Keywords:
COVID-19 - Cognitive Dysfunction - Post-COVID Syndrome - Fatigue
Palavras-chave:
COVID-19 - Disfunção Cognitiva - Síndrome Pós-COVID - Fadiga
I am a 46-year-old neurologist working as an assistant professor of neurology at a
tertiary hospital in Brazil. In March 2020, I designed the NeuroCovid study at the
University of Campinas, combining MRI analyses, neuropsychological and clinical evaluation
and immunological analyses. I chose this multimodal approach because I was involved
in epilepsy research and neuroimaging (neuroimmunology of multiple sclerosis was the
focus of my undergraduate research project for five years) before the pandemic. We
started evaluating post-COVID volunteers in July 2020, and I became infected in August
2020. It was a mild infection without fever, dysgeusia, anosmia or respiratory symptoms.
I presented headache (worsened migraine), severe abdominal pain, sleepiness, diarrhea,
vomiting and hiccups; it was winter, and I felt unusually cold in Campinas, Brazil
(I have experienced -45 Celsius during winter in Canada). These symptoms terminated
within ten days (except the headache), and I truly believed it was over. I was happy
to be back at the hospital to continue to evaluate the post-COVID subjects.
Approximately 3-4 weeks after the acute stage, I knew my migraine had worsened, and
I could not tolerate the atenolol (50 mg) that I had been using as a prophylactic
for migraine and hypertension treatment. This intolerance was mainly during swimming
practice. At the same time, I noticed excessive somnolence during the day, associated
with an increase of 1.5-2.0 hours of night sleep. It felt awkward because I had always
been an energetic person who usually had 6-7 hours of sleep. Now I needed 8-9 hours
of rest, yet I was also experiencing daytime somnolence. I realized that I was having
difficulties writing a grant proposal and performing more complex statistical analyses.
I tried modafinil because I had daytime somnolence; it improved the somnolence but
not my cognitive performance.
At that moment, I realized that I had some cognitive dysfunction impairing my academic
tasks. There were no difficulties with daily tasks or patient care, except the fatigue
and somnolence. I knew my difficulties were mainly in relation to more complex tasks
(sophisticated statistical models and writing papers). I missed deadlines; I could
not write papers as fast as before. I also missed some meetings (I was distracted
and sleepy) and could no longer perform simultaneous tasks, as I used to. I noticed
that I had slower brain processing speed and inattention. I had to struggle with excessive
daytime sleepiness and fatigue, along with a combination of difficulties and frustration
associated with symptoms of depression and anxiety.
However, I am grateful for the support of my team of postgraduate students and colleagues.
I never tried to hide my symptoms and difficulties; they have supported me since the
beginning. We have discussed the drugs that I have been trying because this is a new
virus[1] and almost nothing about any persistent neurocognitive dysfunction that it might
cause is known[2]. I decided to use levetiracetam for migraine prophylaxis[3] because I knew it could somehow improve my brain connectivity[4]. It was a good choice because it reduced the migraine attacks and somehow reduced
the excessive night sleep by 0.5-1.0 hour. Nevertheless, I had to adjust the dose
due to worsening symptoms of depression with the high dose; therefore, I combined
it with an antidepressant (agomelatine).
At the end of 2020, I realized I had to adjust to the new situation and slow down
my pace of life and academic activities. I had already resumed my swimming workouts
(2000 m, with variable intensity and snorkel) 2-3 times/week, combined with Pilates
and one day of strength exercise. There was hope that intensive aerobic exercise would
help recover the cognition[5].
In January 2021, I decided to try low doses of lisdexamfetamine, which finally helped
me work, although not as fast or efficiently as before COVID-19. However, I do not
tolerate it well and only use it 2-3 times on weekdays, especially on busy days at
work. I manage my routine with an online agenda (which I never needed before). I need
to sleep more than before; I do my swimming workouts and respect my fatigue and tiredness.
I take drugs that I never imagined I would need. After each dose of vaccine (COVID-19
and meningitis), it was intriguing that I felt I lost each slight improvement for
approximately four weeks.
After 16 months (end of 2021), I finally thought that part of my old brain was coming
back. Some automatic connections (part of my personality) that I had lost are now
back, such as the names of several patients and their histories. It seems that I have
a slight improvement in brain processing speed. Roughly, if I lost 30% of my natural
speed after COVID-19, I think that I have recovered 10%. It is sad and disappointing.
It is embarrassing and painful not to recognize myself.
I believe that transparency about all the uncertainties surrounding the new coronavirus
is needed[1]. Not much data on the negative impact of prolonged symptoms is available, nor are
the effects of SARS-CoV-2 on either the central or the peripheral nervous system understood[6]. I am frightened because previous studies showed the vulnerability of the hippocampus
to coronavirus[2]. I have studied hippocampal atrophy in epilepsy for almost 20 years, and now I face
the risk that the new coronavirus will act as an initial precipitating injury and
eventually cause hippocampal atrophy and epilepsy. Or it may accelerate a neurodegenerative
process with dementia[2].
In an article now submitted (in collaboration with other researchers), we already
observed grey matter atrophy in the orbitofrontal cortex of mildly infected individuals
(81 individuals with an average age of 37 years), which was associated with poor performance
in the trail-making test[7]. This has also been recently reported in a larger group (401 subjects with an average
of 62 years)[8]. In our study[7], we identified that there was higher frequency of symptoms of anxiety and depression
approximately two months after the COVID-19 diagnosis, which was in line with findings
from an extensive study of survivors[9].
I fear for the numerous survivors of COVID-19 who do not have access to medical attention
for their post-COVID symptoms. I have received several emails from individuals with
similar (or worse) symptoms; they complain that most physicians do not understand
or believe in the multitude of symptoms. It is frustrating because I know all these
symptoms are real and compromise our life and work. As well described previously by
other doctors[1] and in another study[10], the mental health system needs to become prepared to receive survivors with different
neuropsychiatric symptoms, including anxiety and depression.
Longitudinal studies on these symptoms need to be continued in order to more precisely
understand the predisposing factors for neurocognitive and cerebral alterations associated
with SARS-CoV-2. Given the uncertainties about the underlying mechanisms, COVID-19
cannot be prevented or treated specifically; nor can it be predicted whether the alterations
that it causes are temporary, permanent or progressive.
We are starting a new project to offer cognitive rehabilitation to survivors with
post-COVID dysfunction. It is a small, local project. Nevertheless, we expect to bring
hope to individuals and simultaneously collect multimodal data to understand possible
mechanisms behind neurocognitive dysfunction.
