The new coronavirus (SARS CoV 2) as a cause of dizziness in the COVID 19 pandemic

Marcello Cherchi, M.D., Ph.D. Return to Index. Page last modified: April 15, 2020

The pandemic of the coronavirus disease that began in 2019 (COVID 19) has posed a number of challenges for patients and for physicians. Its repercussions are changing rapidly, and our understanding of the disease itself is evolving.

How COVID 19 attacks the body

The pathogen (technically called “severe acute respiratory syndrome coronavirus type 2” or “SARS CoV 2”) belongs to a family of coronaviruses, which are single-stranded RNA viruses contained in a lipid bilayer envelope from which there protrude spike glycoproteins that comprise the “hooks” that let the viruses gain entry into host cells, where they replicate and propagate. These “hooks” attach particularly well to angiotensin-converting enzyme receptors (Ceccarelli, Berretta M Fau - Venanzi Rullo et al. 2020, Yan, Zhang et al. 2020) that are densely expressed in cells in the lungs, which is thought to be why some of the initial and most prominent symptoms of infection involve the respiratory tract, though unfortunately, the disease is not limited to the respiratory tract.

How COVID 19 attacks the brain:

The mechanism by which coronaviruses enter the central nervous system (CNS), and the factors that make specific people vulnerable to this, are incompletely understood (Dales 1995, Dube, Le Coupanec et al. 2018), though recent evidence (Baig, Khaleeq et al. 2020) has demonstrated that there are cells within the CNS that express angiotensin converting enzyme receptors — albeit at a lower density than in the lower respiratory tract. In any case, once the viruses have gained entry into the CNS, they appear capable of advancing by axonal transport (Dube, Le Coupanec et al. 2018).

Other members of the coronavirus family have long been known to invade the central nervous system, and have been found the brain/spinal cord tissue or the cerebrospinal fluid of patients suffering from a variety of neurological diseases, prominent among which are multiple sclerosis (Burks, DeVald et al. 1980, Salmi, Ziola et al. 1982, Hovanec and Flanagan 1983), Parkinson’s disease (Fazzini, Fleming et al. 1992), optic neuritis (Dessau, Lisby et al. 1999), encephalitis (Arabi, Harthi et al. 2015, Li, Li et al. 2016, Morfopoulou, Brown et al. 2016, Nilsson, Edner et al. 2020) and acute disseminated encephalomyelitis (Yeh, Collins et al. 2004). In some of these diseases (e.g., optic neuritis, encephalitis and encephalomyelitis) it is reasonable to suspect that the virus itself is the cause of the disease, while in other conditions (e.g., multiple sclerosis, Parkinson’s disease) it is unclear whether the virus has any causative role.

The accumulating evidence (Filatov, Sharma et al. 2020, Nath 2020, Poyiadji, Shahin et al. 2020) specifically about the virus causing COVID 19 suggests that it can affect the CNS similarly to other members of coronavirus family, though there are differences as well (Ceccarelli, Berretta M Fau - Venanzi Rullo et al. 2020), such as its apparent predilection to impair smell and taste (Gautier and Ravussin 2020, Giacomelli, Pezzati et al. 2020, Mao, Jin et al. 2020, Mermelstein 2020, Vavougios 2020). It is thus reasonable to consider whether it might also be the mechanism for other focal neurological manifestations, including the vertiginous disorders that we see in clinic — though to be clear, this disease is so new that there has not yet been adequate opportunity to study this in any systematic fashion.

A large case series from Wuhan describe dizziness as a symptom in 8% of confirmed COVID 19 patients (Chen, Wu et al. 2020), though another study from Wuhan specifically querying neurological symptoms among confirmed cases of COVID 19 reported dizziness in 16.8% of patients (Mao, Jin et al. 2020). The mechanism by which COVID 19 may cause dizziness is unclear; since the disease appears to be capable of affecting individual cranial nerves (as happens in anosmia (Gautier and Ravussin 2020, Giacomelli, Pezzati et al. 2020, Mao, Jin et al. 2020, Mermelstein 2020, Vavougios 2020), optic neuritis (Dessau, Lisby et al. 1999) and ophthalmoparesis (Dinkin, Gao et al. 2020)), it is conceivable that it causes vestibular neuritis, though this remains a conjecture requiring further study.

References

Arabi, Y. M., A. Harthi, J. Hussein, A. Bouchama, S. Johani, A. H. Hajeer, B. T. Saeed, A. Wahbi, A. Saedy, T. AlDabbagh, R. Okaili, M. Sadat and H. Balkhy (2015). "Severe neurologic syndrome associated with Middle East respiratory syndrome corona virus (MERS-CoV)." Infection 43(4): 495-501.
Baig, A. M., A. Khaleeq, U. Ali and H. Syeda (2020). "Evidence of the COVID-19 Virus Targeting the CNS: Tissue Distribution, Host-Virus Interaction, and Proposed Neurotropic Mechanisms." ACS Chem Neurosci 11(7): 995-998.
Burks, J. S., B. L. DeVald, L. D. Jankovsky and J. C. Gerdes (1980). "Two coronaviruses isolated from central nervous system tissue of two multiple sclerosis patients." Science 209(4459): 933-934.
Ceccarelli, M., E. Berretta M Fau - Venanzi Rullo, G. Venanzi Rullo E Fau - Nunnari, B. Nunnari G Fau - Cacopardo and B. Cacopardo (2020). "Differences and similarities between Severe Acute Respiratory Syndrome (SARS)-CoronaVirus (CoV) and SARS-CoV-2. Would a rose by another name smell as sweet?" European Review for Medical and Pharmacological Sciences 24(2284-0729 (Electronic)).
Chen, T., D. Wu, H. Chen, W. Yan, D. Yang, G. Chen, K. Ma, D. Xu, H. Yu, H. Wang, T. Wang, W. Guo, J. Chen, C. Ding, X. Zhang, J. Huang, M. Han, S. Li, X. Luo, J. Zhao and Q. Ning (2020). "Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study." BMJ 368: m1091.
Dales, S. (1995). "Factors controlling coronavirus infections and disease of the central nervous system. A review." Adv Exp Med Biol 380: 13-22.
Dessau, R. B., G. Lisby and J. L. Frederiksen (1999). "Coronaviruses in spinal fluid of patients with acute monosymptomatic optic neuritis." Acta Neurol Scand 100(2): 88-91.
Dinkin, M., V. Gao, J. Kahan, S. Bobker, M. Simonetto, P. Wechsler, J. Harpe, C. Greer, G. Mints, G. Salama, A. J. Tsiouris and D. Leifer (2020). "COVID-19 presenting with ophthalmoparesis from cranial nerve palsy." Neurology.
Dube, M., A. Le Coupanec, A. H. M. Wong, J. M. Rini, M. Desforges and P. J. Talbot (2018). "Axonal Transport Enables Neuron-to-Neuron Propagation of Human Coronavirus OC43." J Virol 92(17).
Fazzini, E., J. Fleming and S. Fahn (1992). "Cerebrospinal fluid antibodies to coronavirus in patients with Parkinson's disease." Mov Disord 7(2): 153-158.
Filatov, A., P. Sharma, F. Hindi and P. S. Espinosa (2020). "Neurological complications of coronavirus disease (COVID-19): Encephalopathy." Cureus 12(3): e7352.
Gautier, J. F. and Y. Ravussin (2020). "A New Symptom of COVID-19: Loss of Taste and Smell." Obesity (Silver Spring).
Giacomelli, A., L. Pezzati, F. Conti, D. Bernacchia, M. Siano, L. Oreni, S. Rusconi, C. Gervasoni, A. L. Ridolfo, G. Rizzardini, S. Antinori and M. Galli (2020). "Self-reported olfactory and taste disorders in SARS-CoV-2 patients: a cross-sectional study." Clin Infect Dis.
Hovanec, D. L. and T. D. Flanagan (1983). "Detection of antibodies to human coronaviruses 229E and OC43 in the sera of multiple sclerosis patients and normal subjects." Infect Immun 41(1): 426-429.
Li, Y., H. Li, R. Fan, B. Wen, J. Zhang, X. Cao, C. Wang, Z. Song, S. Li, X. Li, X. Lv, X. Qu, R. Huang and W. Liu (2016). "Coronavirus Infections in the Central Nervous System and Respiratory Tract Show Distinct Features in Hospitalized Children." Intervirology 59(3): 163-169.
Mao, L., H. Jin, M. Wang, Y. Hu, S. Chen, Q. He, J. Chang, C. Hong, Y. Zhou, D. Wang, X. Miao, Y. Li and B. Hu (2020). "Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China." JAMA Neurol.
Mermelstein, S. (2020). "Acute anosmia from COVID-19 infection." Pract Neurol.
Morfopoulou, S., J. R. Brown, E. G. Davies, G. Anderson, A. Virasami, W. Qasim, W. K. Chong, M. Hubank, V. Plagnol, M. Desforges, T. S. Jacques, P. J. Talbot and J. Breuer (2016). "Human Coronavirus OC43 Associated with Fatal Encephalitis." N Engl J Med 375(5): 497-498.
Nath, A. (2020). "Neurologic complications of coronavirus infections." Neurology.
Nilsson, A., N. Edner, J. Albert and A. Ternhag (2020). "Fatal encephalitis associated with coronavirus OC43 in an immunocompromised child." Infect Dis (Lond): 1-4.
Poyiadji, N., G. Shahin, D. Noujaim, M. Stone, S. Patel and B. Griffith (2020). "COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features." Radiology: 201187.
Salmi, A., B. Ziola, T. Hovi and M. Reunanen (1982). "Antibodies to coronaviruses OC43 and 229E in multiple sclerosis patients." Neurology 32(3): 292-295.
Vavougios, G. D. (2020). "Potentially irreversible olfactory and gustatory impairments in COVID-19: Indolent vs. fulminant SARS-CoV-2 neuroinfection." Brain Behav Immun.
Yan, R., Y. Zhang, Y. Li, L. Xia, Y. Guo and Q. Zhou (2020). "Structural basis for the recognition of SARS-CoV-2 by full-length human ACE2." Science 367(6485): 1444-1448.
Yeh, E. A., A. Collins, M. E. Cohen, P. K. Duffner and H. Faden (2004). "Detection of coronavirus in the central nervous system of a child with acute disseminated encephalomyelitis." Pediatrics 113(1 Pt 1): e73-76.