In 1982 Willie Nelson released "Always on My Mind" to critical and popular acclaim. The refrain is repeated "You were always on my mind." We all periodically experience the inability to forget. I have always marveled that there are some bits rattling around in my memory that I just cannot seem to jettison, and yet other things that I simply cannot force myself to remember. The mind, it seems, is a complex and curious tool.
Is SARS-CoV-2/COVID-19 on your mind? It’s perhaps somewhat difficult in today’s business environment to get this pandemic off your mind. There are constraints, restrictions, and persistent changes in regulatory and medical methodology. But then we find that COVID is not just on your mind, but it is potentially in your mind? We are learning more about this virus, and it seems sometimes as if each day brings new news, explanations, and perhaps resulting anxiety.
Intertwined in this immediate threat of infection, and array of potential symptoms, is the threat or fear that symptoms may persist. The concept of “long-Covid is not new to this blog. In COVID-19 Regressive Impact (May 2020), I suggested that disease impacts might be characterized in short and long-term categories. Later, in COVID-19 in Comp - An October Update, the term "long COVID" debuted. Since then, I have tried to remain abreast of the long-term impacts, see COVID Update November 2020.
National Public Radio (NPR) reported in early January that scientists have been focused for months on the COVID-19 symptoms involving loss of taste and smell. It is an odd impact of infection and occurs somewhat sporadically among patients. I have personally spoken with COVID victims who complain extensively of this symptom, and others who relate never suffering this particular impact. Despite this lack of consistency, this symptom was primary in the involvement of neurologists with the SARS-CoV-2 infection. However, this symptom is not the end of neurological involvement, according to NPR.
It notes that "many patients who are hospitalized for COVID-19 are discharged with symptoms such as those associated with a brain injury." There is documentation of complaints of "forgetfulness" and "trouble with organizing their tasks." There are also some who further suffer from "seizures" and "psychosis." More recently, there is even a suggestion that COVID-19 could potentially "increase a person's risk of developing Alzheimer's disease." The implication is that lasting neurological effects and risks are being investigated.
Dr. Francis Collins, writing for the National Institute of Health (NIH) Director's Blog, recently expounded on the potential for neurological impacts of this virus, based upon an NIH investigation recently published in the New England Journal of Medicine. The doctor notes the same "taste and smell" connection, but adds potential for "headaches, debilitating fatigue, and trouble thinking clearly." That last one, the article notes, is also referred to as "brain fog," which sounds like a very generalized challenge with both thinking and reasoning with which one might identify having been around family members or friends battling the onset of dementia or Alzheimer's.
These neurological symptoms have driven the investigation of causation using various tools, including extremely powerful magnetic resonance (MRI) examination and autopsy. The focus of these scientists has been on the portion of the brain "that controls our ability to smell ("olfactory bulb") and the brainstem, which regulates breathing and heart rate." The preliminary conclusion is that "both areas" may "be highly susceptible to COVID-19." The cautionary note is the "may," and the concession that perhaps significant ongoing research lies ahead in this regard.
What did the NIH team see and report in its recent article? These MRI images demonstrated "signs of inflammation" and changes in the "tiny blood vessels," some of which even appeared to have "leaked blood proteins into the brain" itself. But, they found "no evidence in the brain tissue samples that SARS-CoV-2 had invaded the brain tissue." The outcome of this research and study has led to the supposition that the COVID-19 "neurological symptoms are likely explained by the body’s widespread inflammatory response to infection and associated blood vessel injury—not by (COVID) infection of the brain tissue itself."
There is also some suggestion that this complex of neurological symptoms may help to explain the increased COVID-19 susceptibility of those who suffer from "pre-existing conditions, such as diabetes, obesity, and cardiovascular disease." It appears possible that such conditions themselves may result in various implications for the circulatory system. Thus, whether through actual pre-existing damage or predisposition to injury, these conditions thereby predispose a COVID-19 victim to exacerbated challenges to blood vessels and inflammation.
Katarina Zimmer, writing in The Scientist, recently noted that these implications should perhaps not be as surprising as they seem. She notes similarly that "scholars have linked the 1918 flu pandemic to" neurological complaints. Furthermore, there is "some evidence that COVID's close relatives, MERS-CoV and SARS-CoV-1 (the COVID virus is named SARS-CoV-2), have been associated with neurological symptoms." Ms. Zimmer suggests that therefore neurological symptoms themselves should perhaps not surprise scientists. She notes, however, that the frequency of such complaints with COVID-19 might nonetheless be noteworthy and even worrisome. The implication is that these impacts are of greater concern in the current pandemic either due to frequency or severity.
The Scientist article notes that some of the autopsy results have demonstrated the presence of COVID-19 in the brain itself. She concludes that both these periodic positive findings and the seemingly absolute absence of such findings in other patients are driving scientific interest in and investigation of these neurological symptoms. Her conclusions are consistent with the NIH hypotheses regarding such symptoms being consistent with inflammation of the brain typically seen with other infections.
Thus, perhaps all of us have COVID on our minds, as Willie Nelson's refrain. Certainly, it is inaccurate or at least unartful to conclude that "it is all in your head." There are, after all a variety of other implications and impacts this disease has on the body. But, there is evidence that to some extent COVID is actually in some people's brains. And, even in those instances where it is not found in the brain, there is mounting evidence of damage to the brain related to the infection (SARS-CoV-2) and disease (COVID-19).
The implications are noteworthy. First, consider the NIH conclusions regarding findings of neurological implications on autopsy. The most serious impact of COVID is obviously loss of life. The study finds the inflammation and blood vessel changes in those who have succumbed to the disease, which is important. Whether the changes are more prevalent in those with the most severe outcomes is not necessarily clear. However, the presence of that finding in victims may be suggestive of the importance of neurological complaints and symptoms in those who seek care. Neurological involvement might assist doctors in assessing risks and challenges for a particular patient.
Second, these neurological symptoms are notably of a longer duration than other symptoms in some cases. The MIT COVID-19 website notes that "absent or diminished senses of taste and/or smell persisting long after other symptoms had resolved" in some patients. There is citation there to one study supporting that "most people appear to regain these senses eventually," but some suggestion that a month may not be an unreasonable expectation in this regard. I have spoken to some who complain of the longevity and intensity of this neurological symptom.
Finally, the jury is out on whether the more serious neurological impacts and signs might remain long after the senses of smell and taste return. Might neurological injury, dementia, confusion, and "brain fog" remain more persistently? Will there be limitations on activity and work that persist in some population of patients? Might this be a valid component for inclusion in consideration of the "long-COVID" more generally speaking?
I’m reminded of a conversation that I had last summer with a young, healthy person, reacting to all of the lockdown and precautions. In this person‘s words: “just let me get it already and get it over with.“ That logic may have certain implications in the short term. Some may see benefit in having the infection and hopefully developing some defensive response or immunity. It may have a different set of concerns for the young compared to the old, with some expectation of less pervasive impacts and implications for the young. But, it may be that concerns about the "long-COVID" are valid in terms of health, well-being, and function of young and old alike. Until it has been two years, five years, or ten years, the impacts of infection as of such anniversaries will remain projected, perhaps anticipated, but uncertain. The impact remains to be seen.
While it might be that COVID is "always on my mind" in these days, perhaps Willie Nelson's lyric is not the point. Perhaps, instead, the focus should be on Avril Levigne's entreaty instead to "Get outta my head." It may be that this disease process actually does enter the brain and eradicating it from that tissue will be critical. Or, the inflammation itself may be the neurological challenge. And, that therefore one of the primary challenges of the "long-COVID" will be in finding methods that successfully limit inflammation, encephalopathy, and brain changes of which symptoms like taste and smell loss are merely precursors or warnings.
In the larger sense, perhaps COVID-19 might be accurately discussed as the computer villain in "War Games" (1983) described nuclear war: "the only winning move is not to play." Perhaps those who are ready to "get it already" might instead consider caution in hopes of not experiencing the short term symptoms or risking the "long-COVID" changes or damage that appear now to be possible. Until more is known, caution and avoidance seem an advisable course as science continues to compile, reconcile, and document findings and conclusions regarding the impacts, immediate and future.
