American Journal of Emergency Medicine 38 (2020) 2444-2454

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage:

Non-respiratory presentations of COVID-19, a clinical review

Marya AlSamman, BA, Amy Caggiula, MD, Sangrag Ganguli, MMSc, Monika Misak, MD, Ali Pourmand, MD MPH ?

Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States

a r t i c l e i n f o

Article history:

Received 6 July 2020

Received in revised form 16 September 2020 Accepted 17 September 2020

Keywords: COVID-19 SARS-CoV-2

Hematology Neurology Gastrointestinal Psychiatry Nephrology Dermatology

a b s t r a c t

Introduction: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) is a highly infectious viral syndrome currently threatening millions of people worldwide. It is widely recognized as a disease of the pul- monary system, presenting with fever, cough, and shortness of breath. However, a number of extrapulmonary manifestations have been described in the literature.

Objective: In this review, we seek to provide a comprehensive summary of the hematologic, gastroenterological, renal, dermatologic, neurologic, and psychiatric manifestations of COVID-19.

Discussion: Hematological presentations of COVID-19 include laboratory abnormalities such as decreasedtotal lym- phocyte count, prolonged prothrombin time , elevated d-dimer, and increased Lactate dehydrogenase . Several of these findings are associated with increased mortality among infected patients. The most common gas- trointestinal symptoms include nausea, vomiting, diarrhea, and abdominal pain. Furthermore, presence of viral RNA in patient stool suggests the possibility of additional testing modalities for COVID-19. Nephrological findings such as proteinuria, hematuria, and elevated BUN and Creatinine levels have been observed. Additionally, several studies demonstrated that patients with COVID-19 who developed Acute kidney injury had a greater risk of mortality. The virus can also present with cutaneous symptoms such as erythematous rashes, urticaria, and chicken pox-likelesions. Neuropsychiatricsymptomshavebeen described in theliterature, andpatients can exhibitfindings consistent with viral encephalitis, cerebral vascular disease, peripheral nerve disorders, and psychosis.

Conclusion: Although COVID-19 does usually present primarily with respiratory symptoms, the extra-pulmonary manifestations of the virus are unpredictable and varied. Better understanding and awareness of these symptoms can lead to more efficient diagnosis, Rapid treatment, isolation, and decreased spread of the disease.

(C) 2020

Introduction

On December 31st, 2019, the city of Wuhan, China first reported cases of a novel virus that was causing severe pulmonary symptoms and deaths [1]. From December to February, SARS-CoV-2 quickly spread to other provinces in China and Europe. This virus was taxonomically re- lated to the SARS-CoV and Middle East respiratory syndrome coronavi- rus (MERS-CoV), and it similarly originated in a non-human host (most likely bat) [2]. To date, the SARS-CoV-2 virus has had devastating effects on human life, healthcare systems, and economies.

SARS-CoV-2 is a beta-coronavirus that has, as of June 2020, infected over 7 million people and resulted in more than 400,000 deaths world- wide. COVID-19 typically presents with pulmonary symptoms such as cough and sore throat and can progress to pneumonia, bronchitis, and Acute respiratory distress syndrome . While the respiratory

* Corresponding author at: Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037, United States.

E-mail addresses: [email protected] (M. AlSamman), [email protected] (S. Ganguli), [email protected] (A. Pourmand).

spread of COVID-19 has been well documented in the literature, further case reports have shown that the virus is not confined to just the lung. SARS-CoV-2 utilizes a spike protein to attach to the host ACE2 receptor, which is found in several organ systems [2]. Upon entering the cell, the virus initiates an immune cascade, which stimulates immune cells, lead- ing to a cytokine storm and eventual destruction of tissues [3]. Its pri- mary mode of transmission is through inhalation, though studies have suggested potential alternative means of spread.

Much has been documented in the literature regarding the respira- tory presentations of the virus, but the extrapulmonary manifestations need further investigation. In this article, we review research on the he- matological, gastrointestinal, renal, dermatologic, neurologic, and psy- chiatric complications of COVID-19.

Methods

The authors searched PubMed, Google Scholar, medRxiv, and SCOPUS for articles using a combination of the keywords “COVID-19,” “SARS-CoV-2,” and “hematology”, “Neurology”, “gastrointestinal”, “psy- chiatry”, “dermatology”, “renal”. This narrative review summarizes the

https://doi.org/10.1016/j.ajem.2020.09.054

0735-6757/(C) 2020

extrapulmonary manifestations of COVID-19 and addresses key points regarding multiorgan involvement. All types of studies were evaluated including systematic reviews, case reports, case-studies, retrospective and prospective studies, letters, perspective, commentaries, and clinical guidelines. The references of all included studies were also reviewed to identify additional sources. Only studies in English (including translated studies) were reviewed. The initial literature search identified 1653 ar- ticles, of which 151 articles were deemed relevant to our research ques- tion. Data from these articles is summarized and reported by organ system.

Results

Hematological symptoms

Several studies have shown that patients infected with COVID-19 share similar laboratory abnormalities including decreased total lym- phocyte count, prolonged prothrombin time, elevated D-dimer levels and increased Lactate dehydrogenase [2-8]. A recent meta- analysis of the laboratory derangements in COVID-19 demonstrated that lymphopenia (35-75% of cases), increased LDH (27-92% of cases), elevated and d-dimer (36-43% of cases) were among the most frequent findings [9].

Lab abnormalities and Severity of disease

Patients with significant lab derangements had more severe disease and a greater need for critical care [2,3,5,6,9-12]. Lymphopenia is often more pronounced in those requiring ICU level care [11-15]. In Singapore, Fan et al. noted that 28% of patients infected with COVID- 19 had lymphopenia, with critical care patients demonstrating signifi- cantly decreased lymphocytes compared with those not requiring ICU treatment [14]. Furthermore, 4 of the 9 ICU patients also exhibited in- creased levels of LDH (median value of 1684 U/L) compared to the non-ICU patients where only 5 of 26 had moderately elevated LDH [14]. Huang et al. demonstrated that in addition to marked lymphope- nia, patients needing intensive care had higher levels of d-dimer (level 2.4 mg/L [0.6-14.4]) on admission than those who did not require it (0.5 mg/L [0.3-0.8], p = 0.0042) and also higher prothrombin times

12.2 s [IQR 11.2-13.4] when compared with non-ICU patients (10.7 s

[9.8-12.1], p = 0.012) [3]. In a study of 140 COVID-19 positive patients by Zhang et al., 58 patients who were considered to have “severe dis- ease” demonstrated a 2-fold increase in d-dimer compared to those with mild disease [16]. Guan et al. also determined that a significant elevation in d-dimer was more pronounced in severe cases (59.6% cardiovascular symptoms“>vs. 43.2% in non-severe) [5].

A meta-analysis examining the role of laboratory abnormalities in patients with severe COVID-19 vs. those with milder disease deter- mined that the most predictive parameters of critical infection were lymphopenia (96.1% vs. 80.4%), thrombocytopenia (57.7% vs. 31.6%), in- creased LDH (58.1% vs. 37.2%) and elevated d-dimer (59.6% vs. 43.2%) [9]. Specifically, in Wu et al.’s retrospective analysis of the risk factors for Disease progression to ARDS, they observed a statistically significant association between lymphopenia and the development of ARDS (P < 0.001) [8]. Several studies also established that higher CRP levels correlated with worse outcomes in COVID-19 such as ARDS, myocardial injury, and death [8,15,17]. As such, tracking hematologic parameters is crucial in determining prognosis and management, particularly with regard to level of care and monitoring.

Lab abnormalities and mortality

In addition to indicating the potential for more severe disease, labo- ratory abnormalities are also a predictor of mortality in infected patients [2,13]. In a case series of 138 patients with COVID-19, the mortality rate was about 4.3% (6 patients). Of those 6, 5 patients had persistent lab de- rangements including increased d-dimer and decreased lymphocyte counts [2]. Another retrospective cohort showed that elevated

d-dimer was associated with a higher rate of in-hospital death with 81% of terminal cases exhibiting d-dimer >1 ug [13]. Tang et al. analyzed abnormal coagulation parameters in patients with SARS-CoV-2 pneu- monia and determined that non-survivors had significantly higher d-dimer, Fibrin degradation products (FDP), and prothrombin time on admission compared to survivors (P < 0.05) [18]. This study was further supported by Han et al. who also demonstrated that d-dimer and FDP were especially predictive of disease progression [19]. A recent report investigating the factors affecting 28-day mortality of patients with se- vere illness showed that elevated d-dimer, increased age, and prolonged PT were associated with a higher mortality [20]. Early recognition of these abnormal results will play a critical role in predicting disease se- verity and improving outcomes with earlier intervention and support- ive therapy.

COVID-19 and coagulopathy

Coagulation parameters are often cited as indicators for worse prog- nosis in patients infected with COVID-19 [17,19,21]. Compared to a healthy control, d-dimer, FDP, and Fibrinogen levels are all increased in COVID-19 patients, while antithrombin (AT) levels are significantly reduced [19]. Emerging data suggests that deregulated thrombin gener- ation and abnormal activation of the coagulation cascade can lead to the development of disseminated intravascular coagulation and is as- sociated with worsening pneumonia and mortality [7,22-24]. DIC was a significantly more common finding in non-survivors (71.4%) vs. survi- vors (0.6%) [18]. Other manifestations of coagulopathy such as the de- velopment of antiphospholipid antibodies and subsequent thrombotic events were reported in 3 ICU patients infected with SARS-CoV-2 in Wuhan, China [25]. Due to coagulation abnormalities, COVID-19 pa- tients are at a higher risk of VTE, especially those with pre-existing co- morbidities [23]. Early monitoring of these parameters can help guide medical management such as the use of VTE prophylaxis and escalation of care.

A study of COVID-19 patients from the First Affiliated Hospital of Zhengshou University, Henan, China demonstrated that infected pa- tients have an overall pro-thrombotic state due to platelet hyperactivity [26]. When SARS-CoV-2 and its spike protein bind directly to the plate- let and ACE2 receptor, there is increased platelet activation and throm- bus formation due to activation of the MAPK pathway. This facilitates the release of coagulation and inflammatory factors, leading to an over- all pro-thrombotic and pro-inflammatory state [26]. The authors also suggest that the addition of ACE2 protein and anti-Spike neutralizing antibodies may be a therapeutic approach to avoid thrombotic events in these patients.

Cardiovascular symptoms

Patients with critical COVID-19 infection can also present with vari- ous cardiovascular symptoms. Animal models and cardiac autopsies suggest that COVID-19 can infect the cardiac tissue by binding to the angiotensin-converting enzyme (ACE) receptors, which can result in myocardial inflammation and damage [27]. Among the reported Cardiac manifestations of COVID-19 are myocardial injury, myocarditis, arrythmias, cardiomyopathy, and heart failure. These symptoms are summarized in Table 1.

Myocardial injury and myocarditis

Myocardial injury is defined as an elevation in biomarkers such as cardiac troponin I. Acute myocardial injury was reported in some of the earliest cases of COVID-19 in Wuhan, China. An early 2019 study among 41 admitted hospital patients in Wuhan reported acute cardiac injury in 12% of the patients [3]. Furthermore, another study of 138 hos- pitalized patients in Wuhan reported that as high as 22% of those who required ICU care experienced acute myocardial injury [2]. Another ret- rospective, observational study of 52 critically ill patients in Wuhan, China reported cardiac injury in 23% of the patients [28]. The increased

Table 1

Studies with COVID-19 patients presenting with cardiac symptoms.

Authors	Publication year	Type of study	Number of patients	Cardiac symptoms (%)
Yang et al. [28]	2020	Retrospective	52	Chest pain (2%), cardiac injury (23%)
Lippi et al. [29]	2020	Meta-analysis	341	Cardiac injury
Huang et al. [3]	2020	Retrospective	41	Cardiac injury (12%)
Ruan et al. [34]	2020	Retrospective	150	Myocardial damage (7%)
Liu, et al. [40]	2020	Retrospective	137	Heart palpitation (7.3%),
Wang, et al. [2]	2020	Retrospective	138	Acute cardiac injury (7.2%), Arrythmia (16.7%)
Bhatla, et al. [41]	2020	Retrospective	700	Cardiac arrest (1.3%), Atrial fibrillation (3.6%), Bradycardia (1.3%), Non-sustained
Amaratunga, et al. [42]	2020	retrospective case series	4	ventricular tachycardia (1.4%) Bradycardia (75%), Prolonged QTc (25%)
Zhou, et al. [13]	2020	Retrospective	191	Coronary heart disease (8%), Heart failure (23%), Acute cardiac injury (17%)

prevalence of cardiac injury among patients with COVID-19 could be ex- plained by the significantly higher levels of cardiac troponin I in severely ill patients [29].

A recent multi-hospital retrospective cohort of nearly 3000 patients demonstrated that myocardial injury was common among hospitalized COVID-19 patients (n = 985, 36%), and that those with a history of car- diovascular disease (CVD) were more likely to experience myocardial injury than those without [30]. Similarly, A study of 44,672 patients with COVID-19 demonstrated that a history of CVD was associated with a five-fold increase in case fatality rate compared to those without CVD (10.5% VS. 2.3%) [31,32].

A study by Lala, et al., showed that mild myocardial injury as evi- denced by small increases in troponin was significantly associated with death (adjusted hazard ratio: 1.75; 95% CI: 1.37 to 2.24; p < 0.001), and that greater elevations correlated with a higher risk of mortality (adjusted HR: 3.03; 95% CI: 2.42 to 3.80; p < 0.001) [30]. Sim- ilarly, a single center retrospective study of 50 COVID-19 ICU patients in Turkey demonstrated that cardiac biomarkers including troponin I and NT-proBNP were higher in non-survivors compared to survivors [33].

Myocarditis has also contributed to mortality associated with COVID-19. In a case series of 150 patients, researchers determined that 7% died from myocarditis with circulatory failure [34]. Clinically, di- agnosing myocarditis can be challenging, especially when differentiat- ing it from acute coronary syndrome. For this reason, echocardiogram evaluation is recommended, and myocarditis associated with COVID- 19 will appear as global wall motion dysfunction without focal wall mo- tion defects [31,35,36]. Additionally, ECG abnormalities may occur as a Gastrointestinal symptoms“>result of myocardial inflammation, such as T wave inversion, PR and ST segment deviations [31]. Autopsy reports of COVID-19 patients have reported high viral loads, mononuclear cells, and lymphocytic infiltration as key players in mediating acute myocarditis [37-39].

Arrythmias

A wide variety of arrythmias have been observed in patients with COVID-19. In a study of 137 patients in Hubei Province, 7.3% of patients reported heart palpitations [40]. In another report of 138 hospitalized patients, cardiac arrythmia was noted in 16.7%, and these arrythmias were more common in ICU patients [2]. In a much larger study of 700 patients, 9 cardiac arrests, 25 atrial fibrillation events, 9 clinically signif- icant bradyarrhythmias, and 10 non-sustained ventricular tachycardias were reported [41]. Additionally, this study noted that ICU admissions were associated with incidents of atrial fibrillation among COVID-19 pa- tients, indicating that these arrythmias can contribute to severity of ill- ness [41]. Lastly, a retrospective case series published in Cureus discussed COVID-19 related prolonged QTc and transient bradycardia as manifestations of the illness [42].

Many etiologies have been proposed to explain the occurrence of arrythmias among COVID-19 patients. Hypoxia, inflammatory damage, abnormal metabolism, neurohormonal stress, and response to medica- tions are some of the likely etiologies [31,35,42]. Furthermore, the effect of pro-inflammatory cytokines on the sinoatrial node could lead to the development of bradycardia in patients with COVID-19 [42].

Cardiomyopathy and heart failure

In a retrospective cohort study of COVID-19 patients in Wuhan, China, Zhou et al. reported heart failure in 23% of admitted pa- tients [13]. This number was as high as 52% in those who did not survive the infection [13]. Another retrospective study dem- onstrated that heart failure and acute cardiac injury were more common in deceased patients, regardless of their Cardiovascular history [43]. Specifically, this study reported heart failure in 24% of deceased patients, nearly half of whom did not have any history of cardiovascular disease or hypertension [43]. It is unclear whether the heart failure was due to a new cardiomyopathy or an exacerbation of existing undiagnosed left ventricular dysfunc- tion, and the etiology is still being investigated [31,35]. Addition- ally, Right heart failure can occur in patients with severe lung injury and ARDS [31,35]. As such, physicians should be cautious of underlying cardiac dysfunction when administering IV fluids [31,35].

Several recent case reports have also highlighted the development of Takotsubo syndrome (TTS) in those infected with COVID-19 [44-47]. One report detailed the case of a patient who developed cardiogenic shock 16 days after infection despite normal initial troponin levels and LVEF [44]. Her bedside echo demonstrated the apical ballooning typical of TTS. Similarly, another case report discussed the case of a previously healthy 50 years old male who developed chest pain and signs of cardio- genic shock 8 days after the onset of symptoms. His echocardiogram showed akinesia of all of his basal segments, and he was ultimately diagnosed with Inverted takotsubo cardiomyopathy [45].

Gastrointestinal symptoms

While the most fatal complications of COVID-19 include ARDS, heart failure, renal failure, liver injury, and multiple organ dysfunc- tion syndrome (MODS), GI symptoms can contribute significantly to morbidity in infected patients [48]. With regard to the gastrointes- tinal system, SARS-CoV-2 can present with nausea, vomiting, diar- rhea, and/or abdominal discomfort [3,49-53]. A cross-sectional analysis of 204 Chinese patients with COVID-19 demonstrated that over half (103 patients, 50.5%) reported experiencing at least one of the GI symptoms. Among those, 78.6% expressed Loss of appetite, 34% complained of diarrhea, 3.9% reported vomiting, and 1.9% indi- cated they had abdominal pain [54]. Similar clinical studies among COVID-19 patients have observed diarrhea in 3% to 61% of patients, nausea in 10% to 58%, and vomiting in 2% to 5%. Other gastrointesti- nal symptoms included Epigastric pain, belching, and anorexia [16,55-58] (summarized in Table 2).

Healthcare workers can easily be overwhelmed by the complex symptomology and acuity of cases. While focusing primarily on the most critical respiratory symptoms, gastrointestinal manifestations can be overlooked. Though GI symptoms are not prominent in most cases and are unlikely life-threatening on their own, clinicians should endeavor to identify these early symptoms in order to prevent the po- tential spread of COVID-19.

GI symptoms and disease severity

Some studies have shown that GI symptoms can manifest be- fore the onset of typical respiratory symptoms [2,59]. The first con- firmed case of COVID-19 in the US presented with a two-day history of nausea without respiratory complaint. Days into the ill- ness, the patient also complained of abdominal discomfort and loose stools [60]. Similarly, a recent report described a COVID-19 patient presenting with diarrhea, borborygmus, anorexia, and nau- sea in the absence of any respiratory symptoms [61]. Early re- search has suggested a correlation between GI symptoms and severity of illness. Henry et al. performed a Pooled analysis of 10 different studies with a total sample of 1989 COVID-19 patients, 598 of whom (30.1%) were deemed as having “severe disease.” This study examined whether patients presenting with GI symp- toms could be at an increased risk of critical illness and poor prog- nosis. The research highlighted a significant association between abdominal pain and illness severity. Furthermore, nausea and vomiting correlated with a marginally increased risk of severe COVID-19, while diarrhea was not reported to be associated with worse disease [62]. Another retrospective case-controlled study of 278 COVID-19 positive patients and 238 COVID-19 negative patients suggested that patients presenting with GI symptoms at time of testing were more likely to test positive for the virus [63]. In comparison, patients without GI symptoms were equally likely to test positive or negative for COVID-19 [63]. Lastly, in the past few months, two cases of paralytic ileus were reported among COVID-19 patients [64]. Histopathology of resected bowel specimen in these cases suggests a role for COVID-19-induced micro-thrombosis leading to GI perforation [64].

Fecal shedding of COVID-19

In addition to research showing the potential correlation between GI symptoms and disease severity, several studies have determined that infected patients can shed viral particles in their stool [65-67]. One study of 42 COVID-19 positive patients demonstrated that about 67% of the patients had viral RNA present in their stool even in the absence of diarrhea or other GI symptoms. Interestingly, among this group, 64% of the patients continued to shed viral particles in fecal specimens even after the nasopharyngeal swabs turned negative [65]. This has been documented in both adult and pediatric patients. Xu et al. con- ducted an epidemiological and clinical study of 10 children with Covid-19 and found that 8 persistently tested positive in stool despite their nasopharyngeal swabs being negative [68].

Fecal specimen testing is just as accurate in detecting COVID-19 as nasopharyngeal swabs [66,69]. Physiologically, the presence of viral particles in feces is plausible as there is a high level of viral receptor an- giotensin converting enzyme 2 (ACE2) in the gastrointestinal tract [70]. While the current research is not definitive, studies have indicated that asymptomatic patients may shed COVID-19 viral particles in their stool [66,71-74]. Whether these particles are infectious and support the argu- ment for possible the fecal-oral transmission of SARS-CoV-2 remains unclear.

Endoscopies

Several studies have examined whether GI procedures such as en- doscopies can safely be performed on COVID-19 positive patients. A study conducted in northern Italy identified 23 COVID-19 patients pre- senting with signs of upper GI bleeding, therefore necessitating urgent endoscopy [75]. The virus has been detected in biopsies of the esopha- gus, stomach, duodenum, and rectum [76]. Since endoscopes are in con- tact with mucus membrane and body fluids, it is possible that these instruments can be implicated in transmission the virus [77]. As such, most guidelines recommend the use of Personal protective equipment during endoscopic examination in order to prevent nosocomial outbreaks of COVID-19 [78-81]. When the virus is highly suspected or confirmed, double gloves and N95 or FFP2/3 masks are indicated and the operative team should be properly trained to wear and remove PPE safely [79].

Renal symptoms

SARS-CoV-2 can have a profound impact on the renal system. Early research has determined that COVID-19 can directly infect kidney tu- bules and cause acute tubular damage and subsequent renal failure [82,83]. An analysis of kidney findings at autopsy of 26 COVID-19 posi- tive patients in Wuhan showed tubular injury and direct viral infiltra- tion of the tubular epithelium [84,85]. Data also suggests that renal dysfunction may be multifactorial due to cytokine storm, hemodynamic changes, direct viral toxicity, or thrombotic microangiopathy [86]. Renal deterioration has been associated with a 5.3-fold increased mortality in COVID-19 patients. Often these patients demonstrate radiographic evi- dence of kidney dysfunction, such as renal interstitial inflammation and edema on CT [87]. A recent published report detailed the case of an African American male patient who presented with acute kidney in- jury due to collapsing glomerulopathy in the context of a COVID-19 in- fection without any signs of respiratory disease, indicating that renal manifestations of COVID-19 are possible even in patients with other- wise mild symptoms [85].

Renal laboratory abnormalities & disease severity

While research suggests that advanced age, organ failure, and ele- vated d-dimer levels are indicators of poor prognosis in COVID-19 pa- tients, a recent study highlights kidney dysfunction as a potential risk factor for mortality, as well [13,87]. A multi-center retrospective study of 193 COVID-19 patients (128 with non-severe disease, 65 severe) in- vestigated the presence of kidney dysfunction and demonstrated that, on admission, 59% of patients had proteinuria, 44% had hematuria, 14% had elevated BUN, and 10% had elevated creatinine levels [87]. These lab derangements were found to be significantly worse in those with critical illness (including non-survivors), and 66% of the patients who developed an AKI (43/65) were considered to have severe disease [87]. Per Pei at el., 75.4% of patients with COVID-19 had an abnormal Urine dipstick at initial presentation [88]. These findings have been reproduced by several other studies which have shown that develop- ment of an AKI is a common lab finding in COVID-19 and a feature of

Table 2

Studies with COVID-19 patients presenting with GI symptoms.

Authors	Publication year	Type of study	Number of patients	GI symptoms (%)
Azwar et al. [52]	2020	Case report	1	Epigastric pain, vomiting
Xu et al. [53]	2020	Retrospective case series	62	Diarrhea (8%)
Huang et al. [3]	2020	Prospective	41	Diarrhea (3%)
Pan et al. [54]	2020	Cross-sectional	204	Diarrhea (17%), vomiting (2%), abdominal pain (1%)
Jin et al. [58]	2020	Retrospective	651	Diarrhea (8.14%), nausea, vomiting
Zhang et al. [16]	2020	Retrospective	140	Nausea (17.3%), Diarrhea (12.9%), Anorexia (12.2%), Abdominal pain (5.8%),
Wang et al. [2]	2020	Retrospective case series	138	Belching (5%), Emesis (5%) Diarrhea (10.1%), Nausea (10.1%), Vomiting (3.6%), Abdominal pain (2.2%)
Nobel et al. [63]	2020	Case-control	278	Diarrhea (61%), Nausea (58%)

those with severe disease [5,10,43,89-91]. Patients with elevated creat- inine at admission were more likely to be admitted to the ICU [4,91-93]. Patients who survive COVID-19-related AKI have been shown to be at an increased risk of developing progressive CKD after the initial infec- tion [86]. The risk CKD is associated with the severity of the AKI and the presence or absence of tubular damage [94]. These results suggest that early recognition of kidney dysfunction in patients with SARS- CoV-2 is important for disposition and monitoring for potential decom- pensation and to reduce the progression to chronic kidney impairment.

Acute Kidney Injury and mortality

In addition to being a predictor of severe disease, Li et al. demon- strated that patients who developed an AKI had a 5.3-fold increased risk of mortality compared to those without kidney abnormalities, illus- trating the importance of renal dysfunction as a negative prognostic indicator for survival [87]. Chen et al. also determined that 25% of non- survivors had developed an AKI during hospitalization [43]. One study noted that the kidney was the third most commonly damaged organ after the lungs and heart in those who died due to COVID-19 [89]. A consecutive cohort study of 710 COVID-19 positive patients confirmed that markers of kidney dysfunction such as elevated BUN and creatinine were independent risk factors for in-hospital death even after adjusting for potential confounders [91]. Mortality for those who presented with evidence of renal failure on admission was 33.7% vs. 13.2% in those with- out kidney dysfunction [91]. Similarly, Pei et al. demonstrated that pa- tients with Renal involvement had higher overall mortality compared to those without (11.2% vs 1.2%) [88]. Patients with chronic kidney disease are particularly vulnerable to Negative outcomes. A recent meta-analysis confirmed that those with pre-existing renal dysfunction appeared to have significantly higher pneumonia-related mortality than those with- out underlying renal disease and are at increased risk for severe COVID- 19 infection [95,96].

When comparing SARS-CoV-2 with SARS-CoV, AKI was a much less common finding (6%) during the 2003 outbreak of SARS, but it was rec- ognized as a significant indicator of mortality (92% of SARS patients with AKI died) [92]. Similarly, renal dysfunction was also associated with in- creased risk of death in patients infected with H1N1 [93]. Evidence of the prognostic implications of kidney injury in other serious respiratory viruses highlights the importance of recognizing dysfunction early in the disease course in order to improve morbidity and mortality. Early recognition and treatment of renal dysfunction may help to improve the prognosis of those infected with COVID-19.

Dermatologic symptoms

Based on a study of 1099 confirmed COVID-19 cases in Wuhan, China, the most common symptoms included fever (43.8% of patients were febrile on admission, and 88.7% of patients became febrile during their hospital stay), cough (67.8%), and fatigue (38.1%). However, the study did note that 2 patients (0.2%) had rashes but did elaborate fur- ther [5]. There are several mentions in the literature of the dermatologic manifestations of SARS-CoV-2, but a predictable pattern has yet to emerge in the research.

Cutaneous symptoms in COVID-19 patients

Dermatologists have become increasingly involved in caring for COVID-19 patients due to shifting clinical responsibilities during the pandemic, thus sparking an interest in the possible cutaneous manifes- tations of SARS-CoV-2. Recalcati, an Italian dermatologist, looked at a cohort of 88 COVID-19 positive patients and determined that 18 (20.4%) developed skin symptoms [97]. The manifestations reported were erythematous rash (15.9%), generalized urticaria (3.41%) and chicken pox-like lesions (1.14%) [97]. Dermatologists in Rome identified

2 of 130 patients with COVID-19 who presented with isolated

herpetiform lesions on their trunk during their inpatient stays [98]. A patient in Barcelona exhibited vesicular lesions on her back 8 days

after COVID-19 diagnosis [98]. A multicenter case series of 22 patients in Italy described a varicella-like exanthem as a specific cutaneous man- ifestation of the virus [99]. Furthermore, the study showed that median time from onset of systemic symptoms (fever, fatigue, or cough) to pre- sentation of the exanthem was 3 days with a median duration of 8 days [99]. 54.5% of patients had vesicular lesions on the trunk, and the lesions were scattered in the majority of cases (72.7%) [99]. 7 of the 22 patients underwent skin biopsy and demonstrated histology consistent with viral infection.

Several case reports have also described the potential skin manifes- tations of COVID-19. A cluster of eight children in the U.K. presented with features similar to atypical Kawasaki including the archetypal skin rash appearance [100]. Following this report, additional cases with similar presentation were observed across the globe. Henry et al. outlined the case of a 27-year-old female who presented with pruritic disseminated erythematous plaques without cough or fever. Two days later she tested positive for COVID-19 after the onset of chest pain and fever [101]. Another case report discussed a 28-year-old female who de- veloped confluent “erythematous-yellowish” papules that progressed to pruritic, hardened plaques 13 days after testing positive for COVID- 19 [102]. Joob and Wiwanitkit detailed the case of a petechial eruption and thrombocytopenia initially thought to be dengue fever, but ulti- mately proven to be COVID-19 after the development of respiratory symptoms [103]. Amatore et al. discussed a 39-year-old male who complained of fever and exhibited “erythematous and edematous non-pruritic annular fixed plaques involving the upper limbs, chest, neck, abdomen and palms, sparing the face and mucous membranes” without cough or dyspnea [104]. The patient was tested for and diag- nosed with COVID-19 after reporting exposure to a family member with the virus. Similarly, Van Damme et al. examined cases of dissemi- nated urticaria in two febrile patients who later developed respiratory symptoms and tested positive for COVID-19 [105].

Cutaneous reactions secondary to drug exposure

Dermatologists have been challenged with differentiating between infectious and allergic etiologies of rashes associated with COVID-19, since they are both clinically and histologically similar. Many of the medication combinations currently under investigation for the treat- ment of the virus may lead to drug eruptions [106]. In a study of 140 COVID-19 patients by Zhang et al., drug hypersensitivity (11.4%) and ur- ticaria (1.4%) were the most prevalent cutaneous symptoms associated with the virus [16]. Jimenez-Cauhe et al. described a patient with “erythemato-purpuric, millimetric, coalescing macules, located in flex- ural regions” that developed 3 days into treatment with hydroxychloroquine and lopinavir/ritonavir [107]. It was unclear whether these lesions were a manifestation of SARS-CoV-2 or an ad- verse reaction to the medications; however, there are no additional re- ports of dermatological symptoms in patients treated with this Combination therapy [107]. Another report described Sterile pustules, similar to the typical findings of Acute generalized exanthematous pustulosis , as a cutaneous manifestation of COVID-19 [108]. Al- though AGEP is classically associated with drugs, it is possible that COVID-19 can predispose certain patients to develop AGEP-like cutane- ous eruptions as a late-onset manifestation of the infection.

Cutaneous reactions secondary to Hypercoagulable states

In addition to potential drug hypersensitivity or direct viral infection of the skin, Manalo et al. hypothesized that underlying DIC and microthrombi may contribute to cutaneous symptoms [109]. The study described two cases of unilateral transient livedo reticularis in non-critically ill COVID-19 positive patients. Similarly, a retrospective study of 7 critically ill patients in Wuhan, China exhibited significant Limb ischemia with plantar plaques and acral cyanosis as dermatologic manifestations of their underlying hypercoagulable state [110].

neurologic symptoms“>Neurologic manifestations“>While the cutaneous manifestations of COVID-19 can vary, early identification of unusual lesions in those without a known trigger is cru- cial to limiting the spread of COVID-19.

Neurologic symptoms

Recent studies have indicated that the SARS-CoV-2 is similar in tax- onomy and sequence to the SARS-CoV virus [111]. The virus utilizes a spike Protein S1 to attach to the host membrane by interacting with host ACE-2 receptor, which is found on neurons, Endothelial cells, kid- neys, lungs, and Small intestine [112]. Upon entering the cell, it initiates an immune cascade which stimulates CD4⁺ T cells, and this sequence of events activates macrophages to produce IL-6, leading to a cytokine storm and eventual systemic destruction of tissues [113]. There are sev- eral neurological manifestations of the virus that are important to rec- ognize and treat early.

The Nervous System & Respiratory Distress

The SARS-CoV-2 virus is known to cause severe respiratory distress through direct invasion into the lung parenchyma as evidenced by the destructive pattern seen on imaging of COVID-19 positive patients. However, some patients with evidence of significant lung damage and severe hypoxic do not develop tachypnea [114]. Scientists have hypoth- esized that there is an abnormal response of the peripheral afferent fi- bers in the lungs and airways that stimulate respiration [114]. Direct entry of the virus into brain tissue, notably the brainstem, may also re- sult in the loss of involuntary control of breathing [115,116].

Neurologic Manifestations

SARS-CoV-2 is believed to enter the nervous system via hematoge- nous spread, directly through the cribriform plate, or through retro- grade neuronal synapses from the olfactory bulb and vagal afferents [111,113,117,118]. Upon entering the nervous system, it can manifest as a viral encephalitis, cerebrovascular disease, or Peripheral nerve symptoms [117,119,120].

• Viral Encephalitis. Various case reports summarized in Table 3 suggest that COVID-19 causes symptoms consistent with meningoen- Peripheral nervous system“>cephalitis [121-124]. Some COVID-19 positive patients presented with altered mental status and fever, and CSF studies showed elevated lym- phocyte count but a negative viral biofire [121-124]. Though these pre- sentations could not be definitively linked to the virus due to the lack of CSF SARS-CoV-2 testing at the time, no other etiology for the viral menin- goencephalitis was found in this COVID-19 positive cohort. A study con- ducted at the Beijing Ditan Hospital did confirm the presence of SARS- CoV-2 in the cerebrospinal fluid of patients with known COVID-19 and symptomsconsistentwith encephalitis by genome sequencing[125]. Ev- idence of infectious toxic encephalitis was also found when cerebral edema was identified during autopsy of COVID-19 patients [38]. A re- cently published report detailed the case of serious neurologic damage and mental abnormalities in a patient whose infection was confirmed by IgM and IgG antibodies in the CSF despite negative nasopharyngeal swabs. After the initial presentation of fatigue and headaches, the patient suddenly developed the Inability to walk, uroclepsia, coprolalia, and de- lusions. His CSF studies were strongly positive for SARS-CoV-2 antibod- ies, and after weeks of antiviral and antipsychotic treatment, he was discharged with mild hand tremors and fatigue [126].

  Cerebrovascular disease

  Psychiatric symptoms“>A large retrospective study of 221 patients with COVID-19 at the Union hospital in Wuhan found that 5% of patients presented with acute ischemic stroke, one patient developed cerebral venous sinus thrombosis (CVST), and one had cerebral hemorrhage [127,128]. Those with cerebrovascular disease were significantly older (71.6 +- 15.7 years vs 52.1 +- 15.3 years; p < 0.05) and had Cardiovascular risk factors. Lab evaluation of this cohort determined that they were

  more likely to have elevated CRP and d-dimer, lymphopenia, thrombo- cytopenia, and uremia [127-129].

  Cerebral hemorrhage is thought to be a consequence of the virus bind- ing to ACE-2 receptors on endothelium, contributing to break down of the blood brain barrier [117,120]. Ischemic changes and CVST are likely sec- ondary to a hypercoagulable and pro-inflammatory state, further sup- ported by elevation in CRP and d-dimer in these patients [117,128,129]. Numerous other studies summarized in Table 2 discuss presentations of cerebrovascular disease in COVID-19 patients [120,128,129].

  While it is theorized in many of the aforementioned studies that pa- tients who are COVID-19 positive are at increased risk for cerebral ische- mia, research out of Piacenza, Italy noted decreased rates of admission for stroke. They reported only 6 admissions for CVA from February 21, 2020 to March 25, 2020 compared to their normal monthly average of approximately 51 cases [130]. The authors put forth a number of theo- ries for these findings, such as thrombocytopenia or the potential neu- roprotective role of IL-6. Research related to CVA incidence in the time of COVID is currently mixed, and further studies need to be conducted to corroborate these findings.

  • Seizures. Since many studies have demonstrated that COVID-19 patients are at increased risk for encephalopathy and cerebrovascular disorders, it has been theorized that these clinical scenarios could lead to seizures [127-129]. However, a large multi-center retrospective study of 304 COVID-19 positive patients in China study evaluated sei- zure activity in a cohort of patients with no prior history of epilepsy [121]. Only two patients were identified as having Seizure-like activity despite the presence of potentially predisposing hypoxia or electrolyte abnormalities in the majority of the cohort. Both patients were later found to have severe electrolyte abnormalities, and symptoms im- proved with correction [121]. A study of 111 COVID-19 patients within the New York academic hospital system investigated EEG abnormalities among infected patients. This study showed that the most frequent EEG finding was generalized slowing (57%) and epileptiform findings were observed in 30% and seizures in 7% (4% were non-convulsive seizures). The study also concluded that only a history of epilepsy and definite clinical seizures prior to EEG testing independently predicted epilepti- form findings on EEG [131].

  • Peripheral nervous system. Though most research efforts have been focused on identifying CNS dysfunction in SARS-CoV-2, some stud- ies have discussed the effect on the peripheral nervous system. One case series reported on a patient with COVID-19-related Miller-Fisher syn- drome and another with polyneuritis cranialis. The first patient devel- oped characteristic features with external ophthalmoplegia, ataxia, and loss of tendon reflexes and recovered after being treated with IVIG [132]. The second had ageusia, areflexia, and abducens palsy consistent with polyneuritis cranialis, which spontaneously and rapidly improved [132]. A large retrospective study by Mao L et al. determined that 5% of patients had hypogeusia and another 5% had hyposmia [129]. Several Chinese studies indicated that up to 70% of patients complained of myal- gias with increases in creatine kinase (CK) present in up to 33%, suggest- ing a possible SARS-CoV-2 Viral myositis [2,3,28,124,133]. A recently published report details the case of acute transverse myelitis after a com- plicated SARS-CoV-2 infection. The patient developed hypotonia in both lower limbs with absent distal reflexes. An MRI with gadolinium contrast showed increased T2 signal between C7-T12 with an LP significant for an elevated IgG index and a positive RT-PCR for SARS-CoV-2. He recovered one week later after treatment with IVIG [134].

    Psychiatric symptoms

    With the rise of COVID-19 cases in the US, social distancing measures have continued significantly past their predicted duration, likely con- tributing to increased anxiety, depression, and loneliness. Prior epi- demics have negatively impacted the psychological health of the

    Table 3

    Studies with COVID-19 patients presenting with neurologic symptoms.

    Study (locations, date)	Methods	Number of Patients	Neurologic Manifestations (% of patients)	Lab Abnormalities
    Mao L, et al. (Wuhan China, 2020) [129]	Retrospective Analysis	214	CNS: Dizziness (16.8%) Headache (13.1%)	CNS: Lower Lymphocyte count, lower platelet count and higher BUN
    			impaired consciousness (8%) Acute cerebrovascular problems (3%) Ataxia (0.5) Seizures (0.5%) PNS: Hypogeusia (5.6%) Hyposmia (5.1%)	PNS: Higher CK
    Li, Y. et al. (Wuhan, China 2020) [128] Lu, L et al. (Hubei, Sichuan, and	Retrospective Analysis Retrospective Multi-Centered	221 306	Acute ischemic stroke (5%) Cerebral venous sinus thrombosis (0.5%) Cerebral hemorrhage (0.5%) Encephalopathy	Elevated CRP and D Dimer: C-reaction protein N/A
    Chongqing China 2020) [121] Gutierrez-Ortiz C, et al. (Madrid,	Study Case Report	2	(2.6%) Seizure (0.7%) Miller-Fisher syndrome	Albumincytologic
    Spain 2020) [132] Duong L, et al.	Case Report	1	Polyneuritis Cranialis Meningoencephalitis	dissociation CSF: High lymphocyte count,
    (Los Angeles, USA, 2020) [122] Yin R, et al. (Wuhan, China,	Case Report	1	Encephalitis	protein elevated and glucose was normal. Negative HSV PCR Lymphocyte count:
    2019) [123]				3.3 x 109/L and C-reactive
    Zhang J et al. (Wuhan, China	Retrospective Analysis	603	Headache (3%)	protein (CRP) level, 10.74 mg/L Decreased Lymphocyte
    2020) [124] Huang C et al. (Wuhan, China	Prospective Study	41	Dizziness (3.5%) Unconsciousness (1.5%) CNS:	Counts, Elevated CRP, Increased LFTs, Elevated Creatinine Low lymphocyte count,
    2019) [3]			Headache (8%)	Elevated D dimer, Elevated
    Wang et al. (Wuhan, China	Retrospective Analysis	138	PNS: Myalgias (44%) Dizziness (9%)	LFTs, normal procalcitonin Low lymphocyte count,
    2020) [2] Yang X et al. (Wuhan, China	Retrospective Analysis	52	Headache (7%) Headache (6%)	Elevated Prothrombin Time, Increased LDH Low lymphocyte count
    2020) [28] Chen N et al. (Wuhan, China	Retrospective Analysis	99	PNS: Myalgia (10%) Confusion (9%) Headache (8%)	Low Lymphocyte count, Low
    2020) [4]				platelets, Low hemoglobin, Increased LDH, Increased D dimer, Increased CRP

    population. A prospective study conducted during the 2003 SARS epi- demic in Hong Kong demonstrated that stress, dysphoria, impaired sleep and concentration were much greater among infected individuals than controls, and 25% of the patients requested follow-up for the neg- ative Psychological effects of being infected [135]. A study examining psychiatric symptoms in SARS survivors one year later indicated that these patients experienced persistent distress with 64% scoring above the GHQ12 threshold for psychiatric morbidity [136]. Additionally, in- fected healthcare workers who survived showed significantly higher social isolation and mental healt”>stress levels, more depression, and symptoms consistent with PTSD [136]. Based on this research, it is possible we will see similar patterns of anxiety, depression and other psychiatric symptoms in those cur- rently affected by COVID-19.

    Cause of psychiatric symptoms

    The Psychological impact of this pandemic is likely multifacto- rial, due in parts to self-isolation, fear of infection, uncertainty, fi- nancial woes, job insecurity, and pre-existing mental health conditions. A recent study out of China using online surveys deter- mined that 16.5% of respondents exhibited moderate to severe de- pressive symptoms, and 28.8% reported severe anxiety [137]. Of

    these respondents, 75.2% attributed their increased anxiety to fear that they or their family members could contract COVID-19 [137]. Misinformation and uncertainly can raise anxiety levels in both healthy individuals and those with preexisting psychiatric conditions [138]. Lunn et al. observed that the absence of effective disease treatment and the uncertainty regarding outcomes for those infected has led to mass panic and anxiety [139]. In addition, the rapid spread of misinformation and bias has induced fear, prej- udice, and xenophobia [140,141].

    Social isolation and mental health

    One of the major consequences of the pandemic is increased social isolation, a risk factor that is strongly associated with de- pression, self-harm, and suicide [142-144]. Older adults are espe- cially vulnerable to the mental health ramifications of social isolation, particularly those in residential care [145]. Mental health experts have stressed the importance of research examining the rates of anxiety, depression, and other psychiatric symptoms to in- form interventions during this public health crisis [142]. An analy- sis of emotional indicators on the Chinese social media platform Weibo during the height of their COVID-19 crisis demonstrated

    that anxiety and depression increased while positive emotional in- dicators (Oxford happiness) decreased [146]. The study also ana- lyzed linguistic expression and determined that there was an increase in the use of the words “health” and “family” and a de- crease in “leisure” and “friend”, highlighting the rapidly evolving priorities in this population during the pandemic [146].

    Patients with pre-existing mental health conditions are both more vulnerable to the psychological impacts of the pandemic and at increased risk of infection, likely due to cognitive impair- ment, diminished efforts for personal protection, lack of awareness of their personal risk, and discrimination [147]. Patients with se- vere Mental illness are also more vulnerable due to significantly higher rates of both homelessness and smoking [148]. Many pa- tients have reported poor adherence to medication during this time, disruption of mental health services, and suspension of sub- stance abuse treatment [149]. Lastly, the close proximity with which many Homeless patients with mental illness live is a signif- icant risk factor for the spread of the virus.

    Psychiatric Manifestations of COVID-19 Infection

    There is some emerging research that suggests a link between COVID-19 infection and severe psychiatric symptoms. A cross- sectional study of 112 patients with COVID-19 reported higher levels of somatization, depression, anxiety, phobias, sleep distur- bances, and eating disorders in infected patients compared to the healthy population [150]. Case reports have detailed the psychiat- ric presentations of patients with SARS-CoV-2 both during their Acute infections and post- clinical recovery. One such patient pre- sented to the hospital with extreme anxiety, suicidal ideation, ag- itation, and hallucination [151]. A case series out of Spain examined viral involvement in new-onset psychiatric symptoms. They discussed several patients who presented to the hospital with psychosis and concomitant infection with SARS-CoV-2 with- out any known history of prior mental health disorders [ 152]. While neither of these reports was able to establish whether the patients’ psychoses were primary or secondary (related to treat- ment or Acute delirium), these findings suggest the need for addi- tional research on the neuropsychiatric manifestations of COVID- 19 infection.

    effective management of mental health problems during the pandemic has proven challenging, especially as infectious concerns inhibit face to face evaluation, and the influx of COVID-19 cases has consumed Healthcare resources. The rapid spread of infection has led to increased rates of depression, anxiety, and feelings of self-isolation within the community. Additionally, some evidence suggests that COVID-19 can present with primary or secondary psychiatric symptoms. More research needs to be performed to fully assess the mental health burden of this crisis, particularly with regard to vulnerable populations.

    Conclusions

    The COVID-19 pandemic has resulted in massive, widespread eco- nomic and public health hardships. While several therapies are still under investigation, there remains no definitive treatment for SARS- CoV-2. Many clinical trials are ongoing, and treatment of COVID-19 cur- rently includes supportive care and symptomatic management. Community-wide public health containment strategies consist of social isolation, distancing, face coverings, and travel restrictions. Despite these efforts, the virus continues to spread, highlighting an even greater need for additional research into the pathophysiology, clinical presenta- tions, and treatment modalities for SARS-CoV-2. Ultimately, it is critical for Frontline healthcare workers to understand and recognize the many clinical manifestations of COVID-19 in order to better protect them- selves, efficiently identify potentially infected patients, and prevent nos- ocomial outbreaks.

    Financial support

    This is a non-funded study, with no compensation or honoraria for conducting the study.

    Declaration of Competing Interest

    The authors do not have a financial interest or relationship to dis- close regarding this research project.

    References

    1. WHO Timeline - COVID-19 [Internet]. [cited 2020 Jun 12]; Available from https:// www.who.int/news-room/detail/27-04-2020-who-timeline-covid-19; 2020.
    2. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323 (11):1061-9.
    3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.
    4. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The Lancet. 2020;395(10223):507-13.
    5. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-20.
    6. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbid- ities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. JAMA. 2020;323(20):2052-9.
    7. Frater JL, Zini G, d’Onofrio G, Rogers HJ. COVID-19 and the clinical hematology lab- oratory. Int J Lab Hematol. 2020;42(Suppl 1):11-8.
    8. Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020;180(7):934-43.
    9. Lippi G, Plebani M. Laboratory abnormalities in patients with COVID-2019 infec- tion. Clin Chem Lab Med. 2020;58(7):1131-4.
    10. Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergo- ing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020;21:100331.
    11. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill pa- tients with COVID-19 in Washington state. JAMA. 2020;323(16):1612-4.
    12. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in critically Ill patients in the Seattle region - case series. N Engl J Med. 2020;382(21):2012-22.
    13. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpa- tients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020;395(10229):1054-62.
    14. Fan BE, Chong VCL, Chan SSW, et al. Hematologic parameters in patients with COVID-19 infection. Am J Hematol. 2020;95(6):E131-4.
    15. Deng Y, Liu W, Liu K, et al. Clinical characteristics of fatal and recovered cases of co- ronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study. Chin Med J (Engl). 2020;133(11):1261-7.
    16. Zhang J, Dong X, Cao Y, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. 2020;75(7):1730-41.
    17. Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hos- pitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020;5(7): 802-10.
    18. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-7.
    19. Han H, Yang L, Liu R, et al. Prominent changes in blood coagulation of patients with SARS-CoV-2 infection. Clin Chem Lab Med CCLM. 2020;58(7):1116-20.
    20. Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagu- lopathy. J Thromb Haemost. 2020;18(5):1094-9.
    21. Giannis D, Ziogas IA, Gianni P. coagulation disorders in coronavirus infected pa- tients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virol. 2020;127:104362.
    22. Lillicrap D. Disseminated intravascular coagulation in patients with 2019-nCoV pneumonia. J Thromb Haemost. 2020;18(4):786-7.
    23. Terpos E, Ntanasis-Stathopoulos I, Elalamy I, et al. Hematological findings and com- plications of COVID-19. Am J Hematol. 2020;95(7):834-47.
    24. Wang YD, Zhang SP, Wei QZ, et al. COVID-19 complicated with DIC: 2 cases report and literatures review. Zhonghua Xue Ye Xue Za Zhi Zhonghua Xueyexue Zazhi. 2020;41(0) E001.
    25. Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and Antiphospholipid antibodies in patients with Covid-19. N Engl J Med. 2020;382(17):e38.
    26. Zhang S, Liu Y, Wang X, et al. SARS-CoV-2 binds platelet ACE2 to enhance thrombo- sis in COVID-19. J Hematol OncolJ Hematol Oncol. 2020;13(1):120.
    27. Oudit GY, Kassiri Z, Jiang C, et al. SARS-coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS. Eur J Clin Invest. 2009;39(7): 618-25.
    28. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, obser- vational study. Lancet Respir Med. 2020;8(5):475-81.
    29. Lippi G, Lavie CJ, Sanchis-Gomar F. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): evidence from a meta-analysis. Prog Cardiovasc Dis. 2020;63(3):390-1.
    30. Lala A, Johnson KW, Januzzi JL, et al. Prevalence and impact of myocardial injury in patients hospitalized with COVID-19 infection. J Am Coll Cardiol. 2020;76(5): 533-46.
    31. Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-

        19. Am J Emerg Med. 2020;38(7):1504-7.

        Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020; 323(13):1239.

    32. Aladag N, Atabey RD. The role of concomitant cardiovascular diseases and cardiac biomarkers for predicting mortality in critical COVID-19 patients. Acta Cardiol. 2020:1-8.
    33. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan. China Inten- sive Care Med. 2020;46(5):846-8.
    34. Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for pa- tients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol. 2020;75(18):2352-71.
    35. Welt FGP, Shah PB, Aronow HD, et al. Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic. J Am Coll Cardiol. 2020;75(18): 2372-5.
    36. Sala S, Peretto G, Gramegna M, et al. Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection. Eur Heart J. 2020;41(19):1861-2.
    37. Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020;8(4):420-2.
    38. Liu Y, Yang Y, Zhang C, et al. Clinical and biochemical indexes from 2019-nCoV in- fected patients linked to viral loads and lung injury. Sci China Life Sci. 2020;63(3): 364-74.
    39. Liu K, Fang Y-Y, Deng Y, et al. Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. Chin Med J (Engl). 2020;133(9):1025-31.
    40. Bhatla A, Mayer MM, Adusumalli S, et al. COVID-19 and cardiac arrhythmias. Heart Rhythm. 2020;17(9):1439-44.
    41. Amaratunga EA, Corwin DS, Moran L, Snyder R. Bradycardia in Patients With COVID-19: a calm before the storm? Cureus. 2020;12(6):e8599.
    42. Chen T, Wu D, Chen H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020;368:m1091.
    43. Bottiroli M, De Caria D, Belli O, et al. Takotsubo syndrome as a complication in a critically ill COVID-19 patient. ESC Heart Fail. 2020. https://doi.org/10.1002/ehf2. 12912.
    44. Solano-Lopez J, Sanchez-Recalde A, Zamorano JL. SARS-CoV-2, a novel virus with an unusual cardiac feature: inverted takotsubo syndrome. Eur Heart J. 2020;41(32): 3106.
    45. Minhas AS, Scheel P, Garibaldi B, et al. Takotsubo syndrome in the setting of COVID-
        

        JACC Case Rep. 2020;2(9):1321-5.

    46. Meyer P, Degrauwe S, Van Delden C, Ghadri J-R, Templin C. Typical takotsubo syn- drome triggered by SARS-CoV-2 infection. Eur Heart J. 2020;41(19):1860.
    47. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol. 2020. https://doi.org/10.1002/jmv.25891 [Internet]. [cited 2020 May 6];Available from.
    48. Lee I-C, Huo T-I, Huang Y-H. Gastrointestinal and liver manifestations in patients with COVID-19. J Chin Med Assoc. 2020;1.
    49. Wong SH, Lui RN, Sung JJ. Covid-19 and the digestive system. J Gastroenterol Hepatol. 2020;35(5):744-8.
    50. Hormati A, Shahhamzeh A, Afifian M, Khodadust F, Ahmadpour S. Can COVID-19 present unusual GI symptoms? J Microbiol Immunol Infect. 2020;53(3):384-5.
    51. Azwar MK, Kirana F, Kurniawan A, Handayani S, Setiati S. Gastrointestinal presen- tation in COVID-19 in Indonesia: a case report. Acta Medica Indones. 2020;52(1): 63-7.
    52. Xu X-W, Wu X-X, Jiang X-G, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retro- spective case series. BMJ. 2020:m606.
    53. Pan L, Mu M, Yang P, et al. Clinical characteristics of COVID-19 patients with diges- tive symptoms in Hubei, China: a descriptive, cross-sectional. Multicenter Study Am J Gastroenterol. 2020;115(5):766-73.
    54. Siegel A, Chang PJ, Jarou ZJ, et al. Lung Base findings of coronavirus disease (COVID- 19) on abdominal CT in patients with predominant gastrointestinal symptoms. Am J Roentgenol. 2020:1-3.
    55. Li L, Huang T, Wang Y, et al. COVID-19 patients’ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol. 2020;92(6):577-83.
    56. Borges do Nascimento IJ, Cacic N, Abdulazeem HM, et al. Novel coronavirus infec- tion (COVID-19) in humans: a scoping review and meta-analysis. J Clin Med. 2020;9(4):941.
    57. Jin X, Lian J-S, Hu J-H, et al. Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. Gut. 2020;69(6):1002-9.
    58. Yang X, Zhao J, Yan Q, Zhang S, Wang Y, Li Y. A case of COVID-19 patient with the diarrhea as initial symptom and literature review. Clin Res Hepatol Gastroenterol. 2020;S2210-7401(20):30085. https://doi.org/10.1016/j.clinre.2020.03.013.
    59. Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382(10):929-36.
    60. Wahab SF, Logstrup BB. Atypical manifestations of COVID-19 in General practice: a case of gastrointestinal symptoms. BMJ Case Rep. 2020;13(8):e237520.
    61. Henry BM, de Oliveira MHS, Benoit J, Lippi G. Gastrointestinal symptoms associated with severity of coronavirus disease 2019 (COVID-19): a pooled analysis. Intern Emerg Med. 2020;15(5):857-9.
    62. Nobel YR, Phipps M, Zucker J, et al. Gastrointestinal symptoms and COVID-19: case- control study from the United States. Gastroenterology. 2020;59(1):373-5.
    63. Ibrahim YS, Karuppasamy G, Parambil JV, Alsoub H, Al-Shokri SD. Case report: par- alytic ileus: a potential extrapulmonary manifestation of severe COVID-19. Am J Trop Med Hyg. 2020. https://doi.org/10.4269/ajtmh.20-0894 [Internet]. [cited 2020 Sep 7];Available from http://www.ajtmh.org/content/journals/10.4269/ ajtmh.20-0894.
    64. Chen Y, Chen L, Deng Q, et al. The presence of SARS-CoV-2 RNA in the feces of COVID-19 patients. J Med Virol. 2020;92(7):833-40.
    65. Tian Y, Rong L, Nian W, He Y. Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;51(9): 843-51.
    66. Cheung KS, Hung IFN, Chan PPY, et al. Gastrointestinal Manifestations of SARS-CoV- 2 Infection and Virus Load in Fecal Samples from the Hong Kong Cohort and Sys- tematic Review and Meta-analysis. Gastroenterology. 2020;159(1):81-95.
    67. Xu Y, Li X, Zhu B, et al. Characteristics of pediatric SARS-CoV-2 infection and poten- tial evidence for persistent fecal viral shedding. Nat Med. 2020;26(4):502-5.
    68. Zhang J, Wang S, Xue Y. Fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia. J Med Virol. 2020;92(6):680-2.
    69. Zhang H, Kang Z, Gong H, et al. The digestive system is a potential route of 2019- nCov infection: a bioinformatics analysis based on single-cell transcriptomes [In- ternet]. Microbiology. 2020. https://doi.org/10.1101/2020.01.30.927806 [cited 2020 May 6]. Available from.
    70. Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential fecal- oral transmission. Gastroenterology. 2020;158(6):1518-9.
    71. Li LY, Wu W, Chen S, et al. Digestive system involvement of novel coronavirus in- fection: prevention and control infection from a gastroenterology perspective. J Dig Dis. 2020;21(4):199-204.
    72. Nouri-Vaskeh M, Alizadeh L. Fecal transmission in COVID-19: a potential shedding route. J Med Virol. 2020;1:jmv.25816. https://doi.org/10.1002/jmv.25816 [Inter- net]. [cited 2020 May 6];Available from http://doi.wiley.com/10.1002/jmv.25816.
    73. Kotfis K, Skonieczna-Zydecka K. COVID-19: gastrointestinal symptoms and potential sources of 2019-nCoV transmission. Anaesthesiol Intensive Ther. 2020; 52(2):171-2.
    74. Mauro A, De Grazia F, Lenti MV, et al. Upper gastrointestinal bleeding in COVID-19 inpatients: incidence and management in a multicenter experience from northern Italy. Clin Res Hepatol Gastroenterol. 2020;S2210-7401(20):30216. https://doi.org/ 10.1016/j.clinre.2020.07.025 S2210740120302163.
    75. Lin L, Jiang X, Zhang Z, et al. Gastrointestinal symptoms of 95 cases with SARS-CoV-

        2 infection. Gut. 2020;69(6):997-1001.

        Perisetti A, Gajendran M, Boregowda U, Bansal P, Goyal H. COVID-19 and gastroin- testinal endoscopies: current insights and emergent strategies. Dig Endosc. 2020. https://doi.org/10.1111/den.13693 [Internet]. [cited 2020 May 6];Available from http://doi.wiley.com/10.1111/den.13693.

    76. Rah KH, Platovsky A. Determining urgent/emergent status of gastrointestinal (GI) Endoscopic procedures in an ambulatory care setting during the coronavirus dis- ease of 2019 (COVID-19) pandemic: additional factors that need to be considered. Anesth Analg. 2020;1. https://doi.org/10.1213/ANE.0000000000004861.
    77. Castro Filho EC, Castro R, Fernandes FF, Pereira G, Perazzo H. Gastrointestinal en- doscopy during the COVID-19 pandemic: an updated review of guidelines and statements from international and national societies. Gastrointest Endosc. 2020; 92(2):440-5.
    78. Ang T, Li J, Vu C, et al. Chapter of gastroenterologists professional guidance on risk mitigation for gastrointestinal endoscopy during COVID-19 pandemic in Singapore. Singapore Med J. 2020;61(7):345-9.
    79. Ang TL. Gastrointestinal endoscopy during COVID-19 pandemic. J Gastroenterol Hepatol. 2020;35(5):701-2.
    80. Diao B, Wang C, Wang R, et al. Human kidney is a target for novel severe acute respiratory syndrome coronavirus 2 infection [Internet]. Infectious Dis. 2020. https://doi.org/10.1101/2020.03.04.20031120 (except HIV/AIDS). [cited 2020 May 6]. Available from http://medrxiv.org/lookup/ doi/10.1101/2020.03.04.20031120.
    81. Perico L, Benigni A, Remuzzi G. Should COVID-19 concern nephrologists? Why and to what extent? The emerging impasse of angiotensin blockade. Nephron. 2020:1-9.
    82. Su H, Yang M, Wan C, et al. Renal Histopathological analysis of 26 postmortem find- ings of patients with COVID-19 in China. Kidney Int. 2020;98(1):219-27.
    83. Peleg Y, Kudose S, D’Agati V, et al. Acute kidney injury due to collapsing glomeru- lopathy following COVID-19 infection. Kidney Int Rep. 2020;5(6):940-5.
    84. Khoshdel-Rad N, Zahmatkesh E, Shpichka A, Timashev P, Vosough M. Outbreak of chronic renal failure: will this be a delayed heritage of COVID-19? J Nephrol. 2020:1-3. https://doi.org/10.1007/s40620-020-00851-9.
    85. Anti-2019-nCoV Volunteers, Li Z, Wu M, et al. Caution on kidney dysfunctions of COVID-19 patients. [Internet] Infect Dis. 2020. https://doi.org/10.1101/2020.02. 08.20021212 (except HIV/AIDS). [cited 2020 May 6]. Available from http:// medrxiv.org/lookup/doi/10.1101/2020.02.08.20021212.
    86. Pei G, Zhang Z, Peng J, et al. Renal involvement and early prognosis in patients with COVID-19 pneumonia. J Am Soc Nephrol. 2020;31(6):1157-65.
    87. Li X, Wang L, Yan S, et al. Clinical characteristics of 25 death cases with COVID-19: a retrospective review of medical records in a single medical center, Wuhan, China. Int J Infect Dis. 2020;94:128-32.
    88. Cai G. Bulk and single-cell transcriptomics identify tobacco-use disparity in lung gene expression of ACE2, the receptor of 2019-nCov [Internet]. medrxiv. 2020.

        https://doi.org/10.1101/2020.02.05.20020107 [cited 2020 May 6]. Available from https://www.preprints.org/manuscript/202002.0051/v2.

        Cheng Y, Luo R, Wang K, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int. 2020;97(5):829-38.

    89. Chu KH, Tsang WK, Tang CS, et al. Acute Renal impairment in coronavirus- associated severe acute respiratory syndrome. Kidney Int. 2005;67(2):698-705.
    90. Jung JY, Park BH, Hong S-B, et al. Acute kidney injury in critically ill patients with pandemic influenza a pneumonia 2009 in Korea: a multicenter study. J Crit Care. 2011;26(6):577-85.
    91. Schiffl H, Fischer R. Clinical cause of presumed acute tubular necrosis requiring renal replacement therapy and outcome of critically ill patients: post hoc analysis of a prospective 7-year cohort study. Int Urol Nephrol. 2012;44(6):1779-89.
    92. Henry BM, Lippi G. Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID-19) infection. Int Urol Nephrol. 2020;52(6):1193-4.
    93. Sarnak MJ, Jaber BL. Pulmonary infectious mortality among patients with end-stage renal disease. Chest. 2001;120(6):1883-7.
    94. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. 2020;34(5):e212-3.
    95. Tammaro A, Adebanjo GAR, Parisella FR, Pezzuto A, Rello J. Cutaneous manifesta- tions in COVID-19: the experiences of Barcelona and Rome. J Eur Acad Dermatol Venereol. 2020;34(7):e306-7.
    96. Marzano AV, Genovese G, Fabbrocini G, et al. Varicella-like exanthem as a specific COVID-19-associated skin manifestation: multicenter case series of 22 patients. J Am Acad Dermatol. 2020;83(1):280-5.
    97. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. The Lancet. 2020;395(10237):1607-8.
    98. Henry D, Ackerman M, Sancelme E, Finon A, Esteve E. Urticarial eruption in COVID- 19 infection. J Eur Acad Dermatol Venereol. 2020;34(6):e244-5.
    99. Estebanez A, Perez-Santiago L, Silva E, Guillen-Climent S, Garcia-Vazquez A, Ramon MD. Cutaneous manifestations in COVID-19: a new contribution. J Eur Acad Dermatol Venereol [Internet]. 2020;34(6):e250-1.
    100. Joob B, Wiwanitkit V. COVID-19 can present with a rash and be mistaken for den- gue. J Am Acad Dermatol. 2020;82(5):e177.
    101. Amatore F, Macagno N, Mailhe M, et al. SARS-CoV-2 infection presenting as a fe- brile rash. J Eur Acad Dermatol Venereol [Internet]. 2020;34(7):e304-6.
    102. van Damme C, Berlingin E, Saussez S, Accaputo O. Acute urticaria with pyrexia as the first manifestations of a COVID-19 infection. J Eur Acad Dermatol Venereol. 2020;34(7):e300-1.
    103. Zheng Y, Lai W. Dermatology staff participate in fight against Covid-19 in China. J Eur Acad Dermatol Venereol [Internet]. 2020;34(5):e210-1.
    104. Jimenez-Cauhe J, Ortega-Quijano D, Prieto-Barrios M, Moreno-Arrones OM, Fernandez-Nieto D. Reply to “COVID-19 can present with a rash and be mistaken for Dengue”: Petechial rash in a patient with COVID-19 infection. J Am Acad Dermatol. 2020;83(2):e141-2.
    105. Ayatollahi A, Robati RM, Kamyab K, Firooz A. Late-onset AGEP -like skin pustular eruption following COVID -19: a possible association. Dermatol Ther. 2020; e14275. https://doi.org/10.1111/dth.14275.
    106. Manalo IF, Smith MK, Cheeley J, Jacobs R. A dermatologic manifestation of COVID- 19: transient livedo reticularis. J Am Acad Dermatol. 2020;83(2):700.
    107. Zhang Y, Cao W, Xiao M, et al. Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia. Zhonghua Xue Ye Xue Za Zhi Zhonghua Xueyexue Zazhi. 2020;41(0) E006.
    108. Baig AM. Neurological manifestations in COVID-19 caused by SARS-CoV-2. CNS Neurosci Ther. 2020;26(5):499-501.
    109. Baig AM, Khaleeq A, Ali U, Syeda H. Evidence of the COVID-19 virus targeting the CNS: tissue distribution, host-virus interaction, and proposed neurotropic mecha- nisms. ACS Chem Nerosci. 2020;11(7):995-8.
    110. Toljan K. Letter to the editor regarding the viewpoint “evidence of the COVID-19 virus targeting the CNS: tissue distribution, host-virus interaction, and proposed neurotropic mechanism”. ACS Chem Nerosci. 2020;11(8):1192-4.
    111. Bernat Bertran Recasens, Maria Martinez-Llorens J, Jose Rodriguez-Sevilla J, Angel Rubio M. Lack of dyspnea in Covid-19 patients; another neurological conundrum? Eur J Neurol [Internet]. 2020. https://doi.org/10.1111/ene.14265 [cited 2020 May 6];Available from https://onlinelibrary.wiley.com/doi/abs/10.1111/ene.14265.
    112. Li Y, Bai W, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. J Med Virol. 2020;92(6):552-5.
    113. Steardo L, Steardo L, Zorec R, Verkhratsky A. Neuroinfection may contribute to pathophysiology and clinical manifestations of COVID-19. Acta Physiol. 2020;229 (3):e13473.
    114. Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID- 19 and other coronaviruses. Brain Behav Immun [Internet]. 2020;87:18-22.
    115. Paybast S, Emami A, Koosha M, Baghalha F. Novel coronavirus disease (COVID-19) and central nervous system complications: what neurologist need to know. Acta Neurol Taiwan. 2020;29(1):24-31.
    116. Gautier J, Ravussin Y. A new symptom of COVID-19: loss of taste and smell. Obesity.

         2020;28(5):848.

         Wang H-Y, Li X-L, Yan Z-R, Sun X-P, Han J, Zhang B-W. Potential neurological symp- toms of COVID-19. Ther Adv Neurol Disord. 2020;13 175628642091783.

    117. Lu L, Xiong W, Liu D, et al. New onset acute symptomatic seizure and risk factors in coronavirus disease 2019: A retrospective multicenter study. Epilepsia. 2020;61 (6):e49-53.
    118. Duong L, Xu P, Liu A. Meningoencephalitis without respiratory failure in a young female patient with COVID-19 infection in Downtown Los Angeles, early April 2020. Brain Behav Immun. 2020;87:33.
    119. Yin R, Feng W, Wang T, et al. Concomitant neurological symptoms observed in a patient diagnosed with coronavirus disease 2019. J Med Virol. 2020. https://doi. org/10.1002/jmv.25888 [Internet]. [cited 2020 May 6];Available from http://doi. wiley.com/10.1002/jmv.25888.
    120. Zhang J, Wang X, Jia X, et al. Risk factors for disease severity, unimprovement, and mortality in COVID-19 patients in Wuhan, China. Clin Microbiol Infect. 2020;26(6): 767-72.
    121. Xiang. First case of 2019 novel coronavirus disease. Google Scholar [Internet]. 2020 [cited 2020 May 6];Available from https://scholar.google.com/scholar_lookup? title=First%20case%20of%202019%20novel%20coronavirus%20disease%20with%20 Encephalitis&journal=ChinaXiv%20T&volume=202003&publication_year=2020 &author=Xiang%2CP&author=Xu%2CXM&author=Gao%2CLL&author=Wang%2 CHZ&author=Xiong%2CHF&author=Li%2CRH.
    122. Wang M, Li T, Qiao F, Wang L, Li C, Gong Y. Coronavirus disease 2019 associated with aggressive neurological and mental abnormalities confirmed based on cere- brospinal fluid antibodies: a case report. Medicine (Baltimore). 2020;99(36): e21428.
    123. Li Y-C, Bai W-Z, Hashikawa T. Response to Commentary on The neuroinvasive po- tential of SARS-CoV-2 may play a role in the respiratory failure of COVID-19 pa- tients. J Med Virol [Internet]. 2020;92(7):707-9 [cited 2020 May 6];Available from http://doi.wiley.com/10.1002/jmv.25824.
    124. Li Y, Li M, Wang M, et al. Acute cerebrovascular disease following COVID-19: a sin- gle center, retrospective, observational study [published online ahead of print, 2020 Jul 2]. Stroke Vasc Neurol. 2020:svn-2020-000431. https://doi.org/10.1136/ svn-2020-000431.
    125. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683-90.
    126. Morelli N, Rota E, Terracciano C, et al. The baffling case of ischemic stroke disappearance from the casualty Department in the COVID-19 era. Eur Neurol. 2020:1-3.
    127. Pellinen J, Carroll E, Friedman D, et al. Continuous EEG findings in patients with COVID-19 infection admitted to a New York academic hospital system. Epilepsia. 2020:epi.16667. https://doi.org/10.1111/epi.16667.
    128. Gutierrez-Ortiz C, Mendez A, Rodrigo-Rey S, et al. Miller Fisher syndrome and poly- neuritis cranialis in COVID-19. Neurology. 2020;95(5):e601-5.
    129. Guidon AC, Amato AA. COVID-19 and neuromuscular disorders. Neurology. 2020; 94(22):959-69.
    130. Hazrati E, Farahani RH, Asl AN, Shahali H. Acute transverse myelitis after SARS- CoV-2 infection: a rare complicated case of rapid onset Paraplegia in a male. Re- search Square [Internet]. 2020:1. https://doi.org/10.21203/rs.3.rs-68798/v1 In Re- view. [cited 2020 Sep 10]. Available from https://www.researchsquare.com/ article/rs-68798/v1.
    131. Chua SE, Cheung V, McAlonan GM, et al. Stress and psychological impact on SARS patients during the outbreak. Can J Psychiatry Rev Can Psychiatr. 2004;49(6): 385-90.
    132. Lee AM, Wong JG, McAlonan GM, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry. 2007;52(4):233-40.
    133. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epi- demic among the general population in China. Int J Environ Res Public Health. 2020;17(5):1729.
    134. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public re- sponses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health con- sequences and target populations. Psychiatry Clin Neurosci. 2020;74(4):281-2.
    135. Lunn P, Belton C, Lavin C, Mc Gowan F, Timmons S, Robertson D. Using behavioural science to help fight the coronavirus. [Internet] Economic and Social Research In- stitute (ESRI); 2020 [cited 2020 May 6]. Available from: https://ideas.repec.org/p/ esr/wpaper/wp656.html.
    136. Department of Psychiatry and Psychological Medicine, University Hospital Centre Zagreb, Zagreb Croatia, Jakovljevic M, Bjedov S, et al. COVID-19 PANDEMIA and public and global mental health from the perspective of global health security. Psychiatr Danub. 2020;32(1):6-14.
    137. Hu Z, Yang Z, Li Q, Zhang A, Huang Y. Infodemiological study on COVID-19 epi- demic and COVID-19 infodemic [Internet]. Research Square. 2020. https://doi. org/10.21203/rs.3.rs-18591/v1 [cited 2020 May 6]. Available from: https://www. researchsquare.com/article/rs-18591/v1.
    138. Holmes EA, O’Connor RC, Perry VH, et al. Multidisciplinary Research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychi- atry. 2020;7(6):547-60.
    139. Elovainio M, Hakulinen C, Pulkki-Raback L, et al. Contribution of risk factors to ex- cess mortality in isolated and lonely individuals: an analysis of data from the UK biobank cohort study. Lancet Public Health. 2017;2(6):e260-6.
    140. Matthews T, Danese A, Caspi A, et al. Lonely young adults in modern Britain: find- ings from an epidemiological cohort study. Psychol Med. 2019;49(2):268-77.
    141. Wand APF, Zhong B-L, Chiu HFK, Draper B, De Leo D. COVID-19: the implications for suicide in older adults. Int Psychogeriatr. 2020:1-6.
    142. Li S, Wang Y, Xue J, Zhao N, Zhu T. The impact of COVID-19 epidemic declaration on psychological consequences: a study on active Weibo users. Int J Environ Res Public Health. 2020;17(6):2032.
    143. Yao H, Chen J-H, Xu Y-F. Patients with mental health disorders in the COVID-19 ep- idemic. Lancet Psychiatry. 2020;7(4):e21.
    144. Druss BG. Addressing the COVID-19 Pandemic in Populations With Serious Mental Illness. JAMA Psychiatry. 2020;77(9):891-2.
    145. Ballivian J, Alcaide ML, Cecchini D, Jones DL, Abbamonte JM, Cassetti I. Impact of COVID-19-related stress and lockdown on mental health among people living with HIV in Argentina. Acquir Immune Defic Syndr. 2020. https://doi.org/10.

         1097/QAI.0000000000002493 [cited 2020 Sep 10];Publish Ahead of Print. Avail- able from https://journals.lww.com/10.1097/QAI.0000000000002493.

         Qin X, Shu K, Wang M, et al. Mental health status of patients with coronavirus dis- ease 2019 in Changsha. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2020;45(6): 657-64.

    146. Ferrando SJ, Klepacz L, Lynch S, et al. COVID-19 psychosis: a potential new neuro- psychiatric condition triggered by novel coronavirus infection and the inflamma- tory response? Psychosomatics. 2020;61(5):551-5.
    147. Parra A, Juanes A, Losada CP, et al. Psychotic symptoms in COVID-19 patients. A ret- rospective descriptive study. Psychiatry Res. 2020;291:113254.