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There are many ways that COVID-19 can damage the brain. As I described in a previous
blog post, some can be devastating, such as encephalitis, strokes, and lack of oxygen to the
brain. But other effects may be more subtle, such as the persistent impairment in sustained
attention noted by Chinese researchers.

In addition to direct effects on the brain, COVID-19 can also have long-term effects on other
organ systems. So-called long haulers can have other lingering symptoms including
fatigue, body aches, inability to exercise, headache, and difficulty sleeping. Some of these
problems may be due to permanent damage to their lungs, heart, kidneys, or other organs.
Damage to these organs — or even just the symptoms by themselves — can impair thinking
and memory and cause brain fog. For example, how can you think clearly if you're feeling
fatigued and your body is aching? How can you concentrate if you were up half the night
and awoke with a headache?

What should you do if you may be experiencing
COVID-19 brain fog?

The first and most important thing to do is to see your doctor and share with them all of the
lingering symptoms you are experiencing. These should include your brain fog and other
neurologic symptoms (such as weakness, numbness, tingling, loss of smell or taste), and
also problems such as shortness of breath, palpitations, and abnormal urine or stool.

What might help clear the brain fog?

To help clear the brain fog, 1 recommend pursuing all of the activities that we know help
everyone's thinking and memory.

Perform aerobic exercise. You may need to start slow, perhaps just two to three minutes
a few times a day. While there is no established “dose” of exercise to improve brain

health, it’s generally recommended you work toward 30 minutes a day, five days a
week.

Eat Mediterranean-style meals. A healthy diet including olive oil, fruits and vegetables,

nuts and beans. and whole arains has been proven to imvrove thinkina. memorv. and
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of frontal lobe and/or hypothalamic/pituitary axis dysfunction occurring after COVID-19 or the surface
glycoprotein? Pandemic isolation fatigue?

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8/16/2021

brain health.

Avoid alcohol and drugs. Give your brain the best chance to heal by avoiding
substances which can adversely affect it.

Sleep well. Sleep is a time when the brain and body can clear out toxins and work
toward healing. Make sure you give your body the sleep it needs.

Participate in social activities. We are social animals. Not only do social activities
benefit our moods, but they help our thinking and memory as well.

Pursue other beneficial activities, including engaging in novel, cognitively stimulating

activities; listening to music; practicing mindfulness; and keeping a positive mental
attitude.

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Comments

Rick Ricketson March 15, 2021

My girlfriend and I are both 66. I did have moderately severe infection with SARS-CoV-2 back in
November 2020. Luckily, she ahas tested negative by PCR, rapid Ag, and CoV-2 Abs. She and I both went
through the two-dose Pfizer schedule. As expected, I had increased residual cognitive dysfunction and
the recurrent rash (surface glycoprotein hypersensitivity). She, however, had never tested positive and
now stated tonight she feels “exhausted and mentally fatigued” after her second dose. Is there evidence

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8/16/2021

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MIND & MOOD

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should you take it?

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Case 2:18-cr-00422-DJH Document 1218-4 Filed 08/16/21 Page 1 of 13

EXHIBIT D


Case 2:18-cr-00422-DJH Document 1218-4 Filed 08/16/21 Page 12 of 13

How is paresthesia treated?

Proper treatment of paresthesia depends on the exact diagnosis of the

underlying cause.

e Besure you take any medication as directed. If you think you are having a
reaction, please call your provider.

« Do not miss any appointments and please call if you are having trouble.

¢ Itis important that you know your medications and test results and can
share them with your provider so they can better care for you.

¢ Working closely with your medical provider is an important part of your
treatment.

When should | call for help?
Call 911 anytime you think you need emergency care. For example, call if:
e« Have symptoms of a stroke like:
o Sudden loss of movement in one side of your face or body.
o New numbness, tingling, or weakness to one side of your body or
face.
o Trouble speaking or understanding what someone is saying to you
o Sudden trouble walking or balancing.
o Sudden and worst headache of your life.
¢ Signs of other emergent conditions like:
co Sudden loss of bowel or bladder control.
o Weakness, numbness, or tingling in both legs or in the pelvis.

Call your doctor now or seek urgent medical care if:
« Your symptoms are worse than normal

Monitor your symptoms and health closely. Please call your health care
provider if you are not improving like you normally do. Following up with your
doctor is a very important part of your health and safety.

Family Medicine
Post-COVID Paresthesia
BDig


2:1 10422-DJH Document 1218-4 Filed 08/16/21 Page 11 of 13

MICHIGAN MEDiciIne © Numbness and Tingling After
UNIVERSITY OF MICHIGAN COVID-19: Care Instructions

What causes numbness and tingling?

Numbness and tingling, also known as paresthesia, is a burning or prickling
sensation that is usually felt in the hands, arms, legs, or feet, but can also occur
in other parts of the body. The sensation, which happens without warning, is

usually painless and described as tingling or numbness, skin crawling, or
itching.

Most people have experienced temporary paresthesia -- a feeling of "pins and
needles" -- at some time in their lives when they have sat with legs crossed for
too long, or fallen asleep with an arm crooked under their head. It happens
when sustained pressure is placed on a nerve. The feeling quickly goes away
once the pressure is relieved.

Chronic numbness or tingling can be a symptom of any number of disorders:
stroke, tumor, multiple sclerosis - to name a few. Also, nerve entrapment
disorders, where a nerve gets compressed or restricted by nearby tissues can
cause paresthesia accompanied by pain. (Carpel Tunnel Syndrome is an
example of a nerve entrapment disorder). COVID-19 can also cause numbness
and tingling in some people. It is difficult to predict who may get paresthesia
following COVID.

How is paresthesia diagnosed?

Diagnostic evaluation is based on determining the underlying condition causing
the paresthetic sensations. Medical history, physical examination, and
laboratory tests are essential for the diagnosis. Doctors may order additional
tests depending on the suspected cause of the paresthesia. If there is concern
your symptoms are related to your history of COVID-19, your doctor may ask
you about your course with the illness.

Family Medicine
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Pi CB2
CBI receptor
receptor ©—Cannabinoid

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STAYING HEALTHY

The endocannabinoid system: Essential and
mysterious

“ — a
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Stay Informed

COVID-19

Recently I received an email from a man who described how he is still struggling with
“cognitive challenges” since recovering from the virus in the spring of 2020. His doctor ran
him through a checkup and a battery of tests. Everything was normal, yet his cognitive
challenges remain. Like this man, many people who have recovered from the acute, life-
threatening effects of COVID-19, but still don't feel that their thinking and memory are back
to normal.

How COVID-19 affects the brain

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March 08, 2021

By: Andrew E. Budson, MD, Contributor

As a cognitive behavioral neurologist, I've been hearing from many individuals who are
complaining of “brain fog” after infection with COVID-19. So I thought it was worth

discussing exactly what COVID-19 brain fog is, and some things to do that might help clear
it.

What is brain fog?

Let's start by trying to understand brain fog. Brain fog is not a medical or scientific term; it
is used by individuals to describe how they feel when their thinking is sluggish, fuzzy, and
not sharp.

We all experience this feeling from time to time. Perhaps you couldn't think clearly when
you were sick with the flu or another illness. Maybe you were jet-lagged and your thinking
was sluggish because it felt like it was 2 AM. Or perhaps you took an antihistamine or
another medication that made your thinking fuzzy for a few hours. In each case you
probably just waited to get back to normal, whether that meant recovering from your
illness, adjusting to the new time zone, or waiting for the side effects of the medication to
wear off.

But what if your thinking didn't return to normal?

What is COVID-19 brain fog?

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What is COVID-19 brain fog — and
how can you clear it?

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Case 2:18-cr-00422-DJH Document 1218-4 Filed 08/16/21 Page 13 of 13

Disclaimer: This document contains information and/or instructional materials developed by
Michigan Medicine for the typical patient with your condition. It may include links to online
content that was not created by Michigan Medicine and for which Michigan Medicine does not
assume responsibility. It does not replace medical advice from your health care provider
because your experience may differ from that of the typical patient. Talk to your health care
provider if you have any questions about this document, your condition or your treatment plan.

Adapted from: NINDS. Paresthesia Information Page. Access at: https://www.ninds.nih.gov/

Reviewer: Heather Vance MD
Plain Language Editor: Ruti Volk, MSI, AHIP

Patient Education by Michigan Medicine is licensed under a Creative Commons Attribution-
NonCommercial-ShareAlike 4.0 International Public License. Last Revised 05/2021

Family Medicine
Post-COVID Paresthesia
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