Small Fiber Neuropathy Associated with SARCoV-2 Infection

Objective: The development and persistence of neurological symptoms following SARS-CoV-2 infection is referred to as “long-haul” syndrome. Here, we aim to study the role of small fiber neuropathy (SFN) underlying neuropathic symptoms associated with COVID-19 infection. Background: Post COVID-19 “long-haul” syndrome include chronic fatigue, brain fog, sleep disturbance and paraesthesias. These symptoms can overlap with those seen in SFN, which have not been investigated given the recent wave of pandemic and patients who developed new onset of symptoms following infection. Design/Methods: Using retrospective study between May 2020 - May 2021, we screened the skin biopsy database of patients who were referred from the Center of Post-COVID Care at the Mount Sinai Hospital. Thirteen patients were identified and undergone routine nerve conduction studies and electromyography which ruled out evidence of a large fiber neuropathy. Patients were then clinically evaluated and consented for skin punch biopsy. All specimens were processed using PGP9.5 immunostaining for evaluating intraepidermal nerve fiber density (IENFD) to confirm SFN. Results: We identified 13 patients, 8 women and 5 men (age 38-67 years) with follow-up duration between 8-12 months. All had negative neuropathy blood profile including HbA1c, ANA, B12, TSH, free T4, and serum immunofixation. Three patients had pre-existing but controlled neuropathy risk factors. None had neurological symptoms prior to the SARS-CoV-2 infection. All patients developed new-onset paresthesias within 2 months following infection, with an acute onset in 7 and co-existing autonomic symptoms in 7. Six patients had biopsyconfirmed SFN, all of whom showed both neuropathy symptoms and signs, with 2 showing autonomic dysfunction. Of the remaining 7 patients with negative skin biopsies, 6 showed no clinical neuropathy signs, and 1 exhibited signs with abnormal autonomic function testing. Conclusions: Our findings support that symptoms of SFN may develop during or shortly after COVID-19 illness. SFN may underlie the paresthesias associated with long-haul post-COVID-19 symptoms.

In hospital outcomes in older adults with COVID-19 and epilepsy

COVID-19 causes high rates of mortality and morbidity in older adults, especially those with pre-existing conditions. Since epilepsy is associated with premature mortality, we aimed to evaluate in-hospital outcomes, including mortality, in older compared (>65) to younger adults (<65) with COVID-19 and epilepsy. We hypothesized that adults >65 years with epilepsy would have higher mortality despite adjustment for comorbidity. This retrospective study in a large multicenter New York health system included consecutive patients with epilepsy admitted with COVID-19 between 3/15/2020-5/17/2021. Epilepsy was identified using a validated ICD-CM based case definition. Outcomes were level of respiratory support, ICU admission, and mortality. Chi-square tests, Fisher's exact tests, Student's t-tests and Mann-Whitney U or Kolmogorov Smirnov tests were conducted as appropriate. Multivariable logistic regression models were generated to examine factors associated with mortality. We identified 173 older and 161 younger adults with epilepsy and COVID-19. Median age of older (>65) compared to younger (<65) adults was 74 vs. 52 (p<.001). A larger proportion of older adults died in hospital (35.8% vs. 23%, p=.01). Older adults were less likely to be discharged to home (21.4% vs. 38.5%, p<.001) and more likely to go to a chronic care facility (19.7% vs. 10.0%, p<.001). Ventilation status (35.8% vs. 39.8%, p=.45) or ICU admission rate (34.7% vs. 44.1%, p=.08) were not significantly different between the age groups. Older adults had higher odds of mortality after adjusting for sex, race, language and Charlson Comorbidity Index (CCI) (OR, 2.04;95% CI, 1.22-3.40, p=0.01). Within the over 65 group, increasing years of age (OR 1.07;95% CI 1.02-1.12, p=0.01), and increasing CCI score (OR 1.16, 95% CI 1.01-1.32, p=0.03) were associated with in-hospital mortality while sex, race, and language were not. Our study found higher in-hospital mortality in older compared to younger adults with epilepsy diagnosed with COVID-19. Consistent with prior work, increasing age and increasing number of comorbid diseases was associated with increased odds of mortality, reinforcing the need to communicate risks of multimorbidity and COVID-19 in older adults with epilepsy.