COVID-19 Infection: Perioperative Implications: 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.

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

The authors declare no new competing interests.