Journal Pre-proof

Neurological manifestations of COVID-19 in children: Time to be more vigilant

Priyanka Madaan, Bhanudeep Singanamalla, Lokesh Saini

PII: S0887-8994(20)30363-5
DOI: https://doi.org/10.1016/j.pediatrneurol.2020.11.006
Reference: PNU 9887

To appear in: Pediatric Neurology

Received Date: 24 October 2020

Revised Date: 9 November 2020
Accepted Date: 12 November 2020

Please cite this article as: Madaan P, Singanamalla B, Saini L, Neurological manifestations of
COVID-19 in children: Time to be more vigilant, Pediatric Neurology (2020), doi: https://doi.org/10.1016/
j.pediatrneurol.2020.11.006.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2020 Published by Elsevier Inc.

 Title page

Title: Neurological manifestations of COVID-19 in children: Time to be more vigilant

Manuscript type: Correspondence

Priyanka Madaan, Bhanudeep Singanamalla, Lokesh Saini*

Author’s affiliations: Pediatric neurology unit, Department of Pediatrics, Post Graduate

Institute of Medical Education and Research, Chandigarh, India

of
ro
*Correspondence:

Dr. Lokesh Saini

-p
re
Assistant Professor
lP

Child Neurology Division

na

Department of Pediatrics

Advanced Pediatric Centre

ur

Post Graduate Institute of Medical Education and Research, Chandigarh, India

Jo

Email: drlokeshsaini@gmail.com; Phone: 9968859725

Word count: 279 including references

No. of figures: 0

Author Contribution: PM prepared the initial draft of manuscript and reviewed the

literature

BS and LS: critical review of the manuscript and reviewed the literature, edited the final

version of manuscript

Conflict of interest: none

Declarations of interest: none

Funding: None

Keywords: COVID-19, children, neurological manifestations

Acknowledgements: None

of
ro
-p
re
lP
na
ur
Jo
 Neurological manifestations of COVID-19 in children: Time to be more vigilant

We read with great interest the article by Burr et al on NMDA- receptor encephalitis

associated with COVID-19 infection.1 Although Anti-NMDAR encephalitis has been

associated with COVID-19 in adults, this is the first report in a child.2 With initial evidence

for COVID-19 in children suggesting an asymptomatic or mild course in most, the

identification and management of novel clinical presentations become even more relevant.

We would like to highlight the para/post-infectious immune-mediated neurological

of
presentations in children where identification of associated COVID-19 is important.

ro
Several neurological presentations have been reported with COVID-19 in children and adults.

-p
Some para-infectious ones include autoimmune encephalitis, autoimmune epilepsy, central
re
nervous system demyelination, Guillain Barre Syndrome, acute necrotizing encephalopathy,

etc.4 With inflammation playing a major role, these probably share a final common pathway.
lP

This also explains the role of immunotherapy in these conditions. Since most para-infectious
na

neurological syndromes have an infectious trigger (such as viruses like Herpes, Dengue, etc.),
ur

COVID-19 testing should be given due importance in patients with these disorders.3
Jo

The asymptomatic or mildly symptomatic children with COVID-19 may not be identified in

the acute phase and may present later with para-infectious complications like demyelination,

etc. We may be missing COVID-19 in children with various isolated neurological

complications such as GBS, demyelination, etc. Hereby we would like to emphasize the need

for COVID-19 testing (RT-PCR and antibodies-IgM and G) in the evaluation of para-

infectious neurological syndromes, other than specific syndrome-based antibodies like anti-

NMDA-R, MOG antibodies, etc. This will not only establish the etiology but also be very

important epidemiologically. With growing evidence on the indirect neurological effects of

the virus such as autoimmunity, it is plausible that many para-infectious manifestations are

underrecognized in children.5
References

1. Burr T, Barton C, Doll E, Lakhotia A, Sweeney M. NMDA-receptor encephalitis

associated with COVID-19 infection in a toddler. Pediatr Neurol 2020; in press. doi:

10.1016/j.pediatrneurol.2020.10.002

2. Monti G, Giovannini G, Marudi A, Bedin R, Melegari A, Simone AM, et al. Anti-

NMDA receptor encephalitis presenting as new onset refractory status epilepticus in

COVID-19. Seizure 2020;81:18-20.

3. Pastel H, Chakrabarty B, Saini L, Kumar A, Gulati S. A case of anti- N-methyl-D-

of
aspartate (NMDA) receptor encephalitis possibly triggered by an episode of Japanese

ro
B encephalitis. Neurol India. 2017;65:895-897.
-p
4. Gupta J, Madaan P, Chowdhury SR, Gulati S. COVID-19 and Pediatric Neurology
re
Practice in a Developing Country. Pediatr Neurol. 2020113:1.
lP

5. Lucchese G. Cerebrospinal fluid findings in COVID-19 indicate autoimmunity.

na

Lancet Microbe. 2020;1:e242.

ur
Jo