Encephalopathy at admission predicts adverse outcomes in patients with SARS-CoV-2 infection.

Lei Tang,Michael Reznik,Raymond Y Huang,Yanhe Xiao,Li Yang,Renyu Liu,Kasey Halsey,Tao Liu,Scott E Kasner,David Kung,Ji Whae Choi,Michael D Feldman,Shixin Liu,Paul J Zhang,Harrison X Bai,Bo Xiao,Jing Wu,Jerrold L Boxerman ,Thi Thanh Van Tran ,Wei Liao ,Daniel D Danoski ,Sohil H Patel

doi:10.1111/cns.13687

Abstract

AimsTo determine if neurologic symptoms at admission can predict adverse outcomes in patients with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2).MethodsElectronic medical records of 1053 consecutively hospitalized patients with laboratory‐confirmed infection of SARS‐CoV‐2 from one large medical center in the USA were retrospectively analyzed. Univariable and multivariable Cox regression analyses were performed with the calculation of areas under the curve (AUC) and concordance index (C‐index). Patients were stratified into subgroups based on the presence of encephalopathy and its severity using survival statistics. In sensitivity analyses, patients with mild/moderate and severe encephalopathy (defined as coma) were separately considered.ResultsOf 1053 patients (mean age 52.4 years, 48.0% men [n = 505]), 35.1% (n = 370) had neurologic manifestations at admission, including 10.3% (n = 108) with encephalopathy. Encephalopathy was an independent predictor for death (hazard ratio [HR] 2.617, 95% confidence interval [CI] 1.481–4.625) in multivariable Cox regression. The addition of encephalopathy to multivariable models comprising other predictors for adverse outcomes increased AUCs (mortality: 0.84–0.86, ventilation/ intensive care unit [ICU]: 0.76–0.78) and C‐index (mortality: 0.78 to 0.81, ventilation/ICU: 0.85–0.86). In sensitivity analyses, risk stratification survival curves for mortality and ventilation/ICU based on severe encephalopathy (n = 15) versus mild/moderate encephalopathy (n = 93) versus no encephalopathy (n = 945) at admission were discriminative (p < 0.001).ConclusionsEncephalopathy at admission predicts later progression to death in SARS‐CoV‐2 infection, which may have important implications for risk stratification in clinical practice.

Highlights

The outbreak of coronavirus disease 2019 (COVID-19), caused by novel severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), has been a serious threat to public health
Encephalopathy was an independent predictor for death in multivariable Cox regression
Due to the high risk of developing critical illness and adverse outcomes and the intensive demands placed on medical resources as the number of severe cases increases, it is critical to identify patients with COVID-19 who may be more susceptible to advanced disease progression at an early stage, preferably at the time of hospital admission

Summary

Introduction

The outbreak of coronavirus disease 2019 (COVID-19), caused by novel severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), has been a serious threat to public health. Recent studies have shown that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has a myriad of neurological manifestations.2–9 Several studies described a high prevalence of serious neurologic manifestations in patients with severe COVID-19, which suggests that the nervous system may become more involved as the disease progresses. 5,9–12 Despite the continuously increasing reports of the neurological symptoms of SARS-CoV-2, our knowledge about the possible association between early neurologic manifestations and subsequent deterioration leading to intensive care unit (ICU) admission, mechanical ventilation, and death remains unknown. We will aim to determine the accuracy of early neurologic manifestations in predicting subsequent adverse outcomes in COVID-19 patients and discuss possible routes of SARS-CoV-2 nervous system involvement based on the current evidence

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