronavirus disease 2019 (COVID-19) emerged in Wuhan, neurological complications affecting both the central and peripheral nervous systems have been reported. Multiple etiological mechanisms as immuno-mediation, direct nerve infection, prolonged intensive care units (ICU) hospitalization and prolonged positioning have been proposed as a cause of peripheral lesion. The aim of this study is to report an observational description of peripheral nervous system complications in patients with severe COVID-19. Method(s): We include patients with COVID-19 infections with weakness or sensory deficit, with one or more EMG tests carried out between April 2020 and December 2021. Standard neurophysiological techniques with motor and sensory nerve conductions, F responses and needle EMG exam in representative upper and lower limb muscles were performed. Result(s): A total of 89 patients were included, 66 males (74%) and 23 females (26%), with an average age of 55.7 years old (range from 11 to 90). Most of them (74%) were studied during hospitalization (16 of them during ICU admission). Nearly all patients (90%) had a prolonged ICU hospitalization (between 8 and 120 days). The reason for consultation was diffuse or focal weakness, difficulty in weaning, facial palsy or sensory deficits. The results of EMG tests showed myopathic findings in 61% of patients, focal peripheral nerve lesions in 64%, Guillain-Barre syndrome (GBS) in 5 (6%), and other types of peripheral polyneuropathy in 24%. From peripheral nerve injuries, peroneal neuropathy was the most frequent (58%), brachial plexopathy was found in 26%, median neuropathy in 25%, ulnar in 11%, lateral femoral cutaneous in 9%, axillary and spinal in 5%, radial and hypoglossal in 4% and musculocutaneous in 2%. Tapia's syndrome was diagnosed in two patients. Peripheral nerve injuries correlated with longer admissions in ICU and prone positioning. The follow-up studies showed a good recovery from myopathy but persistent motor sequelae in axonal GBS patients and in most peroneal nerve injuries. Neurophysiological findings are described. Conclusion(s): Peripheral nerve complications are frequent in patients affected by severe COVID-19 and prolonged hospitalization, mainly focal nerve injuries (61%), critical illness myopathy (64%) and peripheral polyneuropathy (30%) including GBS (5 patients). Prone and prolonged positioning in ICU may be associated with peripheral nerve injuries although other mechanisms cannot be excluded. Copyright © 2022
ABSTRACT
INTRODUCTION: Weakness is a frequent complication in those critically ill due to COVID-19. This study describes its characteristics and the factors that can condition and predict it. PATIENTS AND METHODS: We conducted a prospective, descriptive, observational study of patients admitted to the intensive care unit (ICU) due to COVID-19 between April and May 2020 with muscle weakness. A motor balance equal to or lower than 3/5 according to the modified Medical Research Council muscle strength scale was considered to be severe clinical impairment. Altogether 25 analytical studies, 16 neurophysiological studies and one muscle biopsy were performed, with a telephone follow-up at one month, a comparative analysis between the groups with and without severe compromise, and determination of cut-off points for analytical parameters to predict severe involvement using ROC curves. RESULTS: The sample consisted of 25 patients with a mean age of 58 years (standard deviation ± 9). The median length of stay in the ICU was 27.5 days. All the electromyograms exhibited a myogenic pattern and 75% also showed neuropathy. The group with severe clinical involvement had higher levels of D-dimer (p = 0.08), lactate dehydrogenase (p = 0.03) and interleukin-6 (p = 0.10), and the combination of the alteration of any two of these three parameters predicted severe involvement with a sensitivity of 100% and a specificity of 76.9%. At one month of follow-up, 36% were unable to walk autonomously and 92% continued with muscle weakness. CONCLUSIONS: Weakness in severe COVID-19 patients has a major clinical impact. Its early detection and study by means of predictors of its development may allow for better management. The absence in some cases of classical risk factors for ICU-acquired weakness suggests a different pathophysiology.
TITLE: Debilidad como complicación del paciente crítico por COVID-19: características clínicas y factores pronósticos en una serie de casos.Introducción. La debilidad es una complicación frecuente en el enfermo crítico por COVID-19. Se describen sus características, y los factores que pueden condicionarla y predecirla. Pacientes y métodos. Estudio observacional descriptivo prospectivo con pacientes ingresados en la unidad de cuidados intensivos (UCI) por COVID-19 entre abril y mayo de 2020 con debilidad muscular. Se consideró una afectación clínica grave un equilibrio motor igual o inferior a 3/5 según la escala de fuerza muscular modificada del Medical Research Council. Se han realizado 25 estudios analíticos, 16 estudios neurofisiológicos y una biopsia muscular; seguimiento telefónico al mes; análisis comparativo entre los grupos con y sin afectación grave, y determinación de puntos de corte de parámetros analíticos para predecir afectación grave mediante curvas ROC. Resultados. Se incluyó a 25 pacientes con 58 años (desviación estándar ± 9) de edad media. La mediana de estancia en la UCI fue de 27,5 días. Todos los electromiogramas mostraban un patrón miógeno y el 75%, también una neuropatía. El grupo con afectación clínica grave tenía mayores niveles de dímero-D (p = 0,08), lactato deshidrogenasa (p = 0,03) e interleucina 6 (p = 0,10), y la combinación de la alteración de dos cualquiera de estos tres parámetros pronosticaba la afectación grave con una sensibilidad del 100% y una especificidad del 76,9%. Al mes de seguimiento, el 36% no podía deambular autónomamente y el 92% seguía con debilidad muscular. Conclusiones. La debilidad en el enfermo por COVID-19 grave tiene una repercusión clínica importante. Su detección y estudio precoces mediante predictores de su desarrollo pueden permitir un mejor manejo. La ausencia en algunos casos de los factores de riesgo clásicos para la debilidad adquirida en la UCI sugiere una fisiopatología diferente.