Abstract
SARS-CoV-2 affects mainly the lungs, however, other manifestations, including neurological manifestations, have also been described during the disease. Some of the neurological findings have involved intracerebral or subarachnoid hemorrhage, strokes, and other thrombotic/hemorrhagic conditions. Nevertheless, the gross pathology of hemorrhagic lesions in the central nervous system has not been previously described in Brazilian autopsy cases. This study aimed to describe gross and microscopic central nervous system (CNS) pathology findings from the autopsies and correlate them with the clinical and laboratory characteristics of forty-five patients with COVID-19 from Manaus, Amazonas, Brazil. Forty-four patients were autopsied of which thirty-eight of these (86.36%) were positive by RT-PCR for COVID-19, and six (13.3%) were positive by the serological rapid test. Clinical and radiological findings were compatible with the infection. The patients were classified in two groups: presence (those who had hemorrhagic and/or thrombotic manifestations in the CNS) and absence (those who did not present hemorrhagic and/or thrombotic manifestations in the CNS). For risk assessment, relative risk and respective confidence intervals were estimated. Macroscopic or microscopic hemorrhages were found in twenty-three cases (52,27%). The postmortem gross examination of the brain revealed a broad spectrum of hemorrhages, from spots to large and confluent areas and, under microscopy, we observed mainly perivascular discharge. The association analyses showed that the use of corticosteroid, anticoagulant and antibiotic had no statistical significance with a risk of nervous system hemorrhagic manifestations. However, it is possible to infer a statistical tendency that indicates that individuals with diabetes had a higher risk for the same outcome (RR = 1.320, 95% CI = 0.7375 to 2.416, p = 0.3743), which was not observed in relation to other comorbidities. It is unknown whether the new variants of the virus can cause different clinical manifestations, such as those observed or indeed others. As a result, more studies are necessary to define clinical and radiologic monitoring protocols and strategic interventions for patients at risk of adverse and fatal events, such as the extensive hemorrhaging described here. It is imperative that clinicians must be aware of comorbidities and the drugs used to treat patients with COVID-19 to prevent CNS hemorrhagic and thrombotic events.
Highlights
The coronavirus disease (COVID-19) is caused by a new type of beta coronavirus that is a positive-sense single-stranded RNA virus, and belongs to the Coronaviridae family
Among the patients in the group with hemorrhagic and/or thrombotic lesions in the central nervous system (CNS) (HTM; hemorrhagic and thrombotic manifestations), most of the cases were hospitalized for 10 days before death
Neurological manifestations of COVID-19 have been described, none of these were observed at the time of hospital admission
Summary
The coronavirus disease (COVID-19) is caused by a new type of beta coronavirus that is a positive-sense single-stranded RNA virus, and belongs to the Coronaviridae family. This virus has a genome similar to the viruses of the severe acute respiratory syndrome (SARS-CoV-1) and the Middle East respiratory syndrome (MERS-CoV), both categorized as severe respiratory syndromes [1,2]. In the first published cohort of cases with neurological manifestations, of 214 patients examined, 78 (36.4%) had neurologic manifestations. The authors reported that patients with severe infection were more likely to develop acute cerebrovascular disease, impaired consciousness, and skeletal muscle injury [7]. Other published cases reported meningitis/ encephalitis, stroke, cerebral venous sinus thrombosis, and acute hemorrhagic necrotizing encephalopathy [8,9,10,11]
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