April 23, 2020

Diagnosis and Management of a Patient With Glioblastoma and COVID-19

Casey Brown, DNP, RN, AGPCNP-BC, and Mary Lou Affronti, DNP, RN, MHSc, ANP, Duke Cancer Institute 

A 66-year-old male with glioblastoma (GBM) on chemotherapy presents to the clinic with a 3-day history of nonspecific cough in the setting of seasonal allergies, subtle cognitive decline over the past 48 hours, and a low-grade temperature of 99.9°F. He is on dexamethasone for the treatment of brain edema secondary to his GBM.

This is a clinical presentation that advanced practitioners (APs) in oncology may experience. As an AP, one must know how to proceed in a pandemic such as COVID-19. Patients with cancer who are immunosuppressed secondary to their cancer and chemotherapy are at a higher risk for viral infections, including COVID-19 (Centers for Disease Control and Prevention [CDC], 2020). When a patient presents to the clinic with these symptoms, it is imperative that the AP identify and recognize the potential for COVID-19 infection.

Initial Presentation and Management

Many patients with primary brain tumors experience cognitive changes, which may be exacerbated by stress or illness. In a case series study from China, 36.4% of patients with COVID-19 who were hospitalized presented with neurologic manifestations (Mao et al., 2020). When a patient with this clinical picture presents to clinic, they should immediately be provided a mask, per institutional protocol, and be placed in a room away from patients and staff. During this time, APs should maintain communication with the rest of the team. COVID-19 AP workflows for telehealth can increase consistency, efficiency of communications, and the safety of patients on treatment.

Testing/Diagnosis

When deciding whether to test a patient for COVID-19, one must consider both clinical symptoms, current health status, and recent exposures. Current evidence supports that most patients with COVID-19 experience fever and/or respiratory symptoms including cough or shortness of breath (CDC, 2020). However, in patients with neuro-oncologic diagnoses, symptoms may be altered. Patients may not present with a fever secondary to dexamethasone use. Additionally, cough or shortness of breath may be similar to that experienced with a pulmonary embolism, a common differential diagnosis in patients with cancer.

When evaluating these patients and performing the neurologic exam, many cranial nerve, cognition, and strength tests can be performed in the outpatient setting while maintaining an appropriate distance from the patient or via telehealth. The American Academy of Neurology (AAN) has provided specific recommendations for performing the neurological exam via telemedicine (ANA, 2020). Once an AP decides to test a patient for COVID-19, the patient and family must be educated regarding appropriate precautions to take as though the patient is positive for the virus, while awaiting test results.

Management

As with the general population, initial management of the patient with primary brain cancer with suspected or confirmed COVID-19 is supportive treatment. Given risks of complications associated with a suppressed immune system, holding chemotherapy during the acute illness may be beneficial. Additionally, acetaminophen can be used safely in primary brain tumor patients to combat fever and myalgia.

At this time, there are no guidelines to support increasing steroids for the management of patients with suspected or confirmed COVID-19. In a study of patients being treated with Middle East Respiratory Syndrome (MERS), patients receiving steroids were more likely to require mechanical ventilation and had delayed clearance of the virus from the respiratory tract (Arabi et al., 2018).

In COVID-19–positive patients who require dexamethasone for the management of neurologic symptoms, the AP should aim for the lowest effective dose. This may require the AP to taper dexamethasone. It may be prudent to consider an infectious disease consult as well.

Conclusion

In the wake of the COVID-19 pandemic, oncology APs have been called upon to adapt to the unique circumstances of physical distancing while still providing safe care and effective treatment for immunosuppressed patients with a cancer. In addition to following the CDC guidelines for immunosuppressed COVID-19 patients, specific management recommendations for individuals with primary brain tumors are described above. While developing new ways of taking care of our oncology patients during the COVID-19 pandemic can be challenging, it also provides a collaborative opportunity for new innovative processes (e.g., oncology telehealth) that can be adapted to improve care moving forward.

References

American Academy of Neurology. (2020). Telemedicine and COVID-19 implementation guide: Neurological exam. Retrieved from https://www.aan.com/siteassets/home-page/tools-and-resources/practicing-neurologist--administrators/telemedicine-and-remote-care/20-telemedicine-and-covid19-v103.pdf

Arabi, Y. M., Mandourah, Y., Al-Hameed, F., Sindi, A. A., Almekhlafi, G. A., Hussein, M. A.,…Fowler, R. A. (2018). Corticosteroid therapy for critically ill patients with Middle East Respiratory Syndrome. American Journal of Respiratory and Critical Care Medicine, 197(6), 757–767. https://doi.org/10.1164/rccm.201706-1172oc

Centers for Disease Control and Prevention. (2020). Coronavirus disease 2019 (COVID-19): People who are at higher risk for severe illness. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html

Mao, L., Wang, M., Chen, S., He, Q., Chang, J., Hong, S…Hu, B. (2020). Neurological manifestations of hospitalized patients with COVID-19 in Wuhan, China: A retrospective case series study. medExiv preprint. https://doi.org/10.1101/2020.02.22.20026500

Read more from the APSHO Advance: Special COVID-19 Series