Psychopathology analysis of 23 cases with COVID-19 pneumonia accompanied by abnormal brain imagine


 BackgroundCOVID-19 broke out in Wuhan, China in late 2019.the persons involved maybe influenced in psychology. Abnormality of central never system(CNS) may promote appeared more psychological symptomsin patients with COVID-19 pneumonia.MaterialsAll the cases were from the hospital where the author was located and diagnosed COVID-19 pneumonia with abnormality of cranial CT examination.ResultAll 23 patients performance mental symptoms of consciousness disturbance,cognitive impairment,anxiety and depression,sleep disorder. The more and serious mental symptoms correlated with dangerous and severe or severe type of COVID-19 pneumonia, more physical disease.ConclusionCOVID-19 pneumonia patients with cranial CT abnormality always had mental symptoms.


Background
The novel coronavirus pneumonia( Coronavirus disease 2019,COVID-19)broke out in Wuhan, China in late 2019.Its propagation speed and severity have a signi cant impact on human beings.COVID-19 is an emerging respiratory infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was rst detected in early December 2019 in Wuhan, China.As of April 6, 2020, COVID-19 had quickly spread to the majority of countries worldwide, affected more than 1.1 million individuals, and caused nearly 63,000 deaths.Although studies have described the clinical characteristics of patients with COVID-19 [1,2].At same times,this kind of in uence will also cause a kind of serious stress and cause a variety of psychological problems [3,4].In most cases, there are various manifestations, such as anxiety, depression, compulsion, somatization, etc., and more and more common is sleep disorder [3,4,5,6].The reason of these psychological problems during COVID-19 was both stress and some biological reasons.Because a certain number of new crown pneumonia patients have nervous system symptoms [7,8], including three main aspects of nervous system symptoms.Obviously, these neurological symptoms promote the appearance of psychological symptoms to some extent.The pathological mechanism of neurological symptoms may be from the CNS invasion of SARS-CoV-2, similar to SARS and MERS viruses.As with other respiratory viruses, SARS-COV-2 may enter the CNS through the hematogenous or retrograde neuronal route [7].And the patients with novel coronavirus pneumonia was more likely to develop mental symptoms when neurological symptoms appear.It is an important neurobiological basis when the nervous system, especially the central nervous system, has organic symptoms [8].We report mental symptoms of 23 patients with novel coronavirus pneumonia and brain CT abnormality and analyze their, explore the relationship between the brain imaging characteristics and mental symptoms.

Materials
All the cases were from the hospital where the authors was located.They were Tianyou Hospital A liated to Wuhan University of science and technology and Tongde Hospital A liated to Zhejiang University of traditional Chinese medicine.All patients were diagnosed novel coronavirus pneumonia, and they were all asked for psychiatric consultation because of mental problems and they also had been completed the cranial CT examination.The male patients was 14 cases, female was 9 cases, The age was 51-87 years old.COVID-19 pneumonia is classi ed as dangerous and severe, severe, mild, and common type.The other physical diseases also had been diagnosed by physicians.All patients had positive results of CT.See Table 1 for all patient information.This clinical study was approved by ethic committee of Zhejiang Province Tongde Hospital Results 1. Mental symptoms of patients: the most common are sleep disorders, anxiety and depression, and the most serious is the disturbance of consciousness, including coma and delirium.The most di cult to manage is psychomotor excitement, which brings great di culties to treatment and management.There are other cognitive disorders.A few had compulsive symptoms and psychotic manifestations.
11 cases was company with disturbance of consciousness.9 cases had cognitive disorders,2 cases of which had been diagnosed as Alzheimer's disease ,and 1 of which had been diagnosed as vascular dementia and 1 of which had been diagnosed as mixed dementia before hospitalization.
Most patients had sleep disorders, anxiety and depression.
2. Brain CT results: All patients had positive results.Three results are common.One is senile change, brain atrophy, including ventricular enlargement, widened sulcus, and leukoaraization.The second is cerebral ischemia, including infarct and softening focus, which occurs in the basal ganglia and around the ventricles.The most patients had both brain atrophy and cerebral ischemia.See Figure1-3.
3. COVID-19 pneumonia, psychiatric symptoms and brain imaging: (1) the in uence of covid-19 pneumonia on mental symptoms: most of the patients with consciousness disturbance were critically ill,which type always was dangerous and heavy, almost all patients had sleep disorders, anxiety and depression, and some patients had delirium with psychomotor excitement.(2) The relationship between brain image and mental symptoms: the patients with severe mental symptoms usually occur in the old age and have more physical diseases,especially both brain atrophy and cerebral infarction.3 The some patients had cognitive impairment,which mainly related the brain CT abnormality that may further aggravated in case of COVID-19 pneumonia.(4)Themost patients had anxiety and depression related to both stress and biology impacts of COVID-19 pneumonia see table2.

Discussion
In a new study, of 214 patients included 88 (41.1%) had severe infection and 126 (58.9%) had nonsevere infection.Of these, 78 (36.4%) had various neurologic manifestations that involved CNS, PNS, and skeletal muscles [7].And 40% patients with covid-19 pneumonia had various psychological manifestations that involved depression, anxiety, insomnia [9] ,suicide [10].These result showed that covid-19 pneumonia in uenced both physical and psychological aspects.Disturbance of consciousness is not only a symptom of central nervous system, but also a mental symptom, but more often, it is considered to be a more serious clinical manifestation.It strongly suggests that the central nervous system has been compromised.In our 23 case reports, nearly half of the cases (11 / 23) had disturbance of consciousness.Most of these patients had severe infection, were older and had a variety of physical diseases.These conclusions were similar to those of previous studies [7], but.There is something special about the cases we report, which is that the patients have already suffered from central nervous system injury that is brain atrophy, cerebral infarction or both, as seen by head CT scan.Therefore, this is also an important factor for these patients to have disturbance of consciousness.Moreover, nervous system manifestations were signi cantly more common in severe infections compared with nonsevere infections [7].They included acute cerebrovascular disease, patients with ischemic stroke or with cerebral hemorrhage or with ischemic, impaired consciousness and skeletal muscle injury.In the severe group, some patient had a seizure characterized by a sudden onset of limb twitching, foaming in the mouth, and loss of consciousness [7,8],especially in acute stage of covid-19 [11].But we just report disturbance of consciousness,and also report the disorder of cognition,which also suggest more serious clinical manifestation.
The delirium was one kind of consciousness disturbance.The study showed that 28% patients with severe covid-19 presented confusion during the acute illness [11].When data for patients with COVID-19 were examined (including preprint data), there was evidence for delirium (confusion in 26 [65%] of 40 intensive care unit patients and agitation in 40 [69%] of 58 intensive care unit patients in one study, and altered consciousness in 17 [21%] of 82 patients who subsequently died in another study) [11].When patients presented delirium,they always had disturbance of behavior with agitation,which also was import reason of consultation liaison psychiatry.
As to disturbance of consciousness, the patents with impaired cognition and severe infections,were higher older,had more physical disease,more impaired CNS that be seen by brain CT.The study found 34.1% patients with severe infection of covid-19 had impaired memory during acute stage and 18.9% in the post-illness stage [11].Generally,the impaired cognition was related to exited brain atrophy and cerebral ischemic.But we also do not know that neurologic manifestations are caused by the virus directly or by the pulmonary disease or other organ damage indirectly [8].
It was certain that impairment of CNS induce impaired cognition.In the patients reported,some patients had been diagnosed as Alzhemer's disease, mixed dementia which were disease characterized by disorder of cognition.
And some patients ad been diagnosed as Parkinson's disease which were disease possibly induced disorder of cognition.But what cannot be ruled out is that covid-19 pneumonia can cause cognitive impairment in these elderly patients in a special way, and moreover these patients already have the damage that can be seen by head CT.
Symptoms that are less severe than consciousness and cognitive impairment are negative emotional symptoms.Prevalence of depression and anxiety symptoms were diagnosed in 35.9% and 38.5% of the patients, respectively [9].The most of patients we reported had the depression and anxiety.Coronavirus [11].These results showed that the patients with covid-19 experienced more negative affection,such as depression,anxiety.Our reports also showed most patients experienced depression and anxiety.
There was a ndings showed a high rate of depression and anxiety in COVID-19 patients [9].The prevalence of depression was 35.9%: 20.5% for mild depression, 12.8% for moderate depression, and 2.6% for severe depression.Almost four out of 10 (38.5%) patients were diagnosed with anxiety: 20.5% with mild anxiety, 12.8% with moderate anxiety, and 2.6% with severe anxiety.Nearly a quarter (24.3%) of the patients were diagnosed as having both depression and anxiety.Multivariate linear regression found having family members diagnosed with COVID-19 and family members who died from COVID-19 were independent predictors of both higher depression severity index and anxiety score.Being female was also independently associated with depression severity index in COVID-19 patients.It was very pity that we did not analyzed the risk with depression and anxiety.But ratio of our patients with depression and anxiety was more than 40%.It may also related to their special ndings by head CT.
The patients with brain atrophy and cerebral ischemia always presented emotional regulation disturbance.There was a study revealed brain structural abnormalities in emotional regulation and sensory processing regions of anxious depression, which may suggested distinct neurobiological mechanisms of this MDD speci er and could help explain different clinical manifestations in anxious depression from pure depression [12].But psychological distress of covid-19 may had importer role,as these ndings of previous studies showing that public health emergencies can cause mental-health problems, such as the Wenchuan and Lushan earthquakes [13], the 2014 Ebola Outbreak [14,15], and Severe Acute Respiratory Syndrome (SARS) [16].
Sleep disorder was very common psychological symptom without speci city.About 29.2% (95% CI, 28.8%-29.6%)general population had insomnia.The people with occupational exposure risks and residents in Hubei province had increased odds of symptoms of insomnia (adjusted ORs, 1.60 [95% CI, 1.45-1.77].The con rmed patients with covid-19 had more increased odds of symptoms of insomnia(adjusted ORs, 3.06 [95% CI, 1.73-5.43][17] The systematic review 42% patients had insomnia in acute illness, 100% patients had sleep disorder in the post-illness stage [11].The patients we reported almost had sleep disorder.For patients, besides the impact of psychological factors[18], there may be more important biological factors[19], especially those with severe pneumonia,which induced insomnia,anxiety and depression.COVID-19 may impact both CNS and psychology.Despite the occurrence of symptoms-such as shortness of breath(SOB)-associated with severe manifestations of COVID-19, only the severities of smell and taste loss were associated with depressed mood and anxiety.These results may raise the novel possibility of emotional disturbance as a CNS manifestation of COVID-19 given trans-olfactory tract penetration of the central nervous system (CNS) by coronaviruses [20].
Unfortunately, our report does not have such data.There is no evaluation and test of olfactory and taste sense, no correlation analysis with negative emotion, and no correlation analysis between this and CT results of head, which is insu cient.

Key Point
COVID-19 pneumonia patients with cranial CT abnormality were easier to had mental symptoms,which include severe symptoms of consciousness disturbance ,cognitive impairment,and common symptom of anxiety and depression,sleep disorder.The special attention should been to it.The consultation liaison psychiatry will play import role.

Declarations Acknowledgment
We thank Mr Xing baoping give us study idea and Mr Zhu Jianfeng help us in literature retrieval.We thank Mr Ma Yongchun help us in the nal revision of the article.

Ethic statement
1.This study was approved by Ethic Committee of Zhejiang Province Hospital.Ethic certi cate (LL20200408-023)

2.Consent for publication
All participants agree to publish their data and no con ict in any interests.

Con ict of interest statement
There were not any nancial and non-nancial competing interests.

Authou's contribution
Our authors have different contributions to this article.Sun Fengli participated in collection of data and the writing of the article, Zhongwei Guo ,Xinsheng Chen ,Hongwei Ren ,Jianning Liu participated in the collection of clinical data.Jin Weidong participated in the design , statistical processing and the nal revision of the article.