With interest we read the article by Pantelis et al. about the neurological, neuropsychiatric, and neurodevelopmental comorbidities in patients infected with SARS-CoV-2 (COVID-19).[1] One of the key messages of the review was that neurological involvement is increasingly recognised [1]. We have the following comments and concerns.

Neurological involvement in SARS-CoV-2 infected patients is more divers than discussed. Neurological involvement may be found in the central nervous system (CNS) and the peripheral nervous system (PNS).[2] CNS-disease so far reported in SARS-CoV-2 infected patients include meningitis/encephalitis, acute hemorrhaghic, necrotising encephalopathy (AHNE), auto-immune encephalitis (AIE), encephalopathy, epilepsy, ischemic stroke, intracerebral bleeding, sinus venous thrombosis, acute disseminated encephalo-myelitis (ADEM), posterior reversible encephalopathy syndrome (PRES). Parkinson’s disease, cerebral hypoxia, delirium, myelitis, cerebral hypoxia, and optic neuritis.[2] 

Involvement of the PNS includes hypogeusia, hypo-osmia, myositis, myalgia, myasthenia gravis, myasthenic syndrome, Guillain-Barre syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), critical-ill neuropathy, critical-ill myopathy, and rhabdomyolysis. Since some of these conditions may precede the onset of typical clinical manifestations of COVID-19, it is crucial to know about the spectrum of neurological disease associated with SARS-CoV-2. Alertness about the neurological complications in SARS-CoV-2 infected patients may lead to early diagnosis and thus better outcome in general. 

Not discussed in the review was the effect of drugs given for treating COVID-19 on the CNS and PNS. There is increasing evidence that for example creatine-kinase elevation or even rhabdomyolysis in SARS-CoV-2 infected patients may be frequently triggered by drugs such as azithromycin, piperacillin, meropenem, hydroxyl-chloroquine, steroids, acetaminophen, furosemide, colchicine, hydrochlorothiazide, or propofol. Thus, it is crucial in SARS-CoV-2 infected patients that all drugs applied to these patients are carefully considered with regard to potential side effects. It is also crucial to mention that certain drugs should be avoided in the treatment of COVID-19 particularly if patients additionally have neurological complication or underlying neurological disease such as myasthenia or epilepsy. Certain antibiotics, which trigger seizures and drugs leading to exacerbation of myasthenia gravis should be strictly avoided.[3] 

Overall, the interesting review by Pantelis et al. has a number of shortcomings, which should be addressed before drawing final conclusions. The spectrum of CNS or PNS involvement in COVID-19 is much broader than so far described. Not only frequent neurological manifestations but also rare complications should be considered. Drugs with potential neurological side effects on the CNS or PNS should  be  avoided.  Since  neurological disease in COVID-19 may precede the pulmonary compromise, recognising the association may be the clue to early diagnosis.