What is the best course of action for a 62-year-old female with a history of Multiple Sclerosis (MS) who was diagnosed with COVID-19 3 days ago, is experiencing anxiety and tingling in her hands and feet, and is currently being treated with Zofran (ondansetron) for nausea, but has stable vital signs and no respiratory symptoms?

Management of COVID-19 in a 62-Year-Old Female with Multiple Sclerosis

This patient requires immediate assessment for MS relapse versus COVID-19-related neurological symptoms, psychological support for anxiety, and continuation of symptomatic treatment while monitoring for disease progression.

Immediate Assessment Priorities

Distinguish MS Relapse from COVID-19 Symptoms

• The tingling in hands and feet requires urgent evaluation to determine if this represents new MS symptoms triggered by COVID-19 infection or anxiety-related paresthesias. 1, 2
• COVID-19 infection is associated with new MS symptoms in approximately 20% of patients with MS, and worsening of pre-existing symptoms occurs in over 50% of cases. 2
• Patients with longer MS duration and higher disability scores are at increased risk for symptom exacerbation during COVID-19 infection. 2
• Perform a focused neurological examination specifically assessing for objective sensory deficits, motor weakness, coordination abnormalities, and any signs of spinal cord involvement. 2

Evaluate Disease-Modifying Therapy Status

• Determine if the patient is currently on any disease-modifying therapies (DMTs), as these significantly reduce the likelihood of developing new MS symptoms during COVID-19 infection (OR 0.556). 2
• Most DMTs including interferon, glatiramer, teriflunomide, and cladribine should be continued during COVID-19 infection as they do not increase infection severity or affect vaccine response. 1
• If the patient is on rituximab, be aware this increases the risk of severe COVID-19 outcomes and requires closer monitoring. 1

Management of Anxiety and Neurological Symptoms

Address Psychological Distress

• Provide immediate psychological counseling and mental health education, as over 60% of COVID-19 patients experience anxiety and depression. 3
• Implement non-pharmacological interventions including breathing relaxation training, mindfulness training, and cognitive behavioral therapy. 3
• For moderate to severe anxiety, consider short-acting anxiolytics at the lowest effective dose for the shortest duration, selecting agents with minimal drug-drug interactions. 3
• Establish dynamic evaluation and warning mechanisms for prompt identification of psychological crises requiring escalation of care. 3

Differentiate Anxiety-Related vs. Neurological Paresthesias

• Anxiety-related tingling typically presents bilaterally in hands and feet simultaneously, is non-dermatomal, and may be accompanied by hyperventilation or perioral numbness. 3
• MS-related new symptoms would more likely follow dermatomal or anatomical patterns, be asymmetric, and potentially include other neurological signs. 2
• If examination reveals objective neurological deficits consistent with MS relapse, consider high-dose oral corticosteroids (methylprednisolone 1000 mg daily for 3 days) rather than intravenous administration to minimize viral exposure risk. 4

COVID-19 Specific Management

Symptomatic Treatment

• Continue Zofran (ondansetron) for nausea management as currently prescribed. 3
• Use paracetamol (acetaminophen) for fever management rather than NSAIDs until more evidence is available regarding NSAID safety in COVID-19. 5
• Monitor for development of respiratory symptoms, as stable vital signs at day 3 do not preclude later deterioration. 3

Antiviral Considerations

• If the patient develops worsening symptoms or risk factors for severe disease, consider remdesivir or neutralizing monoclonal antibodies, which have demonstrated effectiveness in MS patients with COVID-19. 1
• The patient's MS diagnosis alone does not automatically indicate severe COVID-19 risk unless she has high disability scores, progressive MS, or is on high-risk immunosuppressive therapy like rituximab. 1, 6

Monitor for Complications

• Assess for bacterial superinfection if fever persists or worsens, as bacterial coinfection occurs in approximately 40% of viral respiratory infections requiring hospitalization. 5
• Evaluate for venous thromboembolism risk and consider prophylactic anticoagulation based on standard COVID-19 protocols. 3
• Screen for cytokine storm development, which can be managed with corticosteroids if it occurs. 3, 1

Ongoing Monitoring and Follow-Up

Short-Term Surveillance

• Establish daily telephone or telemedicine check-ins to monitor symptom progression, particularly respiratory status, neurological symptoms, and psychological wellbeing. 3
• Provide clear instructions for when to seek emergency care: worsening dyspnea, chest pain, confusion, inability to stay awake, or rapidly progressive neurological deficits. 3

Long-Term Considerations

• Continue mental health and psychosocial support after acute COVID-19 resolution, as symptoms may persist. 3
• Reassure the patient that COVID-19 infection does not increase long-term susceptibility to MS relapses or accelerate MS progression based on current evidence. 1
• If not already vaccinated, strongly recommend COVID-19 vaccination after recovery, as it does not trigger MS relapses or diminish DMT efficacy. 1

Critical Pitfalls to Avoid

• Do not automatically attribute new neurological symptoms to anxiety without thorough neurological examination, as COVID-19 can trigger genuine MS exacerbations. 2
• Do not discontinue DMTs during COVID-19 infection (except in specific circumstances with rituximab), as they provide protective effects against developing new MS symptoms. 1, 2
• Do not delay corticosteroid treatment if true MS relapse is identified, but use oral rather than intravenous route to minimize healthcare exposure. 4
• Do not assume stable vital signs at day 3 mean the patient is out of danger; COVID-19 can deteriorate in the second week of illness. 3