In Reply:

We thank Drs. Mahajan, Kapoor, and Prabhakar1  for their response to our review2  and agree that new loss of smell or taste are important, previously unrecognized manifestations of coronavirus disease 2019 (COVID-19). Of symptoms in seroprevalence studies, new loss of taste or smell was the most strongly associated with the detection of SARS-CoV-2 antibodies.3  Thus, these sensory symptoms, which are now included in Centers of Disease Control diagnostic guidelines, may even be more specific for COVID-19 than fever, cough, or dyspnea. Neurologic involvement of COVID-19 might have been expected based on the observations from the 2002 SARS-CoV virus, which was shown to infect brain cells. In mice expressing human angiotensin-converting enzyme 2, the virus entered the brain via the olfactory bulb generating a lethal infection linked to involvement of medullary respiratory centers and secretion of interleukin 6.4  Viral cytopathic effects on the brain could potentially complicate other neurocognitive sequelae of critical illness.

Additional clinical manifestations merit attention. Conjunctivitis has been reported as a presenting syndrome, emphasizing the importance of eye protection to reduce transmission. Maculopapular eruptions and pseudo-chilblains are among dermatologic symptoms of COVID-19.5  Emerging data suggest that COVID-19 may present like Kawaski syndrome in children, with fever, gastrointestinal symptoms, conjunctivitis, rash, and/or myocarditis.6  Now that COVID-19 has become prevalent in many regions, providers must be vigilant for atypical or asymptomatic presentations.

Research Support

Dr. Greenland is supported by VA Merit CX002011 and NHLBI R01 HL151552.

Competing Interests

The authors declare no new competing interests.

References

1.
Mahajan
C
,
Kapoor
I
,
Prabhakar
H
.
COVID-19 infection: Perioperative implications: Comment.
Anesthesiology
.
2020
;
133
:
677
8
2.
Greenland
JR
,
Michelow
MD
,
Wang
L
,
London
MJ
.
COVID-19 infection: Implications for perioperative and critical care physicians.
Anesthesiology
.
2020
;
132
:
1346
61
3.
Sood
N
,
Simon
P
,
Eichner
D
,
Reynolds
J
,
Bendavid
E
,
Bhattacharya
J
.
Seroprevalence of SARS-CoV-2–specific antibodies among adults in Los Angeles County, California, on April 10-11, 2020.
JAMA
.
2020
.
DOI: 10.1001/jama.2020.8279
4.
Netland
J
,
Meyerholz
DK
,
Moore
S
,
Cassell
M
,
Perlman
S
.
Severe acute respiratory syndrome coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ACE2.
J Virol
.
2008
;
82
:
7264
75
.
DOI: 10.1128/JVI.00737-08
5.
Galvan Casas
C
,
Catala
A
,
Carretero Hernandez
G
,
Rodriguez-Jimenez
P
,
Fernandez Nieto
D
,
Rodriguez-Villa Lario
A
,
Navarro Fernandez
I
,
Ruiz-Villaverde
R
,
Falkenhain
D
,
Llamas Velasco
M
,
Garcia-Gavin
J
,
Baniandres
O
,
Gonzalez-Cruz
C
,
Morillas-Lahuerta
V
,
Cubiro
X
,
Figueras Nart
I
,
Selda-Enriquez
G
,
Romani
J
,
Fusta-Novell
X
,
Melian-Olivera
A
,
Roncero Riesco
M
,
Burgos-Blasco
P
,
Sola Ortigosa
J
,
Feito Rodriguez
M
,
Garcia-Doval
I
.
Classification of the cutaneous manifestations of COVID-19: A rapid prospective nationwide consensus study in Spain with 375 cases.
Br J Dermatol
.
2020
.
DOI: 10.1111/bjd.19163
6.
Toubiana
J
,
Poirault
C
,
Corsia
A
.
Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: Prospective observational study.
2020
369:m2094
.
DOI: 10.1136/bmj.m2094