Sunday, March 22, 2020



Dr K K Aggarwal
President CMAAO, HCFI and Past National President CMAAO

COVID Virus behaves like any other virus

No. Most viral illnesses have high lymphocyte counts but COVID 19 have low lymphocyte count.
Dengue taught us the value of platelet count interpreted along with haematocrit and COVID 19 is now teaching us the value of lymphocytes in blood test.
It has been a standard teaching that all viral fever will have high lymphocytes counts. Low count will only occur with HIV, SARS like illness, measles and hepatitis.

Now all studies have shown it to be an important marker of COVID 19
In the latest study published in March 9, 2020, the Lancet, the authors showed that baseline lymphocyte count was significantly higher in survivors than non-survivors; in survivors, lymphocyte count was lowest on day 7 after illness onset and improved during hospitalisation, whereas severe lymphopenia was observed until death in non-survivors.

Clues for COVID-19 include leukopenia, seen in 30% to 45% of patients, and lymphocytopenia, seen in 85% of the patients in the case series from China,

Other associated lab findings are elevated alanine aminotransferase and aspartate aminotransferase levels (37%).

High D-dimer levels and more severe lymphopenia have been associated with mortality.

1.     Chen N, Zhou M, Dong X, Qu J, Gong F. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Jan 30. [Epub ahead of print]
2.     Li Q, Guan X, Wu P, Wang X, Zhou L, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Jan 29.

Most fevers cannot be differentiated clinically
No, here are the tips
Fever with cough and cold- think of flu
Fever with retroorbital eye pain - think of dengue
Fever with joints pain which improves on bending - think of Chikungunya
Fever with lymphocytosis – Think of Viral fever
Fever with lymphopenia: Think of Covid 19, acute hepatitis, HIV
Fever with jaundice: Rules out viral hepatitis
Fever subsides capillary leakage appears in dengue
Low grade evening rise fever think of TB
Fever with chills and rigors: think of malaria, Filaria, UTI, sepsis
Fever with cough and breathlessness: Think of COVID like illness
Fever with ESR > 100: painful thyroiditis, sepsis,
Fever with SGOT > SGPT: dengue,
Fever with angry looking throat with no cough think of streptococcal sore throat
Fever with red eyes: think of Zika illness
Fever with eschar think of scrub typhus
Fever with single chills: Think of pneumonia
Fever with Jaundice: Rule out leptospirosis,
Fever with involvement of skin, joint and or kidney rule out auto immune disease
Fever with TLC > 15000 is sepsis
Fever with positive thump sign on live rule out liver abscess

Its unethical for doctors to create awareness about COVID 19

No, its as per MCI ethics regulations
MCI ethics regulation

  5.2 Public and Community Health: Physicians, especially those engaged in public health work, should enlighten the public concerning quarantine regulations and measures for the prevention of epidemic and communicable diseases. At all times the physician should notify the constituted public health authorities of every case of communicable disease under his care, in accordance with the laws, rules and regulations of the health authorities. When an epidemic occurs a physician should not abandon his duty for fear of contracting the disease himself. 

 7.11 A physician should not contribute to the lay press articles and give interviews regarding diseases and treatments which may have the effect of advertising himself or soliciting practices; but is open to write to the lay press under his own name on matters of public health, hygienic 14 living or to deliver public lectures, give talks on the radio/TV/internet chat for the same purpose and send announcement of the same to lay press.  

Loss of sense of smell is hallmark of COVID-19

No. Post-viral anosmia is one of the leading causes of loss of sense of smell in adults, accounting for up to 40% cases of anosmia. Viruses that give rise to the common cold are well known to cause post-infectious loss, and over 200 different viruses are known to cause upper respiratory tract infections. Previously described coronaviruses are thought to account for 10-15% cases. It is therefore perhaps no surprise that the novel COVID-19 virus would also cause anosmia in infected patients.

There is good evidence from South Korea, China and Italy that significant numbers of patients with proven COVID-19 infection have developed anosmia/hyposmia. In Germany it is reported that more than 2 in 3 confirmed cases have anosmia. In South Korea, where testing has been more widespread, 30% of patients testing positive have had anosmia as their major presenting symptom in otherwise mild cases. []

Lopinavir-ritonavir is the drug of choice

This combined protease inhibitor, which has primarily been used for HIV infection, has in vitro activity against the SARS-CoV  and appears to have some activity against MERS-CoV in animal studies.
Although the use of this agent for treatment of COVID-19 has been described in case reports, there was no difference in time to clinical improvement or mortality at 28 days in a randomized trial of 199 patients with severe COVID-19 given lopinavir-ritonavir (400/100 mg) twice daily for 14 days in addition to standard care versus those who received standard of care alone [
Cao B, Wang Y, Wen D, et al. A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med 2020.

Virus can be transmitted through breast milk

The only report of testing found no virus in the maternal milk of six patients [111]. However, droplet transmission could occur through close contact during breastfeeding. Thus, mothers with confirmed COVID-19 or symptomatic mothers with suspected COVID-19 should take precautions to prevent transmission to the infant during breastfeeding (including assiduous hand hygiene and use of a facemask).

Alternatively, to minimize direct contact, the infant can be fed expressed breastmilk by another caregiver until the mother has recovered, provided that the other caregiver is healthy and follows hygiene precautions.

Women who choose not to breastfeed must take similar precautions to prevent transmission through close contact when formula is used. [Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020; 395:809.]

There are no guidelines for discontinuation of home isolation

The US CDC has issued recommendations on discontinuation of home isolation, which include both test-based and non-test-based strategies.
The choice of strategy depends upon the patient population (eg, immunocompromised versus nonimmunocompromised), the availability of testing supplies, and access to testing.

When a test-based strategy is used, patients may discontinue home isolation when there is:

Resolution of fever without the use of fever-reducing medications AND
Improvement in respiratory symptoms (eg, cough, shortness of breath) AND
Negative results of a US FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens)

When a non-test-based strategy is used, patients may discontinue home isolation when the following criteria are met:

At least seven days have passed since symptoms first appeared AND
At least three days (72 hours) have passed since recovery of symptoms (defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms [eg, cough, shortness of breath])
In some cases, patients may have had laboratory-confirmed COVID-19, but they did not have any symptoms when they were tested. In such patients, home isolation may be discontinued when at least seven days have passed since the date of their first positive COVID-19 test so long as there was no evidence of subsequent illness.
The use of non-test-based strategies that use time since illness onset and time since recovery as the criteria for discontinuing precautions is based upon findings that transmission is most likely to occur in the early stage of infection. However, data are limited, particularly in immunocompromised patients, and this strategy may not prevent all instances of secondary spread. [uptrodate dot com]

You require two tests to declare recovery?

Ideally 4. Factors include resolution of clinical signs and symptoms and negative results of reverse-transcription polymerase chain reaction (RT-PCR) testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on two sequential paired nasopharyngeal and throat specimens (four specimens total, each handled separately), with each pair collected ≥24 hours apart [Centers for Disease Control and Prevention. Interim Considerations for Disposition of Hospitalized Patients with 2019-nCoV Infection. (Accessed on February 11, 2020).]

You can not diagnose COVID 19 without tests
In some cases, testing for COVID-19 may not be accessible, particularly for individuals who have a compatible but mild illness that does not warrant hospitalization.
If the clinician has sufficient concern for possible COVID-19 (eg, there is community transmission), it is reasonable to advise the patient to self-isolate at home (if hospitalization is not warranted) and alert the clinician about worsening symptoms. The optimal duration of home isolation in such cases is uncertain.

Continuing steroids in COVI 19 patients will harm
For individuals with underlying conditions who require treatment with these agents and are without evidence of COVID-19, there is no evidence that routinely discontinuing treatment is of any benefit. In addition, discontinuing these medications may result in loss of response when the agent is reintroduced. This approach is supported by statements from American and other dermatology, rheumatology, and gastroenterology societies.
Normally immunocompromised patients with COVID-19 are at increased risk for severe disease, and the decision to discontinue prednisolone, biologics, or other immunosuppressive drugs in the setting of infection must be determined on a case-by-case basis.

No comments:

Post a Comment