COVID-19: Exploring Uncommon Manifestations and Their Impact


COVID-19 Uncommon manifestations

Dra. Ana Luisa Mendizábal Méndez.

The SARS-CoV-2 coronavirus, the cause of the current pandemic, is still a poorly understood microorganism.

Although it belongs to a family of infectious agents that earlier in this 21st century have caused epidemics such as:

  • SARS-CoV-1 causing Acute Respiratory Distress Syndrome or SARS in 2003.
  • Middle East Respiratory Distress Syndrome or MERS in 2012, the current virus presents unique characteristics of which little information is available.

The U.S. Centers for Disease Control (CDC) believes that people who present with cough and shortness of breath may have COVID-19.

Also, people who have at least two of the following symptoms may have the disease:

  • Fever.
  • Chills.
  • Repeated shaking with chills.
  •  muscle pain
  •  headache
  •  swelling of the throat
  •  Sudden loss of smell or taste.

The last mentioned symptoms (loss of smell or taste) commonly appear together with the rest of the symptoms; however, in approximately 12% of cases, they may precede them(1). While it is not fully understood how SARS-CoV-2 causes these alterations, other coronaviruses are known to have the ability to invade the olfactory bulb. The olfactory bulb is a small structure located within the skull cavity, just above the nasal cavity, considered part of the cerebral cortex. Its function is to generate signals so that the brain can recognize odors associated with different substances or molecules.


This is one of the many ways in which COVID-19 attacks the central nervous system. Other manifestations of SARS-CoV-2 damage to the central nervous system include dizziness in 17% of cases and altered consciousness in up to 9%(2). Most worrisome is the cerebral vascular event of ischemic type, or what people commonly known as “embolism”.


Regenerate response


Ischemic cerebral vascular event is a decrease in oxygen reaching the brain caused by the interruption of blood flow, which in turn is secondary to a clot that clogs one of the cerebral arteries. Although this is a rare event, it has been reported that it can affect people under 50 years of age, even without previously presenting other symptoms of COVID-19(3).


Isolated cases of Guillain-Barré syndrome (4) have also been reported after the onset of COVID-19 symptoms. This condition is characterized by the loss of strength initially in the lower extremities, which progresses to the upper body and is followed by paralysis. This may extend to the breathing muscles, necessitating placement on a mechanical ventilator for breathing.


The ischemic cerebral vascular event is a manifestation in the nervous system of the affectation generated by the virus directly at the level of the lining of the arteries of the organism, known as endothelium. The endothelium undergoes inflammation and, as a result, releases a series of substances that promote the formation of clots. In two studies from different hospitals, it was observed that 1 in 5 or even up to 1 in 3 patients admitted to the Intensive Care Unit (ICU) with COVID-19 present pulmonary thromboembolism(5,6). That is, the formation of clots that obstruct blood flow to the lungs, even though they received anticoagulants.


In one of the studies, it was reported that one out of 10 patients died from this cause.


The SARS-CoV-2 coronavirus also has an affinity for heart cells, and there are several reports of COVID-19 causing inflammation of the heart muscle (myocarditis).


It is thought that acute cardiac damage may occur in up to one in 5 patients and that mortality secondary to this may be as high as 50% (7, 8).


The mechanism by which COVID-19 causes skin alterations is not yet known. However, a study published by a group of Spanish dermatologists involving 375 infected patients found that areas of redness and inflammation on the fingertips or toes, small blisters known as vesicles similar to those occurring in chickenpox infection, urticaria and papules, and even necrosis (the death of skin in some areas of the body) could be observed (9).


Figure 1 shows some of the skin manifestations associated with COVID-19 (9).


It is important to remember that SARS-CoV-2 is a new virus for which there is still insufficient information.


Therefore, as time goes by, serious alterations have been detected, which had not been reported before in other coronavirus infections. Hence the importance of avoiding contagion at all costs and actively participating in the control of the epidemic by maintaining protective measures such as avoiding leaving home and keeping a healthy distance.


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Lechien, J.R., Chiesa-Estomba, C.M., De Siati, D.R. et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol (2020).

Asadi-Pooya AA, Simani L. Central nervous system manifestations of COVID-19. A systematic review: A systematic review [published online ahead of print, 2020 Apr 11]. J Neurol Sci. 2020;413:116832. doi:10.1016/j.jns.2020.116832.

Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. April 28, 2020.

SARS-CoV-2-associated Guillain-Barre Syndrome. April 17, 2020. DOI: 10.1056/NEJMc2009191.

Klok, F A et al. “Incidence of thrombotic complications in critically ill ICU patients with COVID-19”. Thrombosis Research, S0049-3848(20)30120-1. 10 Apr. 2020, doi:10.1016/j.thromres.2020.04.013.

Julien Poissy, Julien Goutay, Morgan Caplan, Erika Parmentier, Thibault Duburcq, Fanny Lassalle, Emmanuelle Jeanpierre, Antoine Rauch, Julien Labreuche and Sophie Susen and on behalf of the COVID-19 hemostasis group of the Lille ICUOriginally published 24 April 2020.

Myocarditis in a patient with COVID-19: a cause of elevated troponin and ECG changes. Denis Doyen, Pamela Moceri, Dorothée Ducreux, Jean Dellamonica. Published:April 23, 2020DOI: 

Irabien-Ortiz, Angela. “Miocarditis fulminante por COVID-19 [Fulminant myocarditis due to COVID-19]” [Fulminant myocarditis due to COVID-19]. Revista española de cardiología, 10.1016/j.recesp.2020.04.001. 10 Apr. 2020, doi:10.1016/j.recesp.2020.04.001.

Galván Casas, C., Català, A., Carretero Hernández, G., Rodríguez-Jiménez, P., Fernández Nieto, D., Rodríguez-Villa Lario, A., Navarro Fernández, I., Ruiz-Villaverde, R., Falkenhain, D., Llamas Velasco, M., García-Gavín, J., Baniandrés, O., González-Cruz, C., Morillas-Lahuerta, V., Cubiró, X., Figueras Nart, I., Selda-Enriquez, G., Romaní, J., Fustà-Novell, X., Melian-Olivera, A., Roncero Riesco, M., Burgos-Blasco, P., Sola Ortigosa, J., Feito Rodriguez, M. and García-Doval, I. (2020), Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. Accepted Author Manuscript. doi:10.1111/bjd.19163.

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