Skip to main content
Advertisement
  • Neurology.org
  • Journals
    • Neurology
    • Clinical Practice
    • Education
    • Genetics
    • Neuroimmunology & Neuroinflammation
  • Online Sections
    • Neurology Video Journal Club
    • Diversity, Equity, & Inclusion (DEI)
    • Neurology: Clinical Practice Accelerator
    • Practice Buzz
    • Practice Current
    • Residents & Fellows
    • Without Borders
  • Collections
    • COVID-19
    • Disputes & Debates
    • Health Disparities
    • Infographics
    • Neurology: Neuroimmunology & Neuroinflammation COVID-19 Article Hub
    • Null Hypothesis
    • Patient Pages
    • Topics A-Z
    • Translations
    • UDDA Revision Series
  • Podcast
  • CME
  • About
    • About the Journals
    • Contact Us
    • Editorial Board
  • Authors
    • Submit Manuscript
    • Author Center

Advanced Search

Main menu

  • Neurology.org
  • Journals
    • Neurology
    • Clinical Practice
    • Education
    • Genetics
    • Neuroimmunology & Neuroinflammation
  • Online Sections
    • Neurology Video Journal Club
    • Diversity, Equity, & Inclusion (DEI)
    • Neurology: Clinical Practice Accelerator
    • Practice Buzz
    • Practice Current
    • Residents & Fellows
    • Without Borders
  • Collections
    • COVID-19
    • Disputes & Debates
    • Health Disparities
    • Infographics
    • Neurology: Neuroimmunology & Neuroinflammation COVID-19 Article Hub
    • Null Hypothesis
    • Patient Pages
    • Topics A-Z
    • Translations
    • UDDA Revision Series
  • Podcast
  • CME
  • About
    • About the Journals
    • Contact Us
    • Editorial Board
  • Authors
    • Submit Manuscript
    • Author Center
  • Home
  • Articles
  • Issues
  • COVID-19 Article Hub
  • Infographics & Video Summaries

User menu

  • My Alerts
  • Log in

Search

  • Advanced search
Neurology Neuroimmunology & Neuroinflammation
Home
A peer-reviewed clinical and translational neurology open access journal
  • My Alerts
  • Log in
Site Logo
  • Home
  • Articles
  • Issues
  • COVID-19 Article Hub
  • Infographics & Video Summaries

Share

September 2020; 7 (5) Clinical/Scientific NotesOpen Access

COVID-19 in MS

Initial observations from the Pacific Northwest

James D. Bowen, Justine Brink, Ted R. Brown, Elisabeth B. Lucassen, Kyle Smoot, Annette Wundes, View ORCID ProfilePavle Repovic
First published May 26, 2020, DOI: https://doi.org/10.1212/NXI.0000000000000783
James D. Bowen
From the Swedish Multiple Sclerosis Center (J.D.B., P.R), Seattle, WA; Providence Multiple Sclerosis Center (J.B., E.B.L., K.S.), Portland, Oregon; EvergreenHealth Multiple Sclerosis Center (T.R.B.), Kirkland; and University of Washington Multiple Sclerosis Center (A.W.), Seattle.
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Justine Brink
From the Swedish Multiple Sclerosis Center (J.D.B., P.R), Seattle, WA; Providence Multiple Sclerosis Center (J.B., E.B.L., K.S.), Portland, Oregon; EvergreenHealth Multiple Sclerosis Center (T.R.B.), Kirkland; and University of Washington Multiple Sclerosis Center (A.W.), Seattle.
DO, MPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ted R. Brown
From the Swedish Multiple Sclerosis Center (J.D.B., P.R), Seattle, WA; Providence Multiple Sclerosis Center (J.B., E.B.L., K.S.), Portland, Oregon; EvergreenHealth Multiple Sclerosis Center (T.R.B.), Kirkland; and University of Washington Multiple Sclerosis Center (A.W.), Seattle.
MD, MPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Elisabeth B. Lucassen
From the Swedish Multiple Sclerosis Center (J.D.B., P.R), Seattle, WA; Providence Multiple Sclerosis Center (J.B., E.B.L., K.S.), Portland, Oregon; EvergreenHealth Multiple Sclerosis Center (T.R.B.), Kirkland; and University of Washington Multiple Sclerosis Center (A.W.), Seattle.
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kyle Smoot
From the Swedish Multiple Sclerosis Center (J.D.B., P.R), Seattle, WA; Providence Multiple Sclerosis Center (J.B., E.B.L., K.S.), Portland, Oregon; EvergreenHealth Multiple Sclerosis Center (T.R.B.), Kirkland; and University of Washington Multiple Sclerosis Center (A.W.), Seattle.
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Annette Wundes
From the Swedish Multiple Sclerosis Center (J.D.B., P.R), Seattle, WA; Providence Multiple Sclerosis Center (J.B., E.B.L., K.S.), Portland, Oregon; EvergreenHealth Multiple Sclerosis Center (T.R.B.), Kirkland; and University of Washington Multiple Sclerosis Center (A.W.), Seattle.
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Pavle Repovic
From the Swedish Multiple Sclerosis Center (J.D.B., P.R), Seattle, WA; Providence Multiple Sclerosis Center (J.B., E.B.L., K.S.), Portland, Oregon; EvergreenHealth Multiple Sclerosis Center (T.R.B.), Kirkland; and University of Washington Multiple Sclerosis Center (A.W.), Seattle.
MD, PhD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Pavle Repovic
Full PDF
Citation
COVID-19 in MS
Initial observations from the Pacific Northwest
James D. Bowen, Justine Brink, Ted R. Brown, Elisabeth B. Lucassen, Kyle Smoot, Annette Wundes, Pavle Repovic
Neurol Neuroimmunol Neuroinflamm Sep 2020, 7 (5) e783; DOI: 10.1212/NXI.0000000000000783

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Permissions

Make Comment

See Comments

Downloads
1566

Share

  • Article
  • Figures & Data
  • Info & Disclosures
Loading

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is marked by a wide range and severity of symptoms. Most patients have mild to moderate symptoms, whereas 10%–15% require hospitalization. Mortality is higher with cardiovascular disorders, diabetes, and older age.1

Little is known about the clinical features of COVID-19 in the context of multiple sclerosis (MS), where some disease-modifying therapies (DMTs) may lead to immunocompromised state. Regarding the use of MS DMTs in the context of the COVID-19 pandemic, clinicians have had to make inferences, based on the DMT's mechanism of action and clinical trial data on infections, whether to continue, stop, or change the therapy in their patients with MS.2

Here, we report our initial experience with COVID-19 among 8 patients with MS (table). The earliest case in our series occurred abroad in the early days of the COVID-19 outbreak. Other infections occurred locally in Washington and Oregon. The source of infection was a close contact in 2 cases, residential nursing facility in 2 cases, travel in 1, but not identified in 3 cases. Our case series consists mostly of female patients (6 of 8), aged 35–74, and most of whom had relapsing-remitting MS (5 of 8). Most of the patients had lower disability (Expanded Disability Status Scale [EDSS] score 1–3.5), with 2 exceptions (EDSS 7.5 and 8.5). Two patients were on injectable agents (1 interferon and 1 glatiramer), 2 on dimethyl fumarate (DMF), 1 on teriflunomide (TFL), and 2 on fingolimod (FNG), whereas 1 patient was not on DMT. None had a relapse or systemic corticosteroids recently. Neither of the patients on DMF had lymphopenia at baseline. Patients with FNG had lymphopenia (0.8 and 0.6 K/ul) at presentation and 6 months before COVID-19 infection, respectively.

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table

Clinical features of MS and COVID-19

The most common presenting symptoms of COVID-19 in this cohort were fever (7 of 8), cough (6 of 8), and headache (4 of 8). Less common symptoms were sneezing (2), anosmia (2), fatigue (2), nausea (1), chills (1), and disequilibrium (1). One patient never developed fever. Two patient had dyspnea and altered mental status. We suspect that their altered mental status was probably due to hypoxia, although direct effect of SARS-CoV-2 on CNS could not be excluded.

COVID-19 diagnosis was confirmed by RT-PCR on a sample obtained by nasopharyngeal swab between 1 and 14 days after symptom onset, reflecting the challenges with laboratory testing at the time. One patient's diagnosis was not confirmed by RT-PCR, but her spouse, who had the same symptoms, tested positive 2 days earlier, so we believe that COVID-19 diagnosis is most likely accurate.

COVID-19 symptoms lasted 6–28 days. Three patients were hospitalized, one of them primarily for observation. Although symptomatic, 2 patients on FNG stopped taking their medication for 2 and 4 days (while febrile). The patient on interferon missed 1 dose. Patients on glatiramer acetate and DMF continued their treatment without interruption.

Two patients died. Both of these patients were severely affected by both MS (EDSS 7.5 17 and 8.5) and COVID-19 (hypoxia, fever, and altered mental status), in addition to having significant comorbidities. On admission, both patients had low absolute lymphocyte counts (0.6 and 0.58 K/uL) and one had increased liver function tests (AST 93 and ALT 66), probably because of the COVID-19 infection1 because laboratory test results were in the normal range 10 months before for the TFL-treated patient. Both patients were placed on supplemental oxygen, but continued to deteriorate. As per advanced directive of both patients, they were not intubated, and they died 3 and 4 days after the admission, respectively. Autopsy was not performed.

The full scope of COVID-19 manifestations in the MS population remains to be defined. To that end, we encourage all clinicians to follow our example and report their cases of COVID-19 in MS and related disorders in North America (covims.org) and elsewhere (msdataalliance.com). In publishing this initial report, we wanted to share our experiences and observations among patients from a region with early community spread of SARS-CoV-2 in the United States.3 We were relieved that most of these infections were mild and in line with observations in general (non-MS) population. At the same time, the fatal outcome in our most disabled patients portends significant risks for patients with advanced MS. Most of our patients remained on their DMTs with no interruption during the COVID-19 infection. However, the generalizability of this finding is limited because none of these were cell-depleting therapies, and most infections were mild. We hope that larger studies will provide more definitive information on additional risks associated with MS DMTs in COVID-19 and hospitalization outcomes to better inform our care for this population.

Study funding

No targeted funding reported.

Disclosure

J.D. Bowen, J. Brink, T. Brown, E.B. Lucassen, K. Smoot, A. Wundes, and P. Repovic report no financial disclosures relevant to the topic of this manuscript. Go to Neurology.org/NN for full disclosures.

Appendix Authors

Table
Table

Footnotes

  • Go to Neurology.org/NN for full disclosures. Funding information is provided at the end of the article.

  • The Aricle Processing Charge was funded by the authors.

  • Received April 14, 2020.
  • Accepted in final form May 7, 2020.
  • Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

References

  1. 1.↵
    1. Guan WJ,
    2. Ni ZY,
    3. Hu Y, et al
    . Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708–1720.
    OpenUrl
  2. 2.↵
    1. Giovannoni G,
    2. Hawkes C,
    3. Lechner-Scott J,
    4. Levy M,
    5. Waubant E,
    6. Gold J
    . The COVID-19 pandemic and the use of MS disease-modifying therapies. Mult Scler Relat Disord 2020;39:102073.
    OpenUrl
  3. 3.↵
    1. Bhatraju PK,
    2. Ghassemieh BJ,
    3. Nichols M, et al
    . Covid-19 in critically ill patients in the Seattle region—case series. N Engl J Med 2020;382:2012–2022.
    OpenUrl

Letters: Rapid online correspondence

  • Reader response: COVID-19 in MS: Initial observations from the Pacific Northwest
    • Khichar Shubhakaran, Senior Professor and Head of Department of Neurology, Dr S.N. Medical College (Jodhpur, India)
    Submitted September 06, 2020
Comment

REQUIREMENTS

You must ensure that your Disclosures have been updated within the previous six months. Please go to our Submission Site to add or update your Disclosure information.

Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment.

If you are responding to a comment that was written about an article you originally authored:
You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid
and apply to letter.

Submission specifications:

  • Submissions must be < 200 words with < 5 references. Reference 1 must be the article on which you are commenting.
  • Submissions should not have more than 5 authors. (Exception: original author replies can include all original authors of the article)
  • Submit only on articles published within 6 months of issue date.
  • Do not be redundant. Read any comments already posted on the article prior to submission.
  • Submitted comments are subject to editing and editor review prior to posting.

More guidelines and information on Disputes & Debates

Compose Comment

More information about text formats

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
NOTE: The first author must also be the corresponding author of the comment.
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g. higgs-boson@gmail.com
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Publishing Agreement
NOTE: All authors, besides the first/corresponding author, must complete a separate Publishing Agreement Form and provide via email to the editorial office before comments can be posted.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

You May Also be Interested in

Back to top
  • Article
    • Study funding
    • Disclosure
    • Appendix Authors
    • Footnotes
    • References
  • Figures & Data
  • Info & Disclosures
Advertisement

Association Between Fluctuations in Blood Lipid Levels Over Time With Incident Alzheimer Disease and Alzheimer Disease–Related Dementias

Dr. Sevil Yaşar and Dr. Behnam Sabayan

► Watch

Related Articles

  • No related articles found.

Topics Discussed

  • All Clinical Neurology
  • Multiple sclerosis
  • COVID-19
  • Viral infections

Alert Me

  • Alert me when eletters are published

Recommended articles

  • Article
    COVID-19 in Patients With Neuromyelitis Optica Spectrum Disorders and Myelin Oligodendrocyte Glycoprotein Antibody Disease in North America
    From the COViMS Registry
    Scott D. Newsome, Anne H. Cross, Robert J. Fox et al.
    Neurology: Neuroimmunology & Neuroinflammation, August 24, 2021
  • Article
    Incidence and Impact of COVID-19 in MS
    A Survey From a Barcelona MS Unit
    Maria Sepúlveda, Sara Llufriu, Eugenia Martínez-Hernández et al.
    Neurology: Neuroimmunology & Neuroinflammation, January 27, 2021
  • Article
    A New England COVID-19 Registry of Patients With CNS Demyelinating Disease
    A Pilot Analysis
    Kelli M. Money, Ashmanie Mahatoo, Soleil Samaan et al.
    Neurology: Neuroimmunology & Neuroinflammation, August 02, 2021
  • Article
    COVID-19 outcomes in MS
    Observational study of early experience from NYU Multiple Sclerosis Comprehensive Care Center
    Erica Parrotta, Ilya Kister, Leigh Charvet et al.
    Neurology: Neuroimmunology & Neuroinflammation, July 09, 2020
Neurology - Neuroimmunology Neuroinflammation: 10 (6)

Articles

  • Articles
  • Issues
  • Popular Articles

About

  • About the Journals
  • Ethics Policies
  • Editors & Editorial Board
  • Contact Us
  • Advertise

Submit

  • Author Center
  • Submit a Manuscript
  • Information for Reviewers
  • AAN Guidelines
  • Permissions

Subscribers

  • Subscribe
  • Sign up for eAlerts
  • RSS Feed
Site Logo
  • Visit neurology Template on Facebook
  • Follow neurology Template on Twitter
  • Visit Neurology on YouTube
  • Neurology
  • Neurology: Clinical Practice
  • Neurology: Education
  • Neurology: Genetics
  • Neurology: Neuroimmunology & Neuroinflammation
  • AAN.com
  • AANnews
  • Continuum
  • Brain & Life
  • Neurology Today

Wolters Kluwer Logo

Neurology: Neuroimmunology & Neuroinflammation
Online ISSN: 2332-7812

© 2023 American Academy of Neurology

  • Privacy Policy
  • Feedback
  • Advertise