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Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China

Educational Objective
To understand the neurological manifestations of hospitalized patients infected with COVID-19
1 Credit CME
Key Points

Question  What are neurologic manifestations of patients with coronavirus disease 2019?

Findings  In a case series of 214 patients with coronavirus disease 2019, neurologic symptoms were seen in 36.4% of patients and were more common in patients with severe infection (45.5%) according to their respiratory status, which included acute cerebrovascular events, impaired consciousness, and muscle injury.

Meaning  Neurologic symptoms manifest in a notable proportion of patients with coronavirus disease 2019.


Importance  The outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, is serious and has the potential to become an epidemic worldwide. Several studies have described typical clinical manifestations including fever, cough, diarrhea, and fatigue. However, to our knowledge, it has not been reported that patients with COVID-19 had any neurologic manifestations.

Objective  To study the neurologic manifestations of patients with COVID-19.

Design, Setting, and Participants  This is a retrospective, observational case series. Data were collected from January 16, 2020, to February 19, 2020, at 3 designated special care centers for COVID-19 (Main District, West Branch, and Tumor Center) of the Union Hospital of Huazhong University of Science and Technology in Wuhan, China. The study included 214 consecutive hospitalized patients with laboratory-confirmed diagnosis of severe acute respiratory syndrome coronavirus 2 infection.

Main Outcomes and Measures  Clinical data were extracted from electronic medical records, and data of all neurologic symptoms were checked by 2 trained neurologists. Neurologic manifestations fell into 3 categories: central nervous system manifestations (dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system manifestations (taste impairment, smell impairment, vision impairment, and nerve pain), and skeletal muscular injury manifestations.

Results  Of 214 patients (mean [SD] age, 52.7 [15.5] years; 87 men [40.7%]) with COVID-19, 126 patients (58.9%) had nonsevere infection and 88 patients (41.1%) had severe infection according to their respiratory status. Overall, 78 patients (36.4%) had neurologic manifestations. Compared with patients with nonsevere infection, patients with severe infection were older, had more underlying disorders, especially hypertension, and showed fewer typical symptoms of COVID-19, such as fever and cough. Patients with more severe infection had neurologic manifestations, such as acute cerebrovascular diseases (5 [5.7%] vs 1 [0.8%]), impaired consciousness (13 [14.8%] vs 3 [2.4%]), and skeletal muscle injury (17 [19.3%] vs 6 [4.8%]).

Conclusions and Relevance  Patients with COVID-19 commonly have neurologic manifestations. During the epidemic period of COVID-19, when seeing patients with neurologic manifestations, clinicians should suspect severe acute respiratory syndrome coronavirus 2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.

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Article Information

Corresponding Authors: Bo Hu, MD, PhD (hubo@mail.hust.edu.cn) and Yanan Li, MD, PhD (liyn@mail.hust.edu.cn), Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.

Accepted for Publication: March 26, 2020.

Published Online: April 10, 2020. doi:10.1001/jamaneurol.2020.1127

Author Contributions: Dr B. Hu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Mao, Jin, M. Wang, Y. Hu, Chen, He, and Chang contributed equally and share first authorship.

Concept and design: Mao, Jin, Y. Hu, He, Miao, B. Hu.

Acquisition, analysis, or interpretation of data: Mao, Jin, M. Wang, Chen, Chang, Hong, Zhou, D. Wang, Li.

Drafting of the manuscript: Mao, Jin, M. Wang, Chen, Chang, Zhou, D. Wang, B. Hu.

Critical revision of the manuscript for important intellectual content: Y. Hu, He, Hong, D. Wang, Miao, Li, B. Hu.

Statistical analysis: Chang.

Obtained funding: Mao, B. Hu.

Administrative, technical, or material support: Mao, Jin, M. Wang, Chen, He, Zhou, D. Wang, Miao, Li, B. Hu.

Supervision: Y. Hu, B. Hu.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by the National Key Research and Development Program of China (2018YFC1312200 to Dr B. Hu), the National Natural Science Foundation of China (81820108010 to Dr B. Hu, No.81974182 to Dr Mao and 81671147 to Dr Jin) and Major Refractory Diseases Pilot Project of Clinical Collaboration with Chinese and Western Medicine (SATCM-20180339).

Role of the Funder/Sponsor: The funding sourceshad no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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