Selected Podcast
COVID-19: Neurological Impact and Considerations
Igor Koralnik, MD, FAAN, FANA, chief of Neuroinfectious Diseases and Global Neurology and professor of Neurology at Northwestern Medicine, discusses the neurological manifestations of patients with COVID-19, the risks for those with neurological diseases that impair the respiratory system such as amyotrophic lateral sclerosis (ALS), myasthenia gravis, multiple sclerosis (MS) and Parkinson’s disease, and how Northwestern Medicine is evolving care during this pandemic.
Featured Speaker:
Igor Koralnik, MD, FAAN, FANA
Northwestern Medicine is proud to welcome Igor Koralnik MD, FAAN, FANA, as the chief of the new Division of Neuroinfectious Disease and Global Neurology within the Department of Neurology. Koralnik is an internationally recognized expert in the management of neurological complications of human immunodeficiency virus (HIV) and infections affecting the nervous system. He is a leading researcher in the investigation of polyomavirus JC (JC virus), the causative agent of progressive multifocal leukoencephalopathy (PML).Koralnik also created a global neurology research program in Lusaka, Zambia, where he and his colleagues are studying opportunistic nervous system infections, tuberculous meningitis and new onset seizures in patients with HIV. He previously served as chief of the Section of Neuroinfectious Diseases at Rush University Medical Center and chief of the Neuroimmunology Division at Beth Israel Medical Center at Harvard Medical School. Transcription:
COVID-19: Neurological Impact and Considerations
Melanie Cole (Host): This is the Northwestern Medicine Podcast on COVID-19 dated March 24, 2020.
Welcome. This is Better Edge, a Northwestern Medicine podcast for physicians. I’m Melanie Cole. And joining me today, is Dr. Igor Koralnik. He’s the Chief of Neuro Infectious Diseases and Global Neurology and a Professor of Neurology at Northwestern Medicine. Today, we’re talking about COVID-19, the risks for those with neurological diseases and how Northwestern Medicine is evolving to treat patients during this pandemic. Dr. Koralnik, thank you so much for joining us. What are the risks for those with neuroinfectious diseases or neurological conditions? We know COVID-19 is not a CNS pathogen, but it’s focused on the respiratory tract. So, can we assume that patients with ALS, MS or perhaps Parkinson’s are at greater risk because these neurologic diseases essentially reduce the capacity of the lung?
Igor Koralnik, MD, FAAN, FANA (Guest): First let me emphasize that COVID-19 is a very huge concern for everyone whether or not you have a neurological condition. So, what we know about the Novel Coronavirus is that it’s very infectious, can be transmitted by people who are still asymptomatic, or have minor symptoms, it targets the receptor called angiotensin converting enzyme 2 or ACE-2 which is present on alveolar lung cells with many other cells in the body. So, the body reacts with an immune response that aims to contain the infection, but it seems to be dysregulated in people who have severe disease. We can see an increase in cells called neutrophils with a decrease in lymphocytes especially CD4 positive T-lymphocytes which are the cells that orchestrates this immune response.
That means that you have people who remain asymptomatic or have minor symptoms especially children and are likely the ones whose immune system is able to contain the virus. And on the other hand, you have people whose immune system fails to contain the virus and have severe lung infection and inflammation and need to be admitted to the ICU.
So, any patient with preexisting conditions affecting their ability to breathe like patients with ALS, certain patients with myasthenia, also patients with a variety of spinal cord disease maybe at higher risk of complications with the COVID-19 disease. Especially if they are older and they have other cardiac or pulmonary comorbidities for example.
Now there is some emerging data regarding how the Coronavirus may affect the nervous system. Some publications coming out of China which are in the process of being published suggest that up to one third of patients may develop some altered mental status, headache, nausea, vomiting, even cerebral vascular events and muscle problems. From what we know from the previous Coronavirus epidemic with SARS in 2003, this virus was found in the brain in some patients and in experimental animals that were inoculated with the virus in the nasopharynx. The virus could be also found in the brain, including the brain stem. So, there may be a potential infection in the brain stem that may affect respiratory centers that are there in some patients. We don’t know if it’s going to be the case for neurological patients to date, but this is something we need to be aware of.
Host: Wow. That’s a very comprehensive answer. Thank you so much Dr. Koralnik. These are unprecedented times for medical care across the board. But for patients who can’t necessarily postpone care, this can be an especially difficult time to navigate. Can you tell us how you and your team are adjusting to the circumstances evolving and continue to deliver quality care to these patients?
Dr. Koralnik: This is an excellent question. And at Northwestern like most places in the US, we have switched to Tele-visits on the phone or on the web for certain patients. And those patients we connect with on the phone or through webcam and we conduct neurological consultations this way. I think patients really appreciate that because first they don’t have to come to the hospital and put themselves at risk and we can still deliver quality care for those patients, especially the patients that we know already, that have come for initial visit prior to the epidemic in the hospital and we know what the issues are.
Of course there are some new patients that we still need to be seen in the hospital if they present with acute symptoms of strokes or altered mental status for example with the family of those patients and those patient should first talk with their primary care physician to determine what is the best course of action whether they need to go straight to the emergency room for example or if we need to arrange an outpatient Tele-visit or a real visit with a neurologist.
Host: Dr. Koralnik, when people with neurological conditions are showing symptoms, or are diagnosed; when are you recommending admission to the hospital and when you answer this, you’re probably fielding a lot of questions from patients as well; and so what are some of those common questions that you are being asked and what advice are you giving?
Dr. Koralnik: So, this is an excellent question. Everybody is concerned about this. And the guidelines are evolving daily. So, it obviously depends on the baseline condition of the patient, whether they are symptomatic or not, their situation at home, can they be taken care of at home and follow the guidelines of the Centers for Disease Control that are obviously always evolving. The questions that we field from the patient is that obviously everyone is concerned. We have to remind them about the importance of social distancing, washing hands, staying at home, sheltering in place depending where they live, but what is also very important is that they keep taking their medications.
Host: Well that is so important. You’re an internationally recognized expert Dr. Koralnik in the management of neurological complications of HIV. This is so interesting. What lessons from the AIDS global epidemic can be applied during this pandemic from your perspective?
Dr. Koralnik: It brings me back to the mid-80s when I was a medical student in Geneva Switzerland, and we were seeing the first patient with AIDS coming to the hospital. These were really uncertain times especially at the beginning since we didn’t know what was causing AIDS and people were extremely concerned about the risk of infection. Soon after the HIV virus was identified, it was understood that certain ways of communication of the virus via intravenous route or sexual contact were the ways people were getting infection. So the general population was not at risk of getting the virus.
For Coronavirus, it’s different since everybody potentially is at risk although we know that some people will have no symptoms and or a benign disease and some other people will be severely affected.
Host: As Chief of the Division of Global Neurology at Northwestern Medicine, your mission is to bring clinical expertise to underserved populations around the world. How do you think a lack of clinical experts in certain countries may have contributed to the spread of COVID-19 or how will underserved populations deal with this spread?
Dr. Koralnik: So, I’m very concerned for countries that are in restricted or limited settings for example, some countries in Sub Saharan Africa where it’s more difficult to diagnose patients with the Coronavirus, to track them, to isolate people and especially to treat them. Since those areas seem to have been less affected by the initial wave of COVID-19, I hope that the local governments there are taking appropriate measures to be ready when this happens because unfortunately, I think this is going to happen even in remote settings and nobody will be immune to that.
Host: Do you think the United States will effectively be able to flatten the curve Doctor?
Dr. Koralnik: We are doing everything we can at this point to diagnose people. The tests are becoming more widely available. That causes an uptick in the number of cases in the US obviously which is always concerning but now we know more who they are. Those people should be properly isolated or quarantined or treated and everybody in the US population is aware about the risk and I think that by following the guidelines from local governments, the Centers for Disease Control, staying at home, social distancing; we hope that these measures will be efficient in allowing us to flatten the curve.
Host: As we wrap up and this is such great quality information Dr. Koralnik. As we wrap up, put this into perspective for us and neurologists and other providers know what you’d like them to know about COVID-19 and neurologic diseases, social distancing, self-quarantine. Help them to calm the nerves of their patients that are worried at this time.
Dr. Koralnik: So, I think it’s very important for every physician and neurologist to be there for your patients, on the phone, on the web, sometimes in person. There is high anxiety in everyone. And this anxiety may worsen symptoms that people may have with their baseline disease. You have to remind your patients that they need to keep taking their medications, and obviously, follow the recommended social distancing, sheltering in place, listen to the evolving recommendations of the CDC. But I think what’s more important to realize that we are all in it together and somehow the distance the virus has put between us is bringing us closer because we are really in the same boat at this point and the most important thing is that we will get through this together.
Host: So important. Dr. Koralnik, thank you for coming on and sharing your incredible expertise with us today. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on COVID-19, please visit our website at www.nm.org to get connected with one of our providers. I’m Melanie Cole.
COVID-19: Neurological Impact and Considerations
Melanie Cole (Host): This is the Northwestern Medicine Podcast on COVID-19 dated March 24, 2020.
Welcome. This is Better Edge, a Northwestern Medicine podcast for physicians. I’m Melanie Cole. And joining me today, is Dr. Igor Koralnik. He’s the Chief of Neuro Infectious Diseases and Global Neurology and a Professor of Neurology at Northwestern Medicine. Today, we’re talking about COVID-19, the risks for those with neurological diseases and how Northwestern Medicine is evolving to treat patients during this pandemic. Dr. Koralnik, thank you so much for joining us. What are the risks for those with neuroinfectious diseases or neurological conditions? We know COVID-19 is not a CNS pathogen, but it’s focused on the respiratory tract. So, can we assume that patients with ALS, MS or perhaps Parkinson’s are at greater risk because these neurologic diseases essentially reduce the capacity of the lung?
Igor Koralnik, MD, FAAN, FANA (Guest): First let me emphasize that COVID-19 is a very huge concern for everyone whether or not you have a neurological condition. So, what we know about the Novel Coronavirus is that it’s very infectious, can be transmitted by people who are still asymptomatic, or have minor symptoms, it targets the receptor called angiotensin converting enzyme 2 or ACE-2 which is present on alveolar lung cells with many other cells in the body. So, the body reacts with an immune response that aims to contain the infection, but it seems to be dysregulated in people who have severe disease. We can see an increase in cells called neutrophils with a decrease in lymphocytes especially CD4 positive T-lymphocytes which are the cells that orchestrates this immune response.
That means that you have people who remain asymptomatic or have minor symptoms especially children and are likely the ones whose immune system is able to contain the virus. And on the other hand, you have people whose immune system fails to contain the virus and have severe lung infection and inflammation and need to be admitted to the ICU.
So, any patient with preexisting conditions affecting their ability to breathe like patients with ALS, certain patients with myasthenia, also patients with a variety of spinal cord disease maybe at higher risk of complications with the COVID-19 disease. Especially if they are older and they have other cardiac or pulmonary comorbidities for example.
Now there is some emerging data regarding how the Coronavirus may affect the nervous system. Some publications coming out of China which are in the process of being published suggest that up to one third of patients may develop some altered mental status, headache, nausea, vomiting, even cerebral vascular events and muscle problems. From what we know from the previous Coronavirus epidemic with SARS in 2003, this virus was found in the brain in some patients and in experimental animals that were inoculated with the virus in the nasopharynx. The virus could be also found in the brain, including the brain stem. So, there may be a potential infection in the brain stem that may affect respiratory centers that are there in some patients. We don’t know if it’s going to be the case for neurological patients to date, but this is something we need to be aware of.
Host: Wow. That’s a very comprehensive answer. Thank you so much Dr. Koralnik. These are unprecedented times for medical care across the board. But for patients who can’t necessarily postpone care, this can be an especially difficult time to navigate. Can you tell us how you and your team are adjusting to the circumstances evolving and continue to deliver quality care to these patients?
Dr. Koralnik: This is an excellent question. And at Northwestern like most places in the US, we have switched to Tele-visits on the phone or on the web for certain patients. And those patients we connect with on the phone or through webcam and we conduct neurological consultations this way. I think patients really appreciate that because first they don’t have to come to the hospital and put themselves at risk and we can still deliver quality care for those patients, especially the patients that we know already, that have come for initial visit prior to the epidemic in the hospital and we know what the issues are.
Of course there are some new patients that we still need to be seen in the hospital if they present with acute symptoms of strokes or altered mental status for example with the family of those patients and those patient should first talk with their primary care physician to determine what is the best course of action whether they need to go straight to the emergency room for example or if we need to arrange an outpatient Tele-visit or a real visit with a neurologist.
Host: Dr. Koralnik, when people with neurological conditions are showing symptoms, or are diagnosed; when are you recommending admission to the hospital and when you answer this, you’re probably fielding a lot of questions from patients as well; and so what are some of those common questions that you are being asked and what advice are you giving?
Dr. Koralnik: So, this is an excellent question. Everybody is concerned about this. And the guidelines are evolving daily. So, it obviously depends on the baseline condition of the patient, whether they are symptomatic or not, their situation at home, can they be taken care of at home and follow the guidelines of the Centers for Disease Control that are obviously always evolving. The questions that we field from the patient is that obviously everyone is concerned. We have to remind them about the importance of social distancing, washing hands, staying at home, sheltering in place depending where they live, but what is also very important is that they keep taking their medications.
Host: Well that is so important. You’re an internationally recognized expert Dr. Koralnik in the management of neurological complications of HIV. This is so interesting. What lessons from the AIDS global epidemic can be applied during this pandemic from your perspective?
Dr. Koralnik: It brings me back to the mid-80s when I was a medical student in Geneva Switzerland, and we were seeing the first patient with AIDS coming to the hospital. These were really uncertain times especially at the beginning since we didn’t know what was causing AIDS and people were extremely concerned about the risk of infection. Soon after the HIV virus was identified, it was understood that certain ways of communication of the virus via intravenous route or sexual contact were the ways people were getting infection. So the general population was not at risk of getting the virus.
For Coronavirus, it’s different since everybody potentially is at risk although we know that some people will have no symptoms and or a benign disease and some other people will be severely affected.
Host: As Chief of the Division of Global Neurology at Northwestern Medicine, your mission is to bring clinical expertise to underserved populations around the world. How do you think a lack of clinical experts in certain countries may have contributed to the spread of COVID-19 or how will underserved populations deal with this spread?
Dr. Koralnik: So, I’m very concerned for countries that are in restricted or limited settings for example, some countries in Sub Saharan Africa where it’s more difficult to diagnose patients with the Coronavirus, to track them, to isolate people and especially to treat them. Since those areas seem to have been less affected by the initial wave of COVID-19, I hope that the local governments there are taking appropriate measures to be ready when this happens because unfortunately, I think this is going to happen even in remote settings and nobody will be immune to that.
Host: Do you think the United States will effectively be able to flatten the curve Doctor?
Dr. Koralnik: We are doing everything we can at this point to diagnose people. The tests are becoming more widely available. That causes an uptick in the number of cases in the US obviously which is always concerning but now we know more who they are. Those people should be properly isolated or quarantined or treated and everybody in the US population is aware about the risk and I think that by following the guidelines from local governments, the Centers for Disease Control, staying at home, social distancing; we hope that these measures will be efficient in allowing us to flatten the curve.
Host: As we wrap up and this is such great quality information Dr. Koralnik. As we wrap up, put this into perspective for us and neurologists and other providers know what you’d like them to know about COVID-19 and neurologic diseases, social distancing, self-quarantine. Help them to calm the nerves of their patients that are worried at this time.
Dr. Koralnik: So, I think it’s very important for every physician and neurologist to be there for your patients, on the phone, on the web, sometimes in person. There is high anxiety in everyone. And this anxiety may worsen symptoms that people may have with their baseline disease. You have to remind your patients that they need to keep taking their medications, and obviously, follow the recommended social distancing, sheltering in place, listen to the evolving recommendations of the CDC. But I think what’s more important to realize that we are all in it together and somehow the distance the virus has put between us is bringing us closer because we are really in the same boat at this point and the most important thing is that we will get through this together.
Host: So important. Dr. Koralnik, thank you for coming on and sharing your incredible expertise with us today. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on COVID-19, please visit our website at www.nm.org to get connected with one of our providers. I’m Melanie Cole.