Dizziness and COVID-19.

Coronavirus 2019 or COVID-19 is a novel entity which had led to many challenges among physicians due to its rapidly evolving nature. Vertigo or dizziness has recently been described as a clinical manifestation of COVID-19. Countless studies, emerging daily from various parts of the world, have revealed dizziness as one of the main clinical manifestation of COVID-19. This is not surprising as dizziness has historically been associated with viral infections.

An earlier published study from China found dizziness to be the most common neurological manifestation of COVID-19.[1] Dizziness was proposed to occur ensuing the neuroinvasive potential of severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2 virus which causes COVID-19. Baig et al postulated that the virus enters the neural tissue from circulation and binds to the angiotensin-converting enzyme 2 receptors found in the capillary endothelium.[2] Apart from that, direct invasion, hypoxia, hypercoagulopathy, as well as immune-mediated insult were among the postulated mechanism of neuroinvasion leading to dizziness.[3]

A literature search was performed using articles published in PubMed on August 1, 2020, to identify dizziness as a clinical manifestation of COVID-19. The keywords used for the article search include giddiness, dizziness, vertigo, COVID-19, SARS CoV 2, Coronavirus disease. To our knowledge, this is the first article that outlines the association between dizziness and COVID-19.

We obtained 14 articles, which include 3 case reports and 11 studies (Table 1). A total of 141 patients were pooled from this review. All patients included in this review had dizziness/vertigo as a presenting symptom. Dizziness was the initial presentation of COVID-19 in 3/141 patients (2.13%),[9,11,13] whereby in 2 of these patients, dizziness was later followed by respiratory symptoms.[9,13] Most of the studies reporting on dizziness as a clinical manifestation hails from China (11/14), the epicenter which gave rise to the pandemic. Of the 14 studies included, dizziness was specifically investigated and treated only in 2 studies[9,11] as dizziness was not the highlight in most studies, it was not investigated and described thoroughly. Additionally, the outcome of dizziness was mentioned only in 1 study by Malayala et al,[11] whereby vestibular rehabilitation was carried out for the patient successfully.

Table 1.

Summary of Characteristics and Main Findings of COVID-19 Patients With Dizziness.

Author	Country	Study design	Total patients with dizziness (%)	Investigation for dizziness	Treatment for dizziness	Outcome of dizziness
Chen et al[4]	China	CS	29 (20)	N/A	N/A	N/A
Chen et al[5]	China	CS	21 (8)	N/A	N/A	N/A
Han et al[6]	China	CR	1	N/A	N/A	N/A
Hu et al[7]	China	CS	1 (4.16)	N/A	N/A	N/A
Karadas et al[8]	Turkey	CS	16 (16.7)	N/A	N/A	N/A
Kong et al[9]	China	CR	1	Electronystagmography, Pure tone, MRI brain	Betahistine, Danshenchuandomazine	N/A
Lo et al[10]	China	CS	2 (20)	N/A	N/A	N/A
Malayala et al[11]	United States	CR	1 (Vestibular neuritis)	Bedside neurological examination, CT brain	Meclizine, Benzodiazepine, Steroids, Vestibular rehabilitation	Resolve
Mao et al[1]	China	CS	36 (16.8)	N/A	N/A	N/A
Mi et al[12]	China	CS	3 (30)	N/A	N/A	N/A
Sia et al[13]	Canada	CR	1 (Isolated)	N/A	N/A	N/A
Vacchiano et al[14]	Italy	CS	11 (10)	N/A	N/A	N/A
Wang et al[15]	China	CS	13 (9)	N/A	N/A	N/A
Wang et al[16]	China	CS	5 (7)	N/A	N/A	N/A

Abbreviations: CR, case report; CS, cross-sectional study; CT, computed tomography; MRI, magnetic resonance imaging; N/A, not available.

Dizziness, albeit a nonspecific COVID-19 symptom, requires thorough investigation notably to determine its leading cause including, acute labyrinthitis, vestibular neuritis, acute otitis media, or secondary to stroke following COVID-19.

We would like to emphasize that dizziness should not be taken lightly as it has been proven to be a notable clinical manifestation among COVID-19 patients. Parallel to that, association with other audiovestibular manifestations such as hearing loss and tinnitus ought to be determined. Persistent dizziness posttreatment from COVID-19 requires referral to the Otorhinolaryngology Department for thorough examination and investigation. Additionally, we recommend vestibular rehabilitation therapy, which has revealed promising results, to be carried out for stable COVID-19 patients with dizziness. Lastly, it is imperative that attending physicians remain vigilant, especially when managing nonspecific symptoms such as dizziness, as it can be easily overlooked.