Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged since December, 2019, and spread worldwide, causing the COVID-19 pandemic. Despite COVID-19 being a respiratory tract infection, the pathophysiology in both adults and children is incompletely understood. Neurological signs and symptoms—from headache to meningitis—have been reported in hospitalised patients.1, 2 SARS-CoV-2 can enter and replicate in neuronal cells in vitro,3 but the association between neurological manifestations and presence of SARS-CoV-2 in cerebrospinal fluid (CSF) has only been tested in a few cases, with one patient testing positive for SARS-CoV-2 in a case report4 and seven of seven patients testing negative in a case series.1
We did retrospective systematic screening of all CSF samples (n=622) received at the virology laboratory of Lyon University Hospital during the COVID-19 epidemic (Feb 1 to May 11, 2020). In the appendix, a figure presents the number of COVID-19 cases and CSF samples screened during this period. Samples were screened for SARS-CoV-2 using a highly sensitive RT-PCR protocol from the Pasteur Institute.5 Overall, 578 CSF samples were tested, corresponding to 555 patients (aged 1 day to 90 years). 144 (25%) of 578 samples were from children (aged ≤15 years), whereas paediatric cases represented 31 (<1%) of 4304 patients with COVID-19. Notably, no peak in CSF sampling was noticed, as was seen for cases of COVID-19 (appendix), suggesting no increase in neurological diseases during the outbreak. Among the 555 patients, 171 (including 37 children) also had respiratory samples tested for SARS-CoV-2 within a period 3 weeks before and 4 weeks after CSF sampling was done; 23 patients (including five children) were positive for SARS-CoV-2 on respiratory samples.
All CSF samples were negative, except for two samples that were slightly positive for SARS-CoV-2 (cycle threshold [Ct]=32 and Ct=35) corresponding to post-mortem samples from two adults with confirmed COVID-19 (respectively, Ct=24 and Ct=22 in respiratory samples). This result was confirmed after a novel nucleic acid extraction of the initial sample. For one patient, a blood sample was available and was positive for SARS-CoV-2 (Ct=25) whereas brain biopsy samples from the two patients were negative, suggesting contamination of the CSF by blood. Importantly, the other 21 CSF samples from the patients with confirmed COVID-19 were negative (including one CSF sample collected post mortem).
To the best of our knowledge, our study is the largest screening for SARS-CoV-2 in CSF samples. SARS-CoV-2 detection in CSF during the outbreak in Lyon was very low (two of 578 samples). These data suggest that, although SARS-CoV-2 is able to replicate in neuronal cells in vitro,3 SARS-CoV-2 testing in CSF is not relevant in the general population. Our findings also emphasise the need for further studies to identify the potential role of the host-immune response on neurological manifestations in patients with COVID-19.
Acknowledgments
We declare no competing interests. BL is a member of the French Scientific Committee for SARS-CoV-2. We thank laboratory technicians for their active participation and help in this study; and Philip Robinson (DRCI, Hospices Civils de Lyon) for help in preparation of this report. This study was done in the field of the global surveillance of SARS-CoV-2 virus by WHO and the Centre National de Référence des Virus des Infections Respiratoires (NRC). Samples used in this study were obtained as part of approved ongoing surveillance done by the NRC at the Infectious Agents Institute (WHO reference laboratory providing confirmatory testing for COVID-19). Investigations were done in accordance with the General Data Protection Regulation (Regulation [EU] 2016/679 and Directive 95/46/EC) and French data protection law (Law 78–17 on Jan 6, 1978, and Décret 2019–536 on May 29, 2019). COVID-Diagnosis HCL Study Group—Geneviève Billaud, Maude Bouscambert, Jean-Sébastien Casalegno, Caroline Charre, Emilie Frobert, Alexandre Gaymard, Vinca Icard, Marion Jeannoel, Marie-Paule Milon, Yahia Mekki, Christophe Ramière, Caroline Scholtès, Jean-Claude Tardy, Mary-Anne Trabaud, Martine Valette, Isabelle Schuffenecker.
Supplementary Material
References
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