Neurological Complications during Treatment of Middle East Respiratory Syndrome

Abstract

Background and PurposeMiddle East respiratory syndrome (MERS) has a high mortality rate and pandemic potential. However, the neurological manifestations of MERS have rarely been reported since it first emerged in 2012.MethodsWe evaluated four patients with laboratory-confirmed MERS coronavirus (CoV) infections who showed neurological complications during MERS treatment. These 4 patients were from a cohort of 23 patients who were treated at a single designated hospital during the 2015 outbreak in the Republic of Korea. The clinical presentations, laboratory findings, and prognoses are described.ResultsFour of the 23 admitted MERS patients reported neurological symptoms during or after MERS-CoV treatment. The potential diagnoses in these four cases included Bickerstaff's encephalitis overlapping with Guillain-Barré syndrome, intensive-care-unit-acquired weakness, or other toxic or infectious neuropathies. Neurological complications did not appear concomitantly with respiratory symptoms, instead being delayed by 2–3 weeks.ConclusionsNeuromuscular complications are not rare during MERS treatment, and they may have previously been underdiagnosed. Understanding the neurological manifestations is important in an infectious disease such as MERS, because these symptoms are rarely evaluated thoroughly during treatment, and they may interfere with the prognosis or require treatment modification.

Middle East respiratory syndrome

“…The clinical presentation of patients infected with MERS-CoV ranges from asymptomatic or mild upper respiratory illness to rapidly progressive pneumonitis, respiratory failure, acute respiratory distress syndrome, septic shock, and multiorgan failure with fatal outcome (figure 5). 2,10,11,[61][62][63][64][65][66][67][68][69][70] It is not possible to distinguish patients with a legitimate asymptomatic MERS-CoV infection from those who develop mild disease because reports to WHO provide signs and symptoms information only at the time of reporting. Many individuals remain asymptomatic whereas some go on to develop mild disease, which is why WHO classifies these individuals as mild or asymptomatic.…”

“…The signs and symptoms associated with MERS are non-specific, with or without multisystem involvement, and thus could be mistaken for other causes of respira tory tract or gastrointestinal illnesses. 2,10,11,[61][62][63][64][65][66][67][68][69][70] Therefore, the clinical diagnosis of MERS can be easily missed. Patients with MERS can typically present with fever, chills, rigors, headache, a non-productive cough, sore throat, arthralgia, and myalgia followed by dyspnoea.…”

“…Some patients with MERS can present with atypical symptoms of mild respiratory illness without a fever and a gastrointestinal illness that precedes the develop ment of pneumonia. 64,67,68 Neuromuscular manifestations include hypersomnolence, weakness, and tingling in the extremities similar to Guillain-Barré syndrome or virusrelated sensory neuropathy. 68 Co-infection of MERS-CoV with other respiratory viruses (such as parainfluenza The pathogen: MERS-CoV • Anti-viral therapeutics including host-directed therapies or immune-based therapies are in development.…”

“…Immunocompromised patients or patients with chronic heart, liver, and kidney disease can present with atypical features, such as a longer incubation period, a longer period from initial PCR positivity to symptom onset, persistent prolonged viral shedding, and increased mortality. [64][65][66][67][68][69][70] MERS-CoV causes more severe disease in people older than 60 years, and those with chronic comorbid diseases such as renal disease, cancer, chronic lung disease, immunosuppression, and diabetes.…”

“…75 MERS should be kept on the differential diagnosis list for ill travellers returning home from MERS-CoV endemic areas who present with acute febrile illness (temperature ≥38°C), aches and pains, headache, cough, dyspnoea, diarrhoea, nausea, vomiting, unexplained leucopenia (white blood cell count <3·5 × 110⁹/L), and thrombocytopenia (platelets <150 × 10⁹/L)-either with or without prominent respiratory symptoms. 2,10,11,[61][62][63][64][65][66][67][68][69][70] It is important that clinicians are alert to the possibility that patients could have MERS in all health-care settings where the virus is circulating so that an accurate diagnosis can be made and infection control measures implemented efficiently. 76…”