key: cord-0750223-0a804yn4
authors: Moreira, Maria Stella; Neves, Itamara Lucia Itagiba; de Bernoche, Claudia Yanet San Martin; Sarra, Giovanna; dos Santos‐Paul, Marcela Alves; Campos Neves da Silva, Fernanda; Schroter, Gabriella Torres; Montano, Tânia Cristina Pedroso; de Carvalho, Cíntia Maria Alencar; Simões Neves, Ricardo
title: Bilateral paresthesia associated with cardiovascular disease and COVID‐19
date: 2020-07-08
journal: Oral Dis
DOI: 10.1111/odi.13539
sha: 4d730cf9c643ffb140da35b6a20be28269a3d444
doc_id: 750223
cord_uid: 0a804yn4

nan

neurological manifestations related to dentistry, as well as aspects highlighting the oral healthy and bacteremia in the aggravation of cardiac patients have not been explored.

The present study demonstrates a case report in which dentistry has shown to play a key role in the evolution of the disease in a patient with both cardiovascular disease and COVID-19. The patient developed bacteraemia of oral origin requiring dental treatment and developed bilateral paresthesia of the inferior alveolar nerve. There is no similar case in the literature. We aim at making a brief review of the literature to alert the dental and medical community about issues that cannot go unnoticed in this crisis we are currently facing.

This 19-year-old white female patient had a past medical history of idiopathic dilated cardiomyopathy and heart failure with reduced ejection fraction. On February 19, 2020, she presented to the Emergency Department (ED) at Heart Institute (InCor) of the Hospital das Clinicas from Medical School of the Universidade de São Paulo with a history of worsening

This article is protected by copyright. All rights reserved dyspnoea on exertion, nausea, vomiting, and fever (38.4 °C). The physical examination showed cold-wet heart failure. Ancillary tests confirmed the diagnosis of right basal pneumonia. A chest X-ray revealed a right basal opacity (Figure1A-B) and the computed tomography (CT) ( Figure   2A -B) showed areas of consolidation interspersed with ground-glass opacities in the same lung region. A diagnosis of acute decompensation of chronic heart failure precipitated by pulmonary infection was made. Antibiotic therapy for community-acquired pneumonia was initiated as well as inotropic and vasopressor therapy.

She was admitted to the intensive care unit with multiple organ dysfunction and developed overt mixed shock requiring escalating doses of vasoactive therapy, mechanical ventilation, and placement of a percutaneous mechanical circulatory assist device (intra-aortic balloon counter pulsation). The patient's overall clinical condition stabilized 10 days from admission. However, later on the course of her hospitalization, a rise of inflammatory markers was noted, prompting investigation of a possible new source of infection. Evidence of bloodstream infection due to S. oralis and S. mitis was recovered, raising suspicion of an oral source. A dental consultation was therefore requested.

She reported odontogenic pain in a focused interview. Oral cavity examination revealed extensive deep carious lesions with pulpal involvement of the mandibular right first and second molars as well as mandibular left first molar. There was no prospect for prosthetic rehabilitation, and the affected teeth were extracted under standard protocol and minimally traumatic surgical technique without complications. Four days after the procedure, bilateral paraesthesia of the lower lip arose as a new complaint shortly followed by respiratory symptoms, nausea, and transient blurred vision. No lesions of the oral mucosa were noticed during the dental consultation. Vascular neurological events were ruled out using brain magnetic resonance angiography. A chest CT scan was also performed revealing a new pulmonary consolidation in addition to pulmonary embolism ( Figure 2C -D). Because of the deteriorating respiratory pattern, real-time polymerase reverse transcriptase chain reaction (PCR) testing for SARS-CoV-2 was considered mandatory. The results confirmed COVID-19. Despite receiving maximal supportive therapy, the patient developed refractory septic shock and died two days after the COVID-19 diagnosis.

Based on currently observed disease patterns, pre-existing cardiovascular disease may not only predispose to SARS-CoV-2 infection, but also increase the risk of adverse outcomes (Driggin et al., 2020) . It has been reported that patients are also exhibiting neurological signs and symptoms that could be ongoing in the recent outbreak without getting noticed or associated to Accepted Article This article is protected by copyright. All rights reserved (Mao et al., 2020) . The patient was admitted at the ED before the first case confirmed in Latin America (Brazil). The later suspicion by COVID-19 and SARS-CoV-2 test at that time led to a later confirmation of SARS-CoV-2 infection.

Respiratory viral infections may be underdiagnosed in patients with suspected sepsis. Our patient's clinical condition worsened despite the use of broad-spectrum antibiotics. This might have been because of the concomitant untreated viral infection. Other studies have demonstrated the interrelationship between viral coinfection and bacteria. These reports showed that bacterial infection occurred during or shortly after respiratory viral diseases and were associated with increased severity and need for hospitalization (Ljungström, Jacobsson, Claesson, Andersson, & Enroth, 2017; Stille, Pierce, & Crawford, 1961) . Therefore, during the COVID-19 pandemic it is important that bacterial infection focus be controlled.

Cardiac patients must have intensive oral health care because of the inherent risk of bacteraemia (Folwaczny, Bauer, & Grünberg, 2019) . A complex microflora colonizes the oral cavity, which is considered an important source of bacteraemia, since oral bacteria are often associated with infective endocarditis and sepsis (Holland et al., 2016) . Oral diseases such as caries, apical periodontitis, and periodontitis have a high prevalence in the general population and are mainly In the reported clinical case, the patient with previous cardiac disease and undiagnosed COVID-19 developed bacteraemia of oral origin that may have aggravated her systemic condition. An invasive dental procedure was necessary to contain this infection. As a consequence, the patient Accepted Article developed bilateral paresthesia of the inferior alveolar nerve, which had a very negative impact on her quality of life. This complication was not expected for the teeth in question and the fact that it occurred on both sides is extremely rare.

While the SARS-CoV-2 is primarily a respiratory pathogen, there are reports of neurological manifestations that may suggest a central and peripheral nervous system involvement (Desforges et al., 2019; Natoli, Oliveira, Calabresi, Maia, & Pisani, 2020) . There are increasing reports in the literature describing neurological manifestations of COVID-19: mostly CNS involvement, and to a lesser degree, peripheral. Mao and colleagues analysed neurological manifestations in hospitalized Chinese patients with COVID-19 and documented a CNS involvement rate of 25%. The peripheral nervous system was affected in 9% of cases (Mao et al., 2020) .

This study suggests that the likelihood of developing neurologic symptoms is linked to disease severity (Mao et al., 2020) , which concurs with our observations. In our case, the incidental finding of bilateral paresthesia of the inferior alveolar nerve during a dental examination performed to rule out a possible endocarditis source brought to consideration the possibility of SARS-CoV-2 neurological commitment. The patient also reported symptoms such as nausea, vomiting, headache, transient visual alteration (being unable to read small letters), and mental confusion. These symptoms have also been reported in previous studies that assessed the involvement of the nervous system in patients with COVID-19 (Mao et al., 2020) .

The coronaviruses can enter the nervous system directly through blood circulation and neuronal pathways or via the olfactory nerve from where it progressively invades subcortical and cortical regions (Natoli et al., 2020) . In the reported case, we suggest that the surgical procedure may have been an entry route for the coronaviruses or a trigger for symptomatological manifestation of an existing infection, resulting in the lower lip paresthesia. However, this hypothesis needs to be better studied, and the pathogenesis of virus better understood.

The symptoms associated with COVID-19 are non-specific ranging from asymptomatic patients to severe cases including pneumonia and death. The identification of these symptoms can be even more challenging when the patient suffers from a heart disease and has several other comorbidities on top of a decompensated clinical condition. This was seen in our patient who presented to the ED before the first COVID-19 case was identified in Brazil.

Manifestations of the peripheral neurological system such as bilateral paresthesia of the inferior alveolar nerve on cardiac patients can be a predictive factor of COVID-19 and impair their quality of life. Oral care and preventive dental procedures are extremely important to avoid bacteraemia in Accepted Article

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Respiratory viral infections are underdiagnosed in patients with suspected sepsis. European journal of clinical microbiology & infectious diseases: official publication of the

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