Neurological Considerations in COVID-19 with Alexander Merkler, MD: Wednesday 07-29-2020




So you graduated Magna cum laude from Brown. You might be smart. That’s awesome. All right, you ready? Let’s go. I think we should have a ten second prayer for, for a great conference. Any preferences for religion?


Alright, let’s have some fun. There we go. Good evening, ladies and gentlemen, welcome to another edition of the pulmonary wellness foundation. COVID rehabilitation and recovery series. My steam guest tonight is dr. Alexander. Murchler M D a native new Yorker. There are a few, those are few and far between, but we’ve heard that they’re growing back who received his undergraduate degree from Brown university, where he graduated Magna cum laude date. This guy is smart. He earned his medical degree from NYU, where he received the prestigious Rosenbluth Glen grant for international lab research. He completed residency in neurology at the Weill Cornell medical college and served as a chief resident in his final year. He then completed a two year fellowship in neuro critical care at Columbia university, Weill Cornell medical college. He is the first name that you will see if you see the recent study called risk of ischemic stroke in patients with COVID-19 versus patients with influenza.


If you are sensing a theme here, this gentleman is not an underachiever. Welcome to the show, dr. Murchler. Well, thank you for that incredibly kind introduction. It’s a pleasure to be here. So our audience tonight very many people who have had COVID or suspected COVID many long haulers, if you will, and the kind of thing that keeps it all together is the brain. So just to make sure we’re all on the same page, can you just talk a little bit about what is the neurologic system and as a neurologist, what does it, what does a neurologist do day to day before COVID sure, of course. So a neurologist takes care of diseases or disorders that involve the brain, the spine, the muscles, the nerves, and, you know, we take care of patients who have any disorder related to any of those organ systems.


So that could be stroke. That could be Parkinson’s, that could be dementia. That could be epilepsy that could be brain tumors. It could be infections of the nervous system. And so there’s a whole host of conditions and disorders that affect the brain, the spine and the nerves. And that’s basically what we did before. COVID at least. Okay. So COVID so initially Kovac came we thought it was respiratory. We thought you’d have a little cold or flu for a couple of weeks turning out to be something totally different. What are some of the neurologic just like sort of an overview of what type of neurologic complications you’re seeing and then sort of like what are the things that you think would potentially expose somebody or predispose somebody to experience them in neurologic complication?


Yeah, sure. So that’s a great question. So, you know, you know, we’re still learning a lot about COVID and we still have a lot more to learn, but what we know is that COVID, doesn’t just affect the lungs. It’s not purely a respiratory disease. It’s not just isolated to the, to the lungs for the pulmonary system. It affects everything. And of course, you know, the heart can be affected the kidneys, the skin, but what I care about is the brain because the brain makes us who we are. And so what we’re learning is that COVID can affect the brain. It can affect the nerves, it can affect the spine, it can affect the muscles, it can affect everything that a neurologist takes care of. And so that means there can be a whole host of different manifestations, neurological manifestations of COVID. So, you know, I think one of my interest, and one of the things that I do research on is stroke.


A stroke is basically when there’s injury to the brain due to a blocked or a burst artery of the brain. And that can cause symptoms like trouble speaking, trouble, walking trouble, moving numbness and tingling, trouble seeing or severe headache. And, you know, stroke is common in general. It affects about 800,000 people each year in America. And what we’ve learned is that COVID can predispose you to have an increased risk of stroke. And I’m happy to talk more about that, but just as a bigger overview, in addition to stroke, coven can cause other problems that are related to the neurological system. So one of the, actually the most common symptom of COVID, that’s not purely respiratory is changes in your, the sense of taste and your sense of smell. And it’s thought that COVID can actually get into the nervous system through the nasal passage way and can affect those areas of the brain that control smelling and tasting. And actually that’s some of the most common symptoms that patients with. COVID have. I’m curious to hear what if you guys have any of those symptoms, but lost taste or smell or changes in taste and smell seem to be


Show of hands, how many people have lost their sense of taste? How many people have lost their sense of smell? How many people have lost both and how many people have altered smell or taste so different than you would expect? Okay, that’s a good number.


Yeah. So that’s one of the more common things. And thankfully at least it seems like the sense of taste and smell do get better. But it can be very bothersome obviously in addition to stroke. And in addition to changes in taste and smell, there are other problems. And so patients can have trouble with the nerves. And so COVID can affect the nerves of the arms and the legs and can lead to weakness or numbness or tingling in any of those body parts.


So when you talk about the loss of taste and smell, what’s the mechanism behind that?


Yeah. So that’s a great question. We don’t know everything again. I’m, I’m usually gonna preface my many of my answers with we don’t know much because that’s the truth, we’re still learning. But what we think is that, you know, this is a a virus that is a respiratory virus. It’s a best respiratory illness. And so it gets into our body predominantly from either our nose or our mouth. And we think that a lot of it comes in through our nose and, you know, there’s a connection actually between the nasal passage and the brain, and that’s called the cribriform plate. And what we think in, you know, in studying prior viruses like SARS and MERS, that those viruses actually can traverse this crypto form plate. So that means that the virus can pass from the nasal passage to the brain. And the first area that you hit, the first area that the virus would get into in the brain is, is the area that controls, smell and smell is very, very linked to taste as well. And so we think that in in many cases of COVID where the virus actually comes in to the nose, it goes into the brain and affects that sort of a, what we call the olfactory pathway or the nasal pathway or the nasal sort of neurons of the brain. And what’s interesting is that the olfactory and the loss of sense of smell and taste are, are common symptoms. And they’re typically actually seen in more, more in patients who have more mild disease actually. So it’s a common manifestation of, of more mild illness.


So with that in mind that if it’s a mild illness, is there any, and this may be a very simplistic way of thinking of it, but is it, is it possible that mild illness kind of heads up and then sort of more severe it gets into the chest and you know, other organs, or is that


I think an interesting question and I don’t know the answer. I think it also could be that when you get the severe illness, you you’re just sicker and you’re, you know, you’re worrying about breathing and you’re worrying about a more serious things like stroke and heart attack and having to go on a ventilator. And so when those types of symptoms happened, you know, the more mild stuff like loss of sense of taste and smell are sort of less important. And we’re not asking our patients lots of smell or taste if we’re going to intubate you. And so I’m not sure it’s an interesting question and it’s possible, but I don’t know if it’s just because we’re, we’re just not asking those sick patients, if they have losses taste or smell, or just it’s, as you’re saying that maybe the virus just stops there in the more mild patients.


Gotcha. And what is your experience been with recovery from that and resolution?


Yeah, so thankfully most patients who have lost or have altered sense of taste and smell do recover, and it can take time. It can take weeks, it can actually take months, but some of the earlier patients that were affected have recovered from that. And we do have some positive you know, evidence from other illnesses. So many respiratory illnesses can alter your sense of taste and smell. So if you’ve ever had the flu before or a bad respiratory illness prior to COVID, you may have noticed that your sense of taste or smell might have been altered. And it’s the same sort of mechanism. The, all of the respiratory illnesses come in through the nasal passage way. And so they’re always at risk to affect the olfactory system. It just like COVID has a much greater affinity or greater propensity to affect the brain and the specificity quickly in that area. But the good news is, as, as I said, that most patients with that type of symptom, the loss of sense of smell or taste do recover.


So when we see people with their masks down under their nose, but covering their mouth, not such a good idea, not so good.


It’s a good idea because that’s where the virus likes to go right into the nose. That’s the, that’s the most important place to actually cover.


And then just in the interest of completing nose and mouth at this point. So is that definitely a neurologic symptom? So if, if that’s your symptom and that’s your long lasting symptom, is there any role for an ear nose and throat doctor there? Or is it a neurotic?


Yeah. Well, I’m glad you asked that question because it’s really interesting. A lot of these patients, a lot of these patients actually had, and it’s, you know, there’s, there’s a fair number of studies now have no other symptoms. They might not have fever. They might not have had, you know, shortness of breath. They might not have even had a cough. And their only symptom was loss of sense of taste and smell. And so who did they see? They went to see the, you know, the ENT that your nose and throat doctors, and that’s how they get. And maybe later, you know, days later they may develop cough or fever or more typical symptoms, but it can be the loss of sense of smell and taste is can often be actually the first symptom, the first sign of any respiratory illness, but specifically COVID.


And so, you know, I don’t think it’s, you know, I think it’s right or, you know, that the patients are going to the ENT doctors because it’s weird not to be able to say something. So I had a buddy of mine who you know, in the beginning of this, he was trying to, you know, he was working in the hospital with me and that was one of those hard to get Cobra tested. So the way he did it was he would eat a chocolate bar every night. And so if you could taste the chocolate, he knew that he probably didn’t have COVID. That was his test.


Interesting. have you heard of smell


Smell tracker now? Yeah.


Okay. I don’t know enough about it to talk about it, but just, just curious if that was something that was widely used, let’s go to your paper. So risk of ischemic stroke in patients with COVID versus patients with influenza, what did you guys find?


Yeah, so this was a study in which we evaluated about 2000 patients, the first 2000 patients with COVID, who came to the hospital that I work at Cornell. And essentially we compared the risk of ischemic stroke, which is the most type of most common type of stroke in patients who had COVID to historical controls who had the flu. And so what that means is we, we went through all the charts of about 2000 patients with COVID and we look to see how many of them had a stroke. And then we look to see about two years ago, how many patients had the flu and among the patients with the flu, we went through all of their charts and we went to see how many patients with flu had a stroke. And we, what we found was that among the patients with COVID who are hospitalized or went to the emergency department because of COPD symptoms, 1.6% of them had a stroke as compared to the flu about 0.2% of them had a stroke, which means that if you had COVID, you were about eight times more likely to have a stroke if you had the flow.


Which basically, you know, the, the message of the paper is that patients with COVID are heightened risk for stroke as compared to the flu. And, you know, the flu is a respiratory illness. We all know that it can be severe, but COVID is much more severe in general and predisposes to a greater risk for vascular complications, I E stroke, heart attack and major sort of multi-system disorder. Okay.


So as I understand it COVID does two things. So it increases


The likelihood of clotting and also reduces a clot license, right. Or the breakdown of class. Is that accurate? Yes. you know, covert, I would say is just like any, any virus, it causes inflammation and increases the body’s inflammatory response. When you have it, you have this, you know, enemy organism that’s in your body. And so what does your body do? It tries to fight and it causes inflammation and COVID seems to cause a huge surge in this inflammation. And not only is it just inflammation, but there’s activation of factors in the blood vessels that predisposes the body to have clot formation. So the combination of that, plus the inflammation makes the body at higher risk form clots. And a stroke is basically a specifically an ischemic stroke is basically a clot, a blood clot within the artery of a brain.


It’s similar to a heart attack, which is a blood clot in the heart. And you know, that can cause chest pain and chest pressure. But when the clot is in the brain, it causes neurological symptoms like in the ability to speak, inability, to move and ability to walk, inability to see and those types of symptoms now. Okay. Weird. so in the interest of completeness, can you just talk a little bit about the difference? We hear a lot of terms like Tia is schemic ice is when the, the brain is not getting enough oxygen, but kind of the difference between Tia ischemic, stroke, hemorrhagic stroke, and what do people need to know as far as like, when should I be getting myself to the, to the emergency room? Yeah. So it’s a great question. So a stroke is, is when, again, there’s injury to the brain due to a blood best problem.


And there’s really two major types of stroke. One is an ischemic stroke, which is when there’s a blockage of an artery of the brain. And that’s by far the most common type of stroke, it causes about 85% of stroke. So it’s basically, you know, the brain has blood vessels or pipes. And in the schemic stroke is one of those blood vessels is clogged up or the pipe is clogged up. And so you don’t get blood, you don’t get oxygen, you don’t get nutrients to the brain. And so the brain dies off. The other type of stroke is a hemorrhagic stroke. A hemorrhagic stroke is when there’s a burst of, of an artery of the brain. So, you know, the same pipes that are in the brain, one of the pipes bursts. And so all the blood spills out into the brain. And so similarly the, the brain can’t get oxygen or nutrients from that blood vessel, but it’s because the blood vessel has burst open rather than been included by a clot.


And so that makes up about 15% of all strokes. A Tia is, or a transient ischemic attack is a mini stroke. And it’s basically a warning sign or impending doom that a major stroke might happen. A Tia is when there’s a transient occlusion of a blood vessel. So for example, you know, those pipes in the brain it’s transiently or temporarily occluded by a clot, you have symptoms. So you might have trouble speaking trouble, walking trouble, moving one side of the body, but then the clock goes away and your symptoms go away and you’re all better. But when you have a Tia like that, it means that you’re at higher risk to have a full blown stroke or had higher risk to have one on another clot form and completely occlude the blood vessel or the pipe, and it would be permanent. And so what, you know, the most important thing is that if you have symptoms of stroke or Tia, you need to go to the hospital.


And the reason to do so is that we have good treatments. We have effective treatments that if you’re having a Tia or a stroke that can reduce, that can basically get rid of the clot and improve your chance of having either no or minimal disability from the stroke. And we can do that by medications. There’s there’s one that, you know, it goes by the name of TPA or the clot Buster, and then there’s another procedure where we can actually go into the brain and remove the clot itself. And so if you have symptoms of stroke and I’ll just go over them again, because I think it’s really important. So if you have trouble seeing, if you have weakness on one side of the body, so your arm or your leg on one side of the body, if you have trouble speaking, if you have trouble understanding someone, if you have trouble walking, those are all some, or you have a slurred speech, those are all signs and symptoms that you might be having a stroke and that you need to go to the hospital emergently.


And are you seeing are you seeing clots more so than, than bleeds in COVID or are you seeing everything


We’re seeing everything? You know, clots are just by far more common in general. And so, you know, among those 2000 patients that, that I mentioned about 30 or so had an ischemic stroke, but a few of them additional patients also had a hemorrhagic stroke or a bleed into the brain as well. So it is possible. Interestingly, you know, one of the ways that we’re treating patients with COVID is by giving them blood thinners. So because patients would cover it or at higher risk to have clots, you know, again, either in the brain and the heart and the legs DVT, the way we treat that is by thinning the blood out by giving a patient, you know heparin or Coumadin or berries, different blood thinning medications. And of course, one of the risks of putting someone on a blood thinner is bleeding. And unfortunately every now and then being on a blood thinner will cause bleeding into the brain, which can be very serious. In addition, just without being on a blood thinner, where we are still seeing that some patients have hemorrhagic strokes are bleeding into the brain, just because of COVID itself, that there’s inflammation in the blood vessels and that the blood vessels to be leaky and burst as well. It’s very rare though. I mean, we’re talking about, well, less than 1% of hospitalized patients with COVID have hemorrhagic type stroke


And last stroke question for now, are you seeing any similarities amongst the patients that are having strokes and what is the implication for people like who’ve never had any neurologic problems before? Are they also having strokes?


Yeah, it’s a fantastic question. So, you know, our study supported the notion that the patients who are really having strokes are the patients who are ill, who are, who are very system systemically or medically ill from COVID. And so these are the patients who are often intubated, you know, on life support who are, you know, getting a lot of medications who may be sedate heavily sedated. Those are the patients who seem to be at highest risk of stroke. In addition, it’s the patients who have risk factors, common risk factors for stroke. So, you know, older patients, just because age in and of itself as a risk factor for stroke, patients have uncontrolled high blood pressure, uncontrolled diabetes, uncontrolled, high cholesterol, uncontrolled, or obesity who have a history of coronary artery disease, a history of prior stroke. Those are the patients who we were seeing, or we are seeing who have stroke.


Now there are reports of patients who are having stroke due to COVID, who don’t have any risk factors who are otherwise young and healthy people, but those really are very few and far between, and it’s unclear that’s just a, they were going to have a stroke anyway. And, you know, COVID just was an incidental finding, or if COVID played a role in having and making them having had strokes, but by far and large, you know, want, you know, really, I want you to get the message out that the patients who are really at highest risk for stroke are those who are highest risk from stroke before. Meaning that they have the risk factors withdrawal, or who are really very, very ill from COVID from a medical standpoint. And that just puts you at higher risk from stroke,


Multisystem disease things. Right?


Exactly. You know, those patients are intubated on a respirator. They can have a Rhythmia’s of their heart, meaning that the heart isn’t functioning properly and develop something called atrial fibrillation. They’re on multiple medications that might put you at increased risk of stroke. There are the patients who are developing DVT, heart attacks, and those just put you at higher risk for stroke. And so they’re just, they’re just medically ill patients. And when you’re that medically ill, you just, your, your chance of having a stroke goes up.


I just want to sneak one more stroke question in now, if that’s okay. So I, I, okay, awesome. So I see a lot of research that shows that patients get into the most trouble in the first four days, like the patients that are gonna have multi-system failure and require intubation or lifesaving, you know interventions then kind of, it’s quiet for a little while and then day 14, for whatever reason, things spike again. And then it sort of settles down is your sense. And, you know, I whenever I talk to doctors, like I’m always interested in what your sense is, as much as the science is awesome, we need it, but I’m also interested as a human being, like, what do you think, do you think that the risk once people have kind of past that acute phase has lessened for stroke, or do you think that’s something that people still have to worry about?


Yeah. So I agree with you that most of the science right now supports that the, you know, if you get infected on day one, you’re really your greatest risks to have serious disease is between like 10 days and maybe 15, 16 days, somewhere in that 10 to two week period, that is your greatest risk to have shortness of breath that requires medical care or really serious illness. And so I think that’s right. I think that’s what we’re seeing from the literature. And that’s what I’m seeing in the hospital. What I saw in the hospital too, that it’s really, there’s a two week sort of lag from being infected, to being very ill. Usually, you know, at five days or so you start to have symptoms they’re mild and then another sort of 10 days, or go another five to 10 days go by.


And that’s really when the real serious symptoms can start. And it’s similar for stroke. I would say that, yes, your risk of stroke starts in that sort of two week period, but it continues onward. You know, again, if you’re hospitalized a day 14 of your illness and you’re very, very sick, then your stroke risk is going to just continue to be elevated until you’ve stopped being really, really sick. And that’s because of what we talked about, that if you’re sedated, you’re at risk for, you know, cloths and arrhythmias and just medical illness. And that’s what puts you, puts you at risk for stroke itself. So I would say that it’s really, the stroke risk begins, you know, around day five, but it continues onward until you’re really done with your illness.


Okay. many of the people on this call are what we call the long haulers. So people, 30 days out, 60 days out, 91, 20 days out still experiencing symptoms. We’ll get to dysautonomia a little bit later. But a lot of these symptoms that people get, they worry are, are they having a stroke? So what, what do you say to somebody like that who wants to get back active again, but they’re getting all these different funky symptoms when they do.


Yeah. So I think that, I mean, again, the, the risk of stroke overall is low. You know, if you’re in the hospital with severe symptoms, we found that the rate of stroke is 1.6%, so less than 2%. So first of all, that’s, you know, that’s not nothing, but it’s not crazy high already. And that’s among sick patients. We’re in the hospital. Once you’re out of the hospital, the risk of stroke was way lower. I mean, we’re talking not even probably a 10th of that percent, it’s probably much, much, much lower. And so, you know, that heightened risk of stroke is really when you have those severe symptoms, once you’re past that, you’re sort of back to your, or assumingly around your baseline risk of stroke, which is low in general. And you know, the best way to prevent stroke is really to in general, lead a healthy lifestyle and control you know, basic things like high blood pressure, high cholesterol, diabetes not be obese and to do exercise and to watch your diet. And I think that as long as you are physically able to, you know, go back and do some exercise and a normal sort of healthy lifestyle, meaning that you’re physically able to do it from a respiratory perspective or from a physical perspective, you should do it because that’s going to be helpful in preventing or lowering the risk of stroke in general. And, and also lowering the risk of stroke related to COVID as well. So I guess the most important thing is to be healthy and to stay active as long as possible.


Awesome. Thank you. So now outside of stroke, can you just talk a little bit about the role of, of just hypoxia and hypoxemia in general in of




Yeah, like how, how much of that, because, you know, one of the big questions was initially people were, were put on ventilators and we thought it was like ventilator ventilator. And, you know, it turns out for some of those people, maybe they could have gotten by with let’s say, high flow oxygen. And then there was the question of, you know, just one other, one other thing, is that a lot of long haulers, so, you know, at least in New York city, I’m sure you saw the same thing I did, which is that patients who at any other given time in history would have been admitted to the ER, certainly. And very often the ICU were sent home to kind of fend for themselves. And for many of these patients really by the grace of God, they survived and we don’t know what happened. You know, we don’t know what happened to them. It could have been a wild rollercoaster ride. So how much of that do you think is hypoxia and what role can hypoxia play in affecting the neurosystem?


Yeah, so I totally agree with you that our healthcare system, you know, especially speaking from the New York perspective was shifted. And, you know, we had such a surge in the number of patients who are severely ill with COVID. We had to make changes in order to accommodate those patients. And as a consequence of that, yeah, the threshold to admit someone to the hospital changed you know, hypoxia can, can affect the nervous system, but it’s really when there’s prolonged and severely low levels of oxygen. And so we’re talking about, you know, if someone’s heart stops and someone has a cardiac arrest, for example, when the heart stops and that basically leads to lack of oxygenation to all of the organs, including the brain. And that’s when we see, you know, permanent brain damage, but really when there’s, you know, when it’s not to that level of basically zero levels of oxygen, when it’s sort of mild levels of hypoxia, we just don’t know. We don’t know, and it may, it may depend on the patient, the level of the oxygen, the way the, how fast it was treated. But I don’t think that we can say that there there’s definitively any brain injury from that at all, but I can also say that there’s zero brain injury from that either. I think it’s very variable and we just don’t have enough data, and we don’t have enough experience to really say at this point in time.


So it sounds like you’re saying it’s a definite maybe.


Yeah. It’s definitely a, maybe


We’re going to quote you on that. So now, if I just, if you could just talk a little bit about the role of cytokine storm, and then I’d love to just go kind of symptom by symptom you know, and, and just briefly, but cytokine storm on the nervous system.


Yeah. I mean, again, I’m not sure if we know that much about it, to be honest with you. I think that it’s related sort of that hyper acute inflammatory cascade, which can, you know, as we discussed, sort of like affect the blood vessels themselves. So if there’s a cytokine storm and you know, the blood vessels are involved, then that can predispose you to have either blockage of the artery causing an ischemic stroke or a rupture of the artery causing a hemorrhage. But there’s really little known specifically about that. And then again, sort of just the cytokine storm can put you just medically or make you medically ill and that can predispose you to having stroke and other problems. The one interesting tidbit that I might add is that there are patients, and we haven’t mentioned this, that can have an encephalitis. So an encephalitis is when the brain is basically the entire brain is inflamed by either the virus or the inflammation related to the virus.


And so encephalitis in general can be caused by various things from viruses to bacteria, parasites, to, you know, auto immune conditions. And there’s a, you know, huge sort of host of different things that can cause it, but viruses are pretty well known to cause it, and COVID has been described as causing this sort of direct inflammatory invasive a brain disorder. It’s extremely rare. I think at this point there are a few cases described in the literature, but it does happen and it can be very, very, very dangerous. And it’s unclear if that’s due to maybe the cytokine storm or to due to medications or just on bad luck of the draw and patients can have some sort of rips bad actor to have the buyers go into their brain and cause the sort of encephalitis picture, I guess I got a little sidetrack about a cytokine, right?


Is encephalitis the same as encephalomyelitis?


Yes. Except in stuff in cephalitis is when the brain’s involved and encephalomyelitis is when the brain and the spinal quarter. Okay.


Gotcha. Gotcha. Thank you. Alright, so I’m going to go through what, you know, what I hear are very, very common themes, particularly from long haulers and what I’d love the context for each one of these is, you know, kind of pre COVID post COVID. What do you think it could be? What are the diagnostic tests he would look you would run? And if, you know, if what potential treatments there were, I know that’s a lot. I was going to ask for your social security number, but I decided to stop there. So if you could just, yeah, I mean, let’s start with headaches. So a lot of PS show of hands, how many people here are suffering from headaches. Okay. Usually the ones that don’t ever get you, you know, those patients that say no, never get a headache. Those are usually the ones that give headaches. How many people give others? A lot of headaches. Raise your hand. Just there’s one honest person. I see. All right. So you got to worry about the ones that have headaches and also give headaches. So a lot of headaches here, what is it what’s happening?


Yeah. So a headache is common, right? So about almost you know, over 10% of the population has some sort of headache disorder and there are a lot of different types of headaches. It can be migraine, it can be tension headache, it can be rare causes of headache. And usually there’s no quote unquote serious aspect, meaning that it’s not a brain tumor, it’s not an infection of the brain. It’s sort of just a migraine or a tension headache or things that, that, that it just, it just common. And we can have good treatment for those. So we have medications, we have lifestyle changes that we can do to sort of figure out our, Hey, are there any warning signs or red flags to rule out some sort of bad pathology? And if not, we’re sort of left with migraine or tension headache, and we can treat that appropriately.


Now there are, you know, scary things that can cause headache like a brain tumor or an infection. And certainly COVID has, seems to be associated with headache as well. And it’s unclear exactly why it could just be that, you know, often when you get a respiratory illness, like the flu, you get headaches, it’s just sort of part of the process of inflammation. And you know, we don’t really know the exact science behind it, but we think that there’s, you know, again, there’s some sort of illness, some foreign body and the body tries to fight it back. And when the body fights it back, there’s inflammation and it’s, you know, your joints feel achy, your muscles feel achy and your head feels achy too. And that sort of headache there and it gets better and can take a lot of time. I mean, again, it can be weeks, it can be months, but typically once the sort of viral illness sides, the body’s response to the illness start to subs starts to subside and you start to feel better. So what I would say is that, you know, in this postcode era yeah, COVID, I’m sorry. A headache can certainly be a manifestation of COVID. And it’s usually seen along with the sort of typical respiratory symptoms


People report that their headaches get worse at night. Why would that be?


That’s a good question. And I’m not sure I have the best answer. I think that sometimes when you lie down, there can be increased sort of pressure in the brain. So, you know, there when you lie down, basically the, the blood sort of pools back and the cerebral spinal fluid, which is the fluid that sort of cushions, the Blaine, the brain is sort of pooled. And so when that occurs, there can be increased pressure. But typically that type of headache occurs in the morning after your, you know, you’ve lined down for hours rather than when you first go to bed. So I’m not sure, I think it’s a good question and I don’t really have the best answer for it.


Do you ever get, sometimes I notice a patient will report headache frequently and it’s often related to their necks. And sometimes just changing pillow can help or something like that. You think there’s any, anything related to that here or unlikely?


I mean, listen, I think that if there are simple things that you ha having tried, I think it’s worthwhile to try it. So obviously getting a good night’s sleep is important. If you have a history of sleep apnea, trying to, you know, use your, your, you know, your CPAP machine, I’m trying to get a good night’s sleep, not take naps during the day, not eat food before you go to bed, not drink a lot of alcohol or smoke. All things to sort of increase your sleep. Hygiene is very important. It may reduce the risk of headaches. And that can include, you know, if you have an uncomfortable pillow, you know, get a comfortable pillow, so you can try to get a good night’s sleep and just be mindful of, of how sleep is important. But at the same time, I’m not confident that if, if really the headache is really sort of related to the, to the COVID and to the inflammatory cascade, those things may, you know, help a little bit, but I’m unsure if that’s really going to solve it. It might just take time.


What about the brain fog that people talk about?


Yeah. I mean, I think that, again, similar to other viral illnesses there’s this sort of, you know, I use the word inflammation a lot of times already here, but that’s sort of what we that’s, that’s sort of how we simplify it because we just, we just don’t understand the brain that well, it’s very difficult. I mean, that’s, that’s why I liked studying it because there’s so much unknown, but whenever there’s, whenever the brain is effected. And so, as we know in COVID, it definitely is there’s, there’s changes that occur. There’s inflammation, there’s blood vessel changes, there’s alterations. And that can just change and cause the sort of, sort of you know, what we call brain fog, which is just that you just don’t, you don’t have the clearest consortium or clear cognition and you feel off. And I think again, like ways to try to make that better is to be healthy, to try to, you know, live your normal day as much as possible to get a good night’s sleep, to eat your meals, to be healthy. And hopefully that would help, but it’s unclear if that’s going to definitively get rid of things. And, you know, I think the main answer is time that time heals all here. And I think that with time, those symptoms will get better.


You know, I kind of view the COVID symptoms is kind of like your house got flooded with seawater and until that kind of recedes, then things aren’t going to get that much better. But your gut is that this should resolve over time.


Yes. I think that it, it, it should or will, and it should. And, and I, I state that because again, besides a very small percentage of people who have, you know, encephalitis or real infection, that’s invaded the brain or stroke that’s caused injury to the brain, most of this other stuff is sort of some inflammation that will heal. It’s sort of like, you know, if you get a, if you, you know, bump your arm and you get a bruise, it’s swollen, there’s inflammation there, there’s a black and blue Mark and it doesn’t go away right away. Right. It’s there, it swells up, I think it’s a little bit better and better and better, but you still see it for a few weeks. Maybe it’s a month and you’ll have a little bit of a scar, but it does get better. And eventually it goes away. And I think the brain, you know, albeit much, much more complicated. It’s not that dissimilar in that unless you truly, you know, broke your bone or, you know, ripped off your arm or something from encephalitis or stroke, the brain should get better. It should be like a bruise that once the inflammation gets better, you should start to feel better. I’m not going to make that a guarantee because we just don’t know enough, but that’s sort of my clinical understanding based on other viral illnesses and what I would say here,


I got scared for a second. I thought you were going to say broke your brain. I was going to say that that would be, I haven’t heard of that one before. But long haulers. That’s good news. This is a good time for everybody to just sort of take a deep breath and say, okay, something awesome to look forward to. As we move along big elephant in the room, dysautonomia, let’s talk dysautonomia in all its forms,


Right? So dysautonomia is essentially when you have trouble with your autonomic system. And so you can have problems like feeling lightheaded, where when you stand up too quickly, you’re going to feel like you pass out. You can pass out something called syncope. You can have trouble you know, with urination or going to the bathroom. You can have problems with, you know, sexual drive desire and and, and various other sort of sexual side effects as well. And this is a tough one. This is tough. We know that COVID can affect the nervous system in terms of the nerves and that’s the nerves really control the autonomic system and can lead to these problems. In addition, COVID can affect the heart and can lead to, you know, trouble with, again, like decrease blood flow from the heart, which again can lead to decreased blood flow to the brain.


And so you can feel these sensations like you’re going to pass out. So I think again with this and, and many other things, the peripheral nerves that control this often do get better. Those are something that do regenerate and get better. And so, as long as again, you haven’t had permanent injury to the heart, through a heart attack or the brain through a stroke that I think the symptoms will start to get better. One of the recommendations I would say is that you have to train yourself. And so, you know, if you’re having trouble standing up and feeling lightheaded, you have to take it very slowly and you have to, you know, work your way there. So instead of just getting up and going for a walk where you might fall and injure yourself, you have to work on going from lying down to sitting and go slowly. And then once you master that, you go from sitting to standing, and then once you master that, and you go from standing to walking and you have to do it in a gradual process so that your body starts to relearn these things. And I think working with a physical therapist, occupational therapist, doing some balance training are sort of key to doing that. It’s just exercising the, the nerves of the body here. That’s going to be key.


You mentioned some nerves that were effect. What specific nerves were you referring to if you had two in mind?


Well, so the Vegas nerve, the vagus nerve is the, you know, one of the biggest nerves that controls you know, your sense of your, your, your parasympathetic response. And so it can lead to a whole host of these problems, but other nerves can be involved as well, different gang lands that affect the gut. And again, the genital system and the carotid arteries and their sense of sort of blood pressure and heart rate and any number, one of any number of them can be involved. But the Vegas is the biggest and the most probably well studied.


Some of the sexual dysfunction might be difficult to assess since everybody’s in quarantine. So that was a hard to say. I think of them. I got to say I’m ladies and gentlemen. I apologize. But, but let me, so here’s a question. So we have a cardiopulmonary boot camp, so we have a 42 day boot camp for cardiac and pulmonary patients. So we tried that with COVID patients and in particular, a lot of the patients that we’re seeing with dysautonomia. So we found that even though we believe this to be a very, very mild program, it’s too vigorous for people to start at. So we’re now in ladies and gentlemen, listen to this next piece of news starting next week, we are going to have a COVID specific bootcamp and we be doing, we will be backing everybody off. But one of my questions and, you know, it’s, these, these patients remind me a little bit of, of pulmonary hypertension patients in their response to exercise and a little bit of like pots patients, is there, like you just mentioned go slow, but is there potential damage, like, are you going to hurt somebody or somebody’s gonna hurt them selves when they have these symptoms and they try to push it?


Or is it more discomfort?


Yeah. So, I mean, it’s a careful balance. I have to say. I think that you don’t want to push yourself to the point where you might be endangering yourself. So again, you don’t want to be, if you can’t stand up without difficulty, you don’t want to be trying to like run on treadmill because of the warriors. You’re going to fall down and break something, and then you’re going to break your brain in that case. Exactly. but I do think that you should, you know, you should be positive and you should be, you know, and that’s sometimes very difficult. It’s easy for me to say to be positive, but you know, this is affected everyone. And, and of course, if you’re affected by COVID, it’s very, it’s upsetting to have these symptoms and it’s frustrating, but I am positive. And I’m optimistic that, you know, with time and, you know, training that you can get better. I think that you just have to, you have to go as fast as, you know, as safe as possible. So, you know, and, and everyone is going to be different, right. So you have to sort of judge it based on, on how safe you can do it, but you should continue to try. You don’t want to sort of give up because yeah. You know, you’ll take steps back.


My position is kind of like take one step at a time if that feels okay, do it again. If that feels okay, do it a third time, just to make sure. And when we’re we know we’re good, let’s take that second step because one thing I’ve found and, you know, luckily we didn’t learn this the hard way per se, but you know, is that some people, they can do four minutes and they could do five minutes and they could do six minutes. But if they do six minutes and 10 seconds, it’s almost like a cutoff switch. And then it’s like, they’re out for hours or days even. So part of what we’re going to be doing is, is, you know, really teaching people how to kind of back things way off and start again. I recorded something for you guys this morning and it’s, it’s similar to what dr.


Murchler just said, which is that, you know, I also am feeling very positive about this. And I, I had a mental shift today and I had a kind of a thought about long haulers in general. And my thought was that it is time to turn the page. Okay. And when I say that, I am not minimizing your plight in any way, shape or form am not saying that you’re faking. I’m not saying you’re being a baby or a wimp, or put on your big boy pants or your big girl pants. That’s not what I’m saying. But one of the things I noticed is that at the beginning, we were fighting to say, hello, we’re here. We have something there’s something to this long haul, or is actually a thing. And more and more every day. And, you know, I give, I give Karen a lot of credit for that among others.


That message is getting out. Right. But I’ll tell you what I think is not the healthiest at a certain point. There are groups where there are 10,000 people, 20,000 people, 50,000 people, and the storyline kind of goes, well, you know, it’s, there is 653 for me, or it’s day 1 million, 2076. And I’ve had these 27 symptoms. And in some of these groups, they’re so big that within seconds, like, it’s like almost like a ticker where everybody piles on and says, these are the, I think at a certain point, we have to acknowledge yes, covert socks, nobody wants it, but we have to start turning the corner and it doesn’t help your system to be constantly focusing on this is what’s wrong. These things, this, and again, by no stretch of the imagination, am I minimizing the experience, but I think it’s time for us to start taking steps forward and rebuilding again and it can be done.


And that is why this is the official start of COVID bootcamp. Stay tuned for that. Sorry, dr. Mark Clark did not mean to do a shameless plug, but I think that people needed to hear that and it’s free. So it’s not a money thing. Let’s talk about so dysautonomia you mentioned something that I hadn’t heard before, which is the, the urinary system. I have one patient who I believe had a disorder denomic kind of her, her mechanism or her manifestation of dysautonomia was GI. So it, whereas other people will get dizzy or lightheaded, she would have to go to the bathroom or she would, you know, is that something that’s common? Yes.


I mean, GI symptoms are common. It’s, you know, I don’t know if that’s, I don’t think I would directly cause that call that dysautonomia, but, you know, diarrhea and abdominal pain have been seen in COVID patients again, as either the initial symptom or as a, in part of the constellation of respiratory plus GI symptoms. But GI actually doesn’t seem to be that uncommon. Actually, what I’m talking about for the design of Nomia is like inability to use the, you know, to either that you peed on yourself without realized it, realizing it, or you know, how to bowel movement without realizing it, or having severe urinary retention or constipation. So it’s a little bit different, but but both important, I guess, dementia,


So severe constipation could be assigned to dysautonomia as well. Yes. Gotcha. Okay. Nerve pain, very common people are experiencing excruciating pain of varying sensations and, you know, kind of descriptions. Can we talk about that for a bit?


Yeah, of course. So, you know, I think in the pre COVID air era, there are lots of different causes of what we call neuropathy, which is when there’s a, you know, nerve pain or numbness or tingling that are referrable to one or two nerves basically or set of nerves. And there’s a whole host of conditions that can do that. So it could be nutritional due to lack of vitamins. It can be secondary to diabetes, it can be toxic secondary to, you know you know overdose of metallic components like gold. It can be secondary to liver disease. It can be secondary to cancer, but it can also be COVID. I mean, basically that’s the answer to everything, right? COVID can do a lot of different things, but COVID can affect the nerves in the body and lead to nerve pain, muscle pain, muscle weakness, numbness, tingling.


And again, if you were severely ill in the hospital, critically ill that just puts you at risk to have injury to the nerves, just purely from being so sick as well. So there’s a lot of risk factors there and reasons why coven can cause nerve pain. And I think the good news here again is that typically the nerves, the peripheral nerves. So again, not the brain, not the spine, but the nerves that come off of the spine typically can regrow. And typically patients who have these types of symptoms can do very well. In general. Again, we don’t have enough data specifically for COVID, but if it falls the same pattern as most other disease diseases that affect the nerves patients who have nerve injury like that typically do get better. That can take a very long time. Remember we’re talking here about Marvis a long time.


Yep. Exactly. This is the nerve, you know, think about it. The nerve can go all the way from your spine to your toe. That’s one nerve, one nerve goes from your spine to your toe. So that’s, you know, feet, you know, multiple feet and not to use feet to toe, but whatever, it’s a long nerve. And so if that’s impaired or injured, it has to regrow. And it takes a really, really, really, really long time to regrow that length of a nerve. And so again, you have to be patient, but I think the knowledge that it should get better and be helpful.


What do we do in the meantime?


Yeah, that’s a good question. So one is that if you’re having numbness and tingling and pain, that’s bothersome, there are what we call neuropathic medications or, or medications that are specifically designed to treat nerve pain. You know, the two classic are Gabapentin and pregabalin otherwise called Lyrica, and those can be efficacious or helpful. There are other therapies as well in terms of, you know, just simple things like exercising and stretching and using hot and cold packs can be helpful. And then there’s more, you know invasive or more second line things like using stimulators or transmitting next stimulation to sort of help with the nerve pain. Those are less studied and it’s unclear how much beneficial those will be. But I think that, you know, you know, if you’re really having tingling and pain, that’s, that’s really related to nerve taking. Some of those medications can be beneficial and again,


And more uncomfortable and dangerous.


Say it again


More, more, more uncomfortable than dangerous. Yeah. Like a nuisance, but not, not anything you have to run to the ER,


That’s absolutely correct. Yes. I wouldn’t. I would not call CA or call that a you know, if you’re having, you know, pain, that’s running down your leg for, you know, a pro you know, it’s been there for months or something, or weeks from the COVID, that’s not something to run to the ed about. That’s something that you can take care of as an outpatient. Gotcha.


Okay. Ladies and gentlemen, I just want to let you know that we have opened the chat for questions. If people want to throw some of those out there, I have a few more for you, dr. Murchler. a lot of people report this sensation of kind of like an internal shaking or a vibration




Longer than others. What, what could that be? Is that also neuropathy? I’m not


Sure. I would depend a little bit about, you know, what exactly the symptom is, but if, you know, for example, if your legs are shaking, it could be one that, you know, you have, you know, it may not be related to cover it, but if it’s related to COVID, it could be that you’re just weak from the COVID that you’re, again, your nerves are affected, your muscles are affected. It could be some dysautonomia. It could just be that you’re deconditioned that you haven’t been walking around as much because you’ve been sick from COVID and you’re just weak because you haven’t used those muscles in a long time. So again, I would say that you have to be careful, but slowly, but progressive going back to your normal routine, as much as possible in a safe manner is the way to do that.


Is there a phenomenon? Because, because I get what you’re saying, what I’m hearing from people is that it’s not necessarily related to activity. So in other words, they could be sitting and watching TV and all of a sudden it’s like someone turned on a vibrator or something.


Yeah. it, it, that sounds more like it’s a nerve, it’s a nerve issue so that you know, if it’s like an electrical sensation or first sensation, that more sounds like it’s a nerve issue. And so I think those things, it depends, you know, if it comes on once every, you know, two weeks for five seconds, you were not going to do anything about it. It’s just time has to, to, to play its course. But if it’s something that, you know, is occurring for hours on end every single day, then it’s time to see a doctor and to sort of consider going on a medication. And one of those nerve medications that I mentioned.


Gotcha. And are there certain like tests, like, you know, another kind of challenge that people have had is that again, they were sent home, they’re now going to internists and, you know, in my experience so far, what I’ve seen is that there’s guys like you in the hospital who saw a ton of COVID patients and saw them often when they were at their sickest. And now there’s the people who are starting to look at these longterm symptoms and then there’s people who are kind of in their offices and like, don’t know anything about it and are getting their stuff from like the news. So as a general kind of neuro screen, are there like two or three tests that you would recommend everybody here get?


No, I wouldn’t say so. I think it very much depends on your symptoms and your signs. So I think that if you’re having symptoms that are concerning for a neurological issue or any symptoms at all, you should discuss them with your physician and, you know, based on the symptoms, if they sound neurological, then I think that you should see a neurologist, but I don’t think that there’s any, you know, quote unquote sort of screening test that has to be done. I think it depends on, you know, where the symptoms are, right. We’re always trying to figure out what tests to order. And so, you know, again, COVID is diverse and pauses, a diverse range of neurological things. So if you’re having problems that are related to your brain, where it might look at your brain, if you’re having trouble or problems relating to your nerves, we might do a nerve conduction test or a test of your nerves. If you’re having trouble that might relate to your spine, we’re going to be doing tests and look at your spine. So, and, and definitely, you know, everyone doesn’t need all those tasks. I think it’s very much individual personalized care that’s necessary here.


I got to mention that at one, one way that I hear people describe it. Sometimes it’s kind of like fizzy, like a fizzy Alka seltzer feel or something like that under the skin. I don’t know if that changes anything I’m going to go to issue. Yeah. Okay. Gotcha. so some of these are gonna be, yes, no questions. I’m not going to make you do any diagnosis here. Can encephalomyelitis be detected in routine blood work?


No. So in order to detect that you need to basically have sophisticated imaging of the brain and spine. So you would need a brain MRI and MRI is basically like a high Def TV picture of the brain that really goes into detail of what it looks like. And you would need that in the, and the spine. And typically we also need a spinal tap as well. So a or otherwise turned a lumbar puncture where you actually, you know, a doctor would stick a needle into your spine and take out fluid and look under the microscope to see if we see evidence of virus there.


Can it affect someone for months without being detected? The answer is yes, because if you don’t get those tests, you’re not going to detect it. Right. Yeah. But you said it’s very, you said it’s very, very rare. So on a scale of one to 10, how much should that be keeping people up at night?


Less than one


Zero point. Okay. Awesome. Okay, perfect. So, yeah, because that, I think, you know, what happened, a couple of articles came out where it was like about chronic fatigue and, and Emmy. And like, I just saw it, the internet went bananas in one day and now that’s a question that I hear every day, but I just saw it happen. Like there was one post and it was on every possible website. All right. I’m going to just read a little bit, headaches were one of the initial COVID symptoms. They, one of my initial covert symptoms, they started with a feeling of pressure in the back of my head. Now the pain is constant on the top of my head. It feels almost like veins moving and shifting. I’ve done an MRI MRA without contrast, will another type of scan be useful to find the origin of this pain or will time heal. Yeah. You want to get out of it easy. Just say time will heal it.


No, that’s a good question. So, you know, the MRI was to rule out any sort of, you know, bad pathology that, you know, would need urgent treatment. So it was to rule out a brain tumor infection stroke, and it sounds like all of those things have been excluded because the MRI didn’t show them. So that’s good news. So what we’re left with is just sort of, again, the sort of like hyper inflammatory process and time hall, time heals all. So, you know, and it’s not just that. So I shouldn’t just say that really, you know, if you’re really still having ongoing symptoms and it’s been a long duration of time, there are medications that can help. There are medications that are specifically targeting headaches. And there’s, there’s really a whole host of them that we use prior to COVID that we still use post COVID that are really pretty beneficial from headaches. And they range from pills to shots to actually doing Botox as well. And so we really have good treatments. And so if the headaches I’ve really been longterm, meaning months long, I would consider, you know, you know, at least talking to your physician about taking the next steps and treating those headaches.


I liked your attitude is very positive and encouraging. Like it’s, it’s making me feel like, you know, and, and I’m hearing it from a lot of people lately that I, I respect and, you know, I’m, I too am really starting to feel like, you know what we’re going to get there.


It’s, it’s, you know, look, it’s a train wreck. You guys got hit by trucks, but we will, we will heal. And, and we will come through this. Are there, are there different types of like sensations that would warn of different things with headaches or are they all just kind of variations of the same thing? Are there different sensations of what, like, would it be sharp, pressing, squeezing? You know, I think people have different sensations, you know, so typically a migraine headache is like a pulse, a tile throbbing, you know, a lot of people get migraines. So a lot of people probably can relate. I get migraines and it’s just, it’s horrible. It’s like, it’s really, you know, you want to go into bed into the dark room, put the covers over yourself and you know, not do anything. And so there’s that type of headache, but there’s other types of headaches, which are sharp, which are, you know, piercing, which are electrical in nature.


And I’ve heard different things from patients who have COVID. So I think that it, it can be any and all of those things, and there are different medications that treat some of those different symptoms. So I think again, discussing with the provider and figuring out what the best strategy is is, is important. What about over the counter medications? Yeah. So it’s a good question. I think that if you’re having an occasional headache, so, you know, if you have a headache every week or every few days, it’s totally fine to take an Advil or an Excedrin or Tylenol, but you have to be careful that you don’t want to overuse those medications, because if you take a lot of them and by a lot, I mean, if you’re taking them daily, you can have what we call a rebound or medication overuse headache, or the headache can paradoxically actually get worse. And it’s not just being addicted to the substances. You just, if the headaches actually can get worse. And so I think it’s totally fine to take a pill every few days, if that helps. That’s fine. And if that treats you great, but if it’s not working, it’s not doing the trick and you find that you’re just taking more and more, it’s really time to speak to a physician.


Have you seen a lot of children with COVID? I don’t take care of patients. I don’t take care of children in general. And so I personally haven’t you know, the data suggests that children can be affected though. It’s less common than adults. But what, what happened? I mean, well, not just with kids, but, but are you seeing anything like ticks or like any ticks or like any type of tremors with people with COVID? That’s an interesting question. I personally haven’t, and I don’t think that the, you know, the data that I’ve seen at least suggest that it’s related to like tic disorder, anything that, but we’ll see. I wouldn’t be shocked if it comes out that way, but of the children, the pediatric illnesses, this sort of, again, this pediatric inflammatory disease akin to this Kawasaki syndrome, which is like a multi-systemic inflammatory disorder of children. And it more effects like the skin and the blood vessels of the heart. It can affect the brain. But, but I haven’t heard anything about like text or anything. No. Are there any


Neurologic kind of manifestations that you’re worried will either not get better or that could potentially progress over time? You can say like use brain fog as an example. Is that something that you also expect to get better? Or is that something that I dunno,


Especially getting better? I think that really the things that are the most concerning are when there’s, you know death of brain tissue or severe and irreversible brain injury. And that really by definition is a stroke, or, you know, as we said, like encephalitis or infection of the brain that does not heal or, you know yeah, those, those really are the two main things, you know, the common things being common it’s really stroke that I would worry would be a permanent and not, you know, healing situation, everything else I’m optimistic, we’ll get better. But I can’t make any guarantees obviously, but, and I think that some of these things may take a long time,


Just try to be patient and, and push forward. So, yup. Bootcamp, we got it. What about sunburn feeling? Is that also, is that also a neuropathy? No redness, but I feel like I’ve been sunburned or burned by a flame.


Yeah. So I think there’s two separate things there. It could certainly be nerve injury or nerve or inflammation of the nerves that can cause this you know, pain feeling that either can be like an electrical sensation. It can be a vibratory sensation. It can certainly be a burn type sensation or a knife Pearson sensation. It really causes different things, or it could be a dermatological manifestation. Again, if there’s no rash, that’s much less likely, but there definitely are rashes described coven and sometimes symptoms of rashes like the pain can, can come on before you actually see the rash. So I would, you know, be careful. And so if you have those sensations, I definitely would, you know, monitor your skin for, if you develop a rash like that.


And so then is that a dermatology issue?


Yes. Then I’m off the hook.


You’re off it, wasn’t you all right. The day after I had my consultation with you pointing at me I started that vibrating from head to toe still happening. So weird happens all over the body


At the same time and has been going on since it started. Yeah. So I mean, again, I think this could be related to inflammation of the nerves. I think that it’s, you know, certainly it would be more intended again to speak with your physician and see if there’s any testing that can be done and might be prudent to do some blood work, to make sure that you’re not deficient in certain vitamins and other sort of basic tests to make sure it’s not unrelated to COVID or consequence of COVID that’s not directly from, COVID just that you’re not, you know, you’re depleted of a vitamin secondary to having it. And I think getting sort of a nerve test in that type of case would be, would be helpful. Are there any supplements or foods that you feel would be beneficial? My general thought and just thought on those types of things are to eat a healthy and well balanced diet, and that is usually the best way to keep your vitamins at appropriate levels. So if you’re someone who eats, you know, healthy and eats, you know, you know, the recommended fruits and vegetables and dairy and meat, you, you do not need to supplement with vitamins because you should be getting that in a normal, healthy diet. What about provision?


I, I see the commercials all the time. It’s, it’s made of like jellyfish, not, not a big not a big proponent. Alright. Here’s another question I lost sight in one eye for a couple of minutes. About 10 days in now have lots of floaters, little bursts of light. Do I need to be more concerned about stroke? Yeah, that sounds like something, right? Yeah. So if you so sudden sudden onset loss of vision is a stroke symptom. It means that you might have had a, or that could be a warning sign that you’ve had a stroke to the eye or a Tia to the eye. Meaning that a clot could have formed in one of the blood vessels that supply the eye, especially if it was painless, meaning that you didn’t have any with it. Now this person’s had these symptoms for 35 days now.


So that occurred last site for 10 days in now, lots of floaters, little burst of light now, 45 days in. Yeah. Yeah. I mean, it depends if the vision has gotten better or not, but what I would suggest is, especially if you’re seeing floaters, sometimes it can be from a clock to the eye I a stroke, but it can also be an awful biological problem. What I would suggest is that you go see an eye doctor because they will be able to diagnose whether this was an optimal logical manifestation or a neurological manifestation to the eye, a stroke of the eye. So that ophthalmologist, well, that would be the ideal person, but they’re often tough to make an appointment with. So seeing an ophthalmologist, at least as a first step is a good choice. Don’t go to an optician. They’re not going to be able to help you.


I’ve had trouble remembering how to do things I do at work. Think of it, a complex task. I’ve known how to do for years and post COVID. I don’t know how to do it. I had memory loss during and somewhat after COVID. Yeah. So I think that’s a sign that, you know, again, it’s unclear if that’s going to be permanent or not. It depends on other other factors. And so I think if you’re having those types of symptoms, it’s, you’re warranted to have some further testing, meaning having an examination by a neurologist or, you know, someone who specializes in memory like a psychiatrist or neurologist, and also getting brain imaging as well. So, you know, again, we want to make sure that you don’t have any stroke or infection that could be leading to those symptoms. So I think in that particular case, I would get imaging.


Do you ever recommend the cognitive exam that Donald Trump recently passed? The mini mental tests? Yes. Joking, joking. I don’t want to start a war and the webinar, you know, I know anytime I mentioned trumpet it’s it gets half the side rowdy. So I won’t we’ll move on what could be going on in the brain. That’s making me dizzy confused and disoriented and foggy and have an act at absence in the I’m sorry, what could be going on in the brain? That’s making me dizzy confused and disoriented and foggy and have a headache in the absence of the giant inflammatory response markers. Yeah. So, I mean, again, it’s their, the, the choices are, this could be sort of that brain fog. That’s a sort of, is going to take time to get better, but, you know, it’s always prudent to make sure that there’s no more serious things that are going on you know, like stroke or infection.


And so again, like getting an exam by a physician by a neurologist or a psychiatrist and getting brain imaging, I think is warranted in those cases. I think it’s important to make sure that you haven’t had any permanent brain injury and to go on from there both from a diagnostic, but also to give you reassurance that if you haven’t had those things, that you are going to get better over time. And if you have had those things, then we want to prevent future strokes from happening. And so it’s important to understand if you’ve had that constant pressure, migraine vision issues along with sinus pressure. I have this about eight hours a day. Yeah. So again, so for headaches, I think that if you’re really having daily headaches, you really should be seeing a doctor. You shouldn’t be overusing over the counter medications. You want to, again, try to be healthy sleep well, but I think it’s time to see a doctor make sure that, you know, imaging has been performed, make sure that there’s, you know, rule out any bad things and then go from there and try to treat it appropriately.




Can you talk a little bit, or are you good for time so far, dr. Mark, are you good? Yes. I’m going to go to the speed round. So how can we tell the difference between nerve issue and myalgia and how are they related? So myalgia means that there’s you know, pain in the muscles. Whereas if there’s a nerve injury or a neuropathy, there’s typically signs and symptoms that are directly related to a specific nerve. And so there’s, you know, pain or numbness or weakness that are in the specific distribution of that nerve. It’s not just sort of a diffuse process. It’s usually one nerve or a collection of nerve that’s involved. And we can distinguish that by both physical examination and history, and also doing a nerve test where we can check the individual nerves or muscles of the body.


I have neuropathy from chemo, but I keep waking up with increased numbness when I was most sick. I lost feeling in my right foot entirely for three days, but it came back. It’s a little disturbing that this still happens to a lesser degree. Is this related to decreased blood circulation or is it some kind of neuropathy like that? I got from chemo? And it’s a good question. I probably can’t totally answer that without, you know, performing an examination and get a little bit more history, but it could be one of the, one of the two, if you’re ready have had one neuropathy. And from the chemotherapy, you are probably at higher risk to develop further neuropathy either from covert or something else. So again, I think it’s Warren to speak with your physician, get an examination to try to distinguish the two and again, consider doing a nerve conduction test as well.


How can we discuss tacky Brady syndrome? My heart rate goes from 38 to 100 at rest. And up to one 60 with a company, shortness of breath with minimal activity with our physicians. I think for that, you’re going to have to speak with my cardiology colleagues because that’s the cardiology level. And we did talk and we did talk about this the other night. So if you haven’t seen that and we did get some new information since then, so feel free to reach out. I fear longterm brain damage is occurring. You don’t think so. I mean, for me, dr. Murchler but but you feel that a lot of this stuff is going to clear, I do information crews. I really do. And I say that because I, you know, I’m basing it from what we know from other diseases that if you, you know, again, if you don’t have a stroke, if you don’t have any like veer, you know, damage, it’s irreversible to the brain, and this is all related to inflammation, it should clear. And it may


Not clear tomorrow. It may not clear in two weeks. It may not clear in two months, but you should be getting better over time. My gut feeling is like probably like six to nine months based on what I’m seeing and trajectory. I think, you know, we’re normal boot camp is like 42 days. And I think it’s gonna take about three or four or five times that time for people that are really bad. But I, my other feeling is that kind of like when the inflammation subsides. So like, you know, I, I always say that you’re only going to get better as fast as your slowest system and for a lot of these things, it’s tipping point. And you know, my experience is that the neurologic system is particularly like this, where like the nerves are growing and it’s like, you could have two trains that are like an inch apart from each other in a tunnel. And it’s until they make that final connection, it’s still dark. So my hope is that, you know, once you kind of get off and running, you’re going to be off and running is is a nerve conduction velocity test the same as an EMG. Yeah. There’s two parts to it. One is the nerve conduction test and the other part is the EMG. So one test the nerve and the other part like looks into the muscle and together you can sort of figure out an answer.




My, my neurologist is doing Botox for my migraine. Soon. He avoids the subject of COVID. Would this be safe for me to do with my symptoms of COVID now mostly shortness of breath, chest pain going on four and a half months. Yes. if you’re receiving Botox for headaches, it really shouldn’t interfere with any pulmonary symptoms. So I don’t think there should be a problem with that. How does Botox help a headache? So there’s there are a few studies several years ago that that showed that in randomized trials that Botox was efficacious or helpful for patients who had migraines. So we don’t exactly know how it works, but the Botox has given in multiple parts on the forehead here, here, here, and here. And, you know, basically paralyzes the muscle and patients experience an improvement in their migraines with Botox. And I bet that was found out on the upper East side of Manhattan.


Yeah. Well, there’s a little benefit of giving the Botox, obviously. So yeah, that’s where that’s like, just like the allergy and sensitivity to gold was found in the hip hop community. A lot of rappers had this sensitivity. I’ve been saving that one for you. Would halter studies be appropriate? I’m trying to help my physicians with potential and useful diagnostics. Halter is a different story. Yeah. It’s helpful, but it’s cardiology. Yeah. So exactly. If you’re, you know, we use Holter in the neurology world, if we’re trying to figure out if the stroke came from the heart. So a lot of strokes can originate from arrhythmias, like atrial fibrillation in the heart. And so we try to identify that by using a Holter monitor. So if you’ve had a stroke, then hold the monitor is definitely something that would be worthwhile from a, at least from a neurological perspective.


This is a very interesting question. I have periods where I have trouble understanding written communication and write things incorrectly. Usually it then evolves into vision deterioration, although not major then forgetting names and not recognizing faces. The biggest problem is that it gets bad. Usually before I realized this is an issue that’s not general inflammation, right? Yeah. That sounds more like there’s that there’s a war definitely a reason to have a scan of the brain because we want to understand why you’re having difficulty with writing and vision. And it can be from a whole host of different things. But I think in that particular case, we need some more information we need to examine you and we need to get some imaging of the brain. Yeah. That’s a definite neuro workup right there. That’s not COVID I don’t think. And I forget things a lot.


Let me just see if this is the same person, different person, continuing the conversation. And I forget things a lot for getting an appointment as normal for getting that. I had lunch plans, Thursday, normal for getting, I had the call after prompting. I can’t remember the call at all. That’s the new normal and that, you know, there’s, there’s I think there’s some, I think it was Oliver sacks who said this, where they say, if you forget the name of a key, like you for kids, forget the name of a key and that’s for everybody. But if you forget what a key does, is that related to this? Is this a concern for you? I mean, I think it’s a concerning symptom, whether it’s related to COVID or not, I’m not sure, but you know, if you’re having new memory problems and you’re forgetting the names of objects or forgetting to remember your appointments and that’s a new problem, it definitely warrants further investigation. For sure.


I call it ZZ dizzy, Wiki. I dunno. I dunno what it is, but no, I think we’re talking about that. The vibrating under the skin, negative D dimer, cat scan, other bloods, is it possible? You just don’t know what to test for. Definitely. There’s a lot of unknowns here. Huge. But what do you do for these ZZ dizzy? Weedies I mean, it depends, it depends on what the symptoms are and depends how severe they are. First. We have to decide, you know, on examination if they’re normal or not, and then go from there. Sometimes we, we might, we might want imaging. It depends on the patient and the symptoms. Here’s an interesting question. Can a strong pulsating feeling in the stomach be caused by the Vegas nerve?


I would say probably not. Typically we’re talking more about, you know, feeling like you’re going to pass out or having more other types of autonomic problems. That sounds more of like some sort of dominant issue that I don’t think so. What about aneurysm? Is that like an aortic aneurysm or something? Could that sort it’s worth checking out though, right? Yes. It’s worth seeing your doctor about it, but not a neurologist. Yeah. There are so many collections of symptoms seen in Kobe. Could it be that the constellation of symptoms be a result of inflammation of the brain yes. As the brain controls your body and depending on how your brain is inflamed as how symptom service. Yeah. That’s been the theme, right? Yes. How do we decrease our body’s reaction to pain or perceive pain? I think that could be a Nobel prize winning answer there. I was just thinking, if you figure this one out, you’re going to wind up with a gold allergy.


I don’t know the answer, but you know what, one thing we’ll talk about a lot in the coming weeks is because this is such an inflammatory you know, constellation of things, the inflammation and the pain is all very tied into the autonomic nervous system, particularly the sympathetic nervous system. So there’s like a lot of, you know, adrenaline mediated type of responses. And it’s like pain causes, anxiety causes, increased heart rate causes can cause increased blood pressure. A lot of that stuff is, is, is cyclical. And it’s kind of tied up in a constellation. One thing that’s very helpful with that stuff is the breathing exercises, meditation calming the sympathetic nervous system you know, trying to increase parasympathetic flow. And we have a lot of good guests coming up in the next couple of weeks. I think you guys are gonna like it.


My cardiologist said I should go off eloquence because of my meningioma and low platelet count. My hematologist thinks I should keep the blood thinner and maybe go off Metoprolol. Whose side are you on dr. Martha? I’m just that I know you’re not gonna answer that. And you can that’s doing it is doing activity like they do with stroke rehab beneficial for neurologic issues due to COVID. Yeah. I mean, I think it depends on what your neurological issues are, but if it’s weakness or numbness or balance, then, then yes, it’s basically a stroke rehab type activity. If it’s loss of sensation of smell and taste, no, probably not.


I’m sorry. I’m going to have to sign off in about a minute. I’m just letting you know, but a minute. Okay. I’m gonna, I’m gonna just give me just, just give me the quick, first thing that pops into your head for long haul, and we’re still suffering from various symptoms and finding it difficult to return to full time work. Would accommodations be able to be made for the ADA? You were too quick. I think on that one, but I heard of something. That’s a, maybe that’s a, maybe I’m going to answer for you in the interest of time. I missed that. What tests spinal tap and what this video will be available for replay. We can’t use the final minute for that. Very painful to radiating to the back dizziness and vertigo and vision loss. Why vision loss, vertigo, and what was the other thing? Dizziness, dizziness, vertigo, vision loss. Yeah. So again, for those types of symptoms, especially the, the, you know, the vision loss, you need to see your doctor. You need to get an examination and most likely you need imaging as well.




I’m going to call it. I I’m going to call it. I think he did it. I think we made it. So I’m dr. Mark Clark. Super fascinating. I knew you were going to be smart, but you are in the right thing and you have a big smart brain. So thank you so much for being here. This was awesome. I’m really enlightening. And I am going to unmute everybody. If I can figure out how Beth is going to unmute everybody so that we can audio logically show our appreciation to you. And then we are going to have a couple of announcements. Really thank you so much. This was so enlightening. And if there’s anything I can do for you in the future, do not hesitate to ask. Doesn’t have to have anything to do with medicine or rehab. I walked dogs. I washed cars. Thank you so much. I am grateful for your time babysit kids. I would love to, I would love to where do you live? What gives us, give me a general area.


All right. Well, let me know when. All right. I really appreciate it. Thank you so much for the opportunity to be here. Pleasure be well. That was so great. That was so great. Don’t jump off. Everybody has said have some announcements. All right, ladies and gentlemen, Sunday night, we will be back doing a open discussion and we’re going to talk bootcamp. Okay. So listen, get yourselves ready because it’s about to be on. This is the time. Okay. If you need to have that cry, what can we, can we meet somebody? Who’s doing a hip hop song while, while we’re talking here. So, so, so guys, no joke, like I really think that, you know, I am not minimizing anybody symptoms. Okay. You can’t hear me. You can hear me. You can hear me. Okay. My headset went down, but now it’s time. The acute phase is, is, is, is subsiding.


Not that every the symptoms of society and I get that, but now is not the time to continue. There’s something called the repetition compulsion, which is that we are, you know, magnified. We want to just repeat and repeat and repeat and join in. It’s like, if I’m walking in the street and somebody bumps into me and doesn’t even say, excuse me, and then I go to work. And I’m like, you won’t believe what happened when I went to work today. And it’s like, you, there’s very good evidence that shows that you have physiologic manifestations of that emotional experience. COVID is very physical. It’s very physiological. It’s emotional, it’s heavy. It’s spiritual for many people. It’s the stress of not just going through something yourself, but your community, your city, your state, your country, the world it is heavy, but, but we cannot sit here forever and we must start to at least begin to turn the page.


Okay. Long haulers. We hear you. Okay. We see you. Okay. We know that this is a thing, but let’s try to shorten the hall. Let’s try to shorten the hall and let us start you know, really doing things to take steps forward and to you know, to really to start moving forward. And you know, the one thing that I’m most grateful for about this week is I wanted to specifically have a cardiologist on, I want to specifically have a neurologist on for my own information to say, what can we do with patients? What will be okay, but will not be okay? What will be you know, dangerous. And this is going to get better. So hang in there Sunday night, Q and a open discussion. Talk about bootcamp and we start next week. Any questions before we go?


What time? Sunday night


Having a PM. 7:00 PM. Eastern time, Eastern time, ladies and gentlemen have a great evening. You too. Look on the bright side. At least you got to get to meet me. Okay. I’m glad you got to see me tonight.


Love your shirt, my shirt. I like mine.


Laura, you should equate with what time? Sunday.


Thank you. I’m that troublemaker?


That’s all right. We’re used to dealing with your type in Brooklyn. Have a good night, everybody.