166 CMAAO CORONA FACTS and MYTH COVID Illness in Bangladesh

166 CMAAO CORONA FACTS and MYTH  COVID Illness in Bangladesh

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1018: Minutes of Virtual Meeting of CMAAO NMAs on “CMAAO view on COVID-19 in Bangladesh”

25^th July, 2020, Saturday

9.30am-10.30am

Participants

Member NMAs

Dr KK Aggarwal, President CMAAO

Dr Yeh Woei Chong, Singapore Chair CMAAO

Dr Marie Uzawa Urabe, Japan

Dr Ashraf Nizami, Pakistan

Dr Sajjad Qaisar, Pakistan

Dr Md Jamaluddin Chowdhury, Bangladesh

Invitees

Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia

Dr S Sharma, Editor IJCP Group

Dr Md Jamaluddin Chowdhury from the Bangladesh Medical Association presented data on the situation of COVID-19 in Bangladesh. This was followed by a discussion among the participating NMAs on COVID-19 status in Bangladesh.

COVID-19 Situation in Bangladesh- Health Perspective

Dr Md Jamaluddin Chowdhury

Bangladesh Medical Association

• Bangladesh is the most densely populated country of the world with a population density of 1116/sq km.
• The first case of Covid in the country was detected on 8^th March.
• So far, Bangladesh has done more than one million tests; the number of tests conducted per million is 6629.
• Bangladesh allows private facilities to conduct Corona test by their own RT PCR machine.
• However, the number of tests has reduced; the reason for this decline is not known, the cost of the test may have been a factor.
• Bangladesh has not started antigen test yet. Also, antibody testing has not been started for surveillance.
• No. of confirmed cases is 218658; no. of deaths confirmed due to Covid-19 is 2836.
• No of total deaths (documented or undocumented) indicate the total number of infected cases.
• Analysis of one month data from 25^th June to 24^th July shows that the number of deaths (confirmed) is not so high and ranges between 35 and 50. But there may be some undocumented cases.
• The number of critical cases is reducing; the number of ICU beds dedicated for Covid-19 cases is 201; of these 133 are occupied.
• Initially there was a shortage of high flow nasal cannula; also initially private hospitals and clinics were not providing any service. Now they are given service, both diagnostic and curative.
• Hydroxychloroquine is not being used for patients; ivermectin is also not advised in the national guideline, but the patients are taking the drug randomly.
• An ongoing trial is investigating the efficacy of combination of ivermectin and doxycycline for treatment of Covid-19 patients with the approval of Bangladesh Medical Research Council.
• Health care workers who have treated patients infected with Covid-19 have faced social stigma from local people.
• The number of doctors infected is 2229; the number of doctors deceased is 68.
• Supply of PPE is now satisfactory. Initially there was question about its quality.
• Contact tracing is going on but it is insufficient due to shortage of employees or volunteers.
• Wearing mask has recently been made compulsory by law.
• A 45-day lockdown was ordered in the country, but was not observed strictly. At present, no significant lockdown program is on implementation.
• Most of the confirmed cases are in the age group 21-40 years.
• The number of cases in females is 29% vs 71% in males.
• The number of deaths in females is 23% vs 77% in males.

Other key points from the discussion

• Countries in South Asia (India, Bangladesh, Pakistan, Sri Lanka, Nepal) should have similar data.
• Mortality in Bangladesh is 1.2-1.3%; mortality in Delhi is now 0.3%; a sero-surveillance study in Delhi has shown that 22.8% have developed antibodies. Because the mortality is low, people are not accepting the lockdown guidelines.
• Mortality in our countries should be 0.1-0.3%; the virus is not so deadly here.
• Less than 1% needs ventilators; rest can be managed at home, nursing homes and smaller hospitals as long as there is facility for HFNC.
• Start early anticoagulant (LMWH); treat with tenecteplase if no improvement despite LMWH.
• All patients should identify Day zero. Measure SpO2 on Day 3-6. If there is exertional dyspnea, this means there is pneumonia + clot; give antiviral + LMWH + steroids, all should recover.
• We need to build up AII rooms similar to countries like China, Hong Kong, Singapore, South Korea.
• Hydroxychloroquine has no role if steroids are given; role of antibiotics is to prevent secondary infection.
• Start pool test; if positive then presume that all in family are infected. Singapore allows pooled test with 64 samples at a time; Kerala allows 20 samples and ICMR allows 5 samples.
• A lockdown now is not the answer.
• In India, doctors are on duty for 7 days; they are not allowed to go home; they stay in a hotel for 5 days and are allowed to go home only if they test negative.
• Asymptomatic people are not actually asymptomatic. They may be missing atypical symptoms such as headache, single diarrhea, sore throat, nasal obstruction etc. Even a single symptom can be Covid positive.
• Public should strictly follow the SOPs in their workplace.
• Undue interference by law has created confusion. The Supreme Court of India has given a decision that petitions against policy decisions regarding Covid-19 will not be entertained.
• Pakistan Medical Association has demanded home isolation with proper monitoring of the patients (by GPs/Family Practitioners), if the person has the capacity or resources to be isolated.
• In Singapore, enforcing of stay at home orders is done by security people, while medically, if people have illness, they are shifted out to a facility.
• Issues about stigmatization, ethics and interference in professional autonomy are very real. We have to be on alert about these.

165 CMAAO CORONA FACTS and MYTH COVID Post COVID Illness

165 CMAAO CORONA FACTS and MYTH COVID Post COVID Illness

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1009: Can the Virus Disrupt the Endocrine System?

Through its effects on angiotensin-converting enzyme 2 (ACE2), researchers from Louisiana State University say that SARS-CoV-2 may disrupt various endocrine functions throughout the body.

1010: Potential Treatments, but Hard to Test

Dipyridamole a cheap, FDA-approved drug typically prescribed with blood thinners to prevent strokes, could help patients with COVID-19.

1011: Researchers at Johns Hopkins wanted to test another cheap generic drug — alpha-blocker prazosin, which prevents inflammatory surges.

1012: Oral petechial lesions observed in a small number of COVID-19 patients in addition to skin rash exanthem, is a new symptom of the virus. Madrid researchers examined the oral cavity of 21 patients with the virus who also had a skin rash, and published their findings in a research letter in JAMA Dermatology.  The presence of enanthem in a patient with a skin rash is a useful finding that suggests a viral aetiology rather than a drug reaction.

1012: Test to Guide Steroid Treatment: Hospitalized COVID-19 patients with high levels of inflammation may benefit significantly from dexamethasone and other steroids. Researchers at Albert Einstein College of Medicine and Montefiore Health System in the Bronx, New York, concluded that patients with low levels of inflammation may experience a significantly higher risk for severe outcomes with steroid use. They also found that a C-reactive protein test can help physicians decide which patients are likely to benefit.

1013: Combination Therapy Quells Cytokine Storm: In a new study, the combination of high-dose methylprednisolone and tocilizumab was associated with faster respiratory recovery, lower likelihood of mechanical ventilation, and fewer in-hospital deaths among COVID-19 patients experiencing a hyperinflammatory state known as a cytokine storm compared with those who received supportive care alone. Researchers compared patients who received the treatments with historic controls and found that participants in the treatment group were 79% more likely to achieve at least a two-stage improvement in respiratory status.

1014: Bleeding complications linked to antithrombotic strategy used in non‐critically ill COVID-19 patients: Findings from a study in the Journal of Thrombosis and Haemostasis dispute the currently adopted strategy of giving weight-adjusted doses of anticoagulants to non-critically ill patients with COVID-19 in the absence of thromboembolic complications. Researchers led by Raffaele Pesavento, MD, Department of Medicine, University of Padua, Padua, Italy, noted that "the increasing awareness that low-dose anticoagulants may be ineffective for prevention of thrombotic complications in the course of COVID-19, including the development of micro-thrombosis in the lung vessels, has induced several clinicians to consider the use of sub-therapeutic or even therapeutic doses of antithrombotic agents in all admitted patients, challenging their hemorrhagic potential. The results of our retrospective cohort study do not support this strategy."

"As (sub)-therapeutic doses of antithrombotic drugs failed to reduce the risk of fatal or non-fatal thrombotic complications while simultaneously increasing the haemorrhagic risk, their use in patients with non-critically ill COVID-19 should be discouraged," the authors said.

SOURCE: Journal of Thrombosis and Haemostasis

1015: Clinical improvement of severe COVID-19 pneumonia in a pregnant patient after caesarean delivery:  A case of COVID-19 in a pregnant patient with severe respiratory compromise, whose clinical status significantly improved after caesarean delivery was described in BMJ Case Reports.

 

A 35-year-old gravida 10 para 7 at 29 3/7 weeks gestation presented to the labour and delivery unit with a 2-week history of cough and fever. The patient also reported dyspnoea that worsened with ambulation, myalgias and dysuria. On the day of presentation, she became increasingly hypoxic, requiring 8 L/min of oxygen via nasal cannula. A COVID-19 nasopharyngeal PCR test on admission was positive and her laboratory results were significant for lymphopenia and elevated LDH, D-dimer and C reactive protein (CRP). Additionally, her chest X-ray findings were consistent with COVID-19, with extensive patchy airspace opacities in the middle and lower lung fields. 

In the SICU, the patient’s condition worsened on hospital day 2 with increasingly elevated oxygen requirements. On hospital day 3, she received tocilizumab 400 mg intravenously. Nonetheless, her respiratory status continued to worsen, and by hospital day 5, she required 15 L/min of oxygen through a Venturi mask with desaturation of her SpO₂ to the low 80th percentile on ambulation.

Despite worsening respiratory status, the patient’s acute phase reactants “remarkably” improved, where her CRP down-trended from 179 mg/L at admission to 7.4 mg/L by day 5. Throughout her hospitalisation in the SICU from hospital days 2 to 9, the patient remained afebrile but was visibly tachypneic with increased work of breathing. Meanwhile, her D-dimer level continued to rise, peaking at 3037 ng/mL. 

Because the patient remained dependent on 15 L/min of oxygen and showed signs of clinical worsening with potential imminent need for intubation, an interdisciplinary team agreed on proceeding with caesarean delivery with neuraxial anaesthesia for expedited delivery, and possible intraoperative intubation if the patient was unable to tolerate prolonged supine position. 

The patient eventually underwent an uncomplicated primary caesarean delivery at 30 5/7 weeks gestation with spinal anaesthesia on hospital day 10, while being maintained on 15 L/min of oxygen during the procedure and she did not require intubation. A male neonate was delivered and his chest X-ray on day of life 3 showed no evidence of pulmonary disease, and COVID-19 nasopharyngeal PCR testing collected 2 hours after delivery and on day of life 3 were negative.

The patient’s clinical status rapidly improved postoperatively, where she had a SpO2 to the low 90th percentile on room air at 2 hours post-caesarean, which improved to 100% on 15 L/min of oxygen in the recovery room, and her cough and work of breathing significantly improved. Her oxygen requirements gradually decreased, and by postoperative day 2, she was weaned to 4 L/min of oxygen via nasal cannula. 

The patient remained on therapeutic enoxaparin postpartum until she was stable enough to obtain a CT angiogram, given the continued concern for a concomitant pulmonary embolism. Her CT angiogram was negative for pulmonary embolism, but consistent with COVID-19 infection, showing extensive bilateral patchy ground glass infiltrates and small consolidations. Meanwhile, COVID-19 nasopharyngeal PCR tests continued to be positive on postoperative days 7, 8 and 9. Nonetheless, the patient was discharged on postoperative day 9 as she was symptomatically improved, saturating well on room air and meeting all postoperative milestones. Eventually, her COVID-19 test was negative on postoperative day 14.

In cases of severe respiratory distress from COVID-19 pneumonia, patients may experience a reversal in poor respiratory status after the physiological changes of pregnancy are removed.

This is the first case to describe the use of tocilizumab for COVID-19 infection in a pregnant patient.

Tocilizumab exposure during pregnancy has mostly been studied in patients with severe rheumatologic diseases.

SOURCE: BMJ Case Reports

1016: Antibody levels in patients with mild COVID-19, appear to drop by half within 36 days. The research was conducted by F. Javier Ibarrondo, PhD, and colleagues and was published online on July 21 in a letter to the editor of The New England Journal of Medicine. Ibarrondo is associate researcher at the David Geffen School of Medicine at University of California, Los Angeles (UCLA). (The original letter incorrectly calculated the half-life at 73 days.)

1017: Although acute kidney injury is seen in a substantial minority of patients with severe COVID-19, no evidence of the presence of SARS-CoV-2 was found in kidney biopsies from a small series of such patients, according to researchers.

Kidney biopsy research shows that the kidney injury from COVID-19 virus happens due to complications of the disease and is not because of direct viral infection of the kidney. [Journal of the American Society of Nephrology]

164 CMAAO CORONA FACTS and MYTH COVID Post COVID Illness

164 CMAAO CORONA FACTS and MYTH COVID Post COVID Illness

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1008:

Chronic COVID or POST COVID illness

COVID-19 can mean weeks' long illness, even in young adults and those without chronic conditions who have mild disease and are treated in outpatient settings, according to survey results in today's Morbidity and Mortality Weekly Report from the Centres for Disease Control and Prevention (CDC).

In a multistate telephone survey of symptomatic adults who tested positive for SARS-CoV-2, 35% had not returned to their usual state of wellness when they were interviewed 2 to 3 weeks after testing.

Delayed recovery (symptoms of fatigue, cough, and shortness of breath) was evident in nearly a quarter of 18- to 34-year-olds and a third of 35- to 49-year-olds who were not sick enough to require hospitalization.

This is post Covid state

1.    On 9^th day virus is non infectious

2.    Is post Covid persistent inflammation or immunologic reactions

3.    Like arthritis in chikungunya

4.    Like post herpetic neuralgia

5.    Like post viral syndrome, CFS etc

6.    Is quite common and presents in India more with low grade fever and obstruction in throat. It can also present with SOB, exertional tachycardia and below knee pains.

163 CMAAO CORONA FACTS and MYTH COVID Cardiac Markers

163 CMAAO CORONA FACTS and MYTH  COVID Cardiac Markers

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1007:  Redefine cardiac injury marker cut-offs to predict 28 days mortality in COVID-19 inpatients

The abnormal cardiac biomarker pattern seen in patients with COVID-19 is significantly associated with a higher risk of death, and the cut-offs of those markers for effective prognosis of 28-day mortality of COVID-19 appear to be much lower than for regular heart disease, at 49% of currently recommended thresholds, according to a study in Hypertension.

The biomarkers are high-sensitivity cardiac troponin I (hs-cTnI), creatine kinase-MB (CK-MB), NT-proB-type natriuretic peptide (NT-proBNP), creatine phosphokinase (CK) and myoglobin (MYO).

Their retrospective cohort study enrolled patients diagnosed as COVID-19 and admitted to 9 hospitals in Hubei Province, China, from December 31, 2019, to March 4, 2020. The study included 3219 patients with myocardial biomarker measurement, and 2814 without. The primary endpoint was 28-day all-cause mortality.

Compared to patients without cardiac injury biomarker measurement, patients with biomarker values were older (median age at 57) and had higher percentages of pre-existing comorbidities and more severe symptoms.

All five myocardial biomarkers were significantly associated with 28-day all-cause death of COVID-19. 

After adjusting for age, gender and comorbidities such as hypertension, diabetes, coronary heart disease and cerebrovascular disease, the 28-day mortality hazard ratio for hs-cTnI was 7.12, NT-proBNP was 5.11, CK-MB was 4.86, MYO was 4.50, and CK, a much less specific cardiac biomarker, was 3.56.

In patients showing heart injury during the entire hospitalization, neutrophil percentage and CRP were rapidly and simultaneously increased after disease onset, immediately followed by the increases of CK-MB, MYO, and hs-cTnI.

The significant elevation of IL-6 occurred only after the increases of these myocardial markers and was highly elevated mainly in patients with evidence of cardiac injury.

162 CMAAO CORONA FACTS and MYTH COVID Drugs Update

162 CMAAO CORONA FACTS and MYTH  COVID Drugs Update

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1003:  Pfizer will get $1.95 billion from the U.S. government to produce 100 million doses of their COVID-19 vaccine candidate. (Reuters)

1004: More data suggested humoral immunity faded quickly in people with mild COVID-19 illness. (New England Journal of Medicine)

1005: Small study suggests rapid decay of anti–SARS-CoV-2 antibodies in persons with mild COVID-19
DG Alert: Findings from a study published in The New England Journal of Medicine “raise concern” that humoral immunity against SARS-CoV-2 may not be long lasting in persons with mild illness. Javier Ibarrondo, David Geffen School of Medicine at University of California, Los Angeles, California, and colleagues evaluated 34 persons (20 females and 14 males; mean age: 43 years, [range, 21 to 68]). Of these, 30 participants had their infection confirmed by PCR, while the other 4 participants had CLI.  Most of the participants had mild illness.
A total of 31 of the 34 participants had two serial measurements of IgG levels, while the remaining 3 participants had three serial measurements. The first measurement was obtained at a mean of 37 days after the onset of symptoms (range, 18 to 65), and the last measurement was obtained at a mean of 86 days after the onset of symptoms (range, 44 to 119).
The initial mean IgG level was 3.48 log10 ng per milliliter (range, 2.52 to 4.41). On the basis of a linear regression model that included the participants’ age and sex, the days from symptom onset to the first measurement, and the first log10 antibody level, the estimated mean change (slope) was reported to be −0.0083 log10 ng per milliliter per day (range, −0.0352 to 0.0062). The authors noted that this corresponds to a half-life of approximately 73 days over the observation period. Further, they reported that the 95% confidence interval for the slope was −0.0115 to −0.0050 log10 ng per milliliter per day (half-life, 52 to 120 days).
The protective role of antibodies against SARS-CoV-2 is unknown, but these antibodies are usually a reasonable correlate of antiviral immunity, and anti–receptor-binding domain antibody levels correspond to plasma viral neutralizing activity. Given that early antibody decay after acute viral antigenic exposure is approximately exponential, we found antibody loss that was quicker than that reported for SARS-CoV-1.
Reference: https://www.nejm.org/doi/10.1056/NEJMc2025179

1006: Treatment of AMI and acute stroke will be  Tenecteplase

The COVID-19 pandemic could hasten the switch to tenecteplase for stroke and AMI treatment because it is given as a single, 5-second IV bolus that takes about 2 minutes to mix, prepare, and administer rather than the more than 1 hour for weight-based bolus and subsequent infusion of alteplase.

161 CMAAO CORONA FACTS and MYTH COVID Drugs Update

161 CMAAO CORONA FACTS and MYTH  COVID Drugs Update

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1002: Medscape Excerpts:

Remdesivir

Much-anticipated results from the National Institute of Allergy and Infectious Diseases' clinical trial of remdesivir, published in May, confirmed preliminary results suggesting that the drug shortens the disease course for hospitalized COVID-19 patients. That earlier report resulted in the US Food and Drug Administration (FDA) issuing an emergency use authorization for the drug. Drugmaker Gilead subsequently released results from the sponsored, randomized phase 3 SIMPLE trial, which found that a 5-day course of the drug improved outcomes among patients hospitalized with COVID-19 who did not need ventilation.

The National Institutes of Health said that the most benefit was in patients on oxygen who did not require ventilation.

Dutch investigators have cautioned that it can be associated with rare but severe liver complications.

Take home message: Remdesivir is administered intravenously, limiting its use to hospitalized patients. However, phase 1 trials of an inhaled nebulized version were initiated in late June 2020 to determine whether remdesivir can be used on an outpatient basis and at earlier stages of disease.

The FDA has warned against use of remdesivir in combination with hydroxychloroquine (HCQ) .

Dexamethasone

British researchers that the RECOVERY trial involving over 6000 patients had been halted early due to positive results. The investigators reported that dexamethasone reduced death rates by about a third among severely ill hospitalized COVID-19 patients. Initial reaction in the United States was mixed.

While a number of clinicians indicated that the results confirmed their own experience, others were wary of embracing the study results prior to peer review.

Infectious Diseases Society of America (IDSA) announced that the drug will now be incorporated into COVID-19 treatment guidelines. Dexamethasone, or an equivalent steroid such as methylprednisolone or prednisone, is recommended for hospitalized patients who require supplemental oxygen, mechanical ventilation, or extracorporeal mechanical oxygenation.

Take home message: Corticosteroids are not generally recommended for treatment of COVID-19 or any viral pneumonia, the UK RECOVERY trial changed that. IDSA guidelines include low-dose dexamethasone (6 mg orally or intravenously daily for 10 days) in patients requiring respiratory support. At present, the World Health Organization has cautioned clinicians to reserve use for severely ill patients.

Hydroxychloroquine

Initial data suggested that HCQ and chloroquine, sometimes in combination with azithromycin, had some degree of efficacy in treating COVID-19. But those studies were rapidly followed by newer data from observational trials, suggesting that the drugs were not only without benefit but also could be dangerous in some patients. After 2 months of controversy, the FDA revoked the emergency use authorization it had previously granted for use of these agents in inpatient settings.

The matter seemed to be put to bed until early July when the Henry Ford Hospital released results of a retrospective, observational trial of HCQ with azithromycin that concluded that the combination, if given within the first 2 days of hospital admission, reduced COVID-19 mortality.

Trials of HCQ as preventive therapy are ongoing, though a randomized trial published in early June found that the drug was ineffective as prevention and that side effects were common.

Take home message: While some continue to tout its benefit, particularly if given early in the course of infection, there is little evidence at this time to support its use at any stage of illness.

Other Antimicrobials

Azithromycin. While some initial trials of azithromycin in combination with HCQ were promising, later results have not held up and major cardiology organizations now warn against the combination. There are no recommendations for use of this antimicrobial.

Antiviral agents. The UK-based RECOVERY trial examined other drugs in addition to dexamethasone, concluding that the combination of lopinavir and ritonavir had no benefit in hospitalized patients. A Japanese trial of favipiravir, determined that patients given the drug early in the trial showed more improvement than those who received delayed doses, but the results did not reach statistical significance.

Convalescent plasma. While a very small Chinese pilot study of convalescent plasma reported in April that its use in severely ill COVID-19 patients raised antibody titers, reduced viral load, and led to symptom improvement, other studies have not yet shown it to be effective. The FDA has approved its use in patients with serious or immediately life-threatening infection.

Colchicine. An open-label, randomized trial currently underway in Greece has reported that hospital course was slightly shorter and the time to clinical deterioration improved in patients treated with colchicine, although there were no significant differences between treated and untreated groups in cardiac and inflammatory biomarkers.

Nitric oxide. Inhaled nitric oxide was studied as a supportive measure for patients with SARS-CoV-1 infection in 2004. It was found to reverse pulmonary hypertension, improve severe hypoxia, and shorten the length of ventilatory support. A phase 2 study is underway in patients with COVID-19, with the goal of preventing disease progression in those with severe acute respiratory distress syndrome.

Zinc. Initial trials of HCQ often studied it in combination with azithromycin and zinc. While some studies have suggested that zinc may be somewhat effective in treatment of upper respiratory infections, some of which are caused by coronaviruses, the National Academies of Sciences, Engineering, and Medicine cautions that there is no evidence to suggest that the supplement has a role in the treatment or prevention of COVID-19.

Monoclonal antibodies. The use of human antibodies is being investigated by a number of teams around the world. Eli Lilly has reported positive interim results of its trials of monoclonal antibodies, and anticipates FDA review and possible approval by September. European trials of another antibody could begin as early as this summer. And trials of a third agent are planning to start in August in Singapore.

160 CMAAO CORONA FACTS and MYTH COVID Update

160 CMAAO CORONA FACTS and MYTH  COVID Update

Dr K Aggarwal
President CMAAO
With inputs from Dr Monica Vasudev


994:   When the prevalence of COVID-19 is high, even atypical imaging features are more likely to be COVID-19.

995: Typical chest CT findings in COVID-19 pneumonia include bilateral, peripheral and basal-predominant ground-glass opacities (GGOs) and/or consolidation, followed later by a mixed pattern of crazy paving, architectural distortion and perilobular abnormalities superimposed on GGOs that slowly resolve.

996: Upper lobe or peribronchovascular distribution of GGOs, cavitation, lymphadenopathy, and pleural thickening are found atypically

997: Other viral pneumonias can be more challenging to distinguish from COVID-19. For example, GGOs can be seen in up to 75% of adenovirus cases, more than 75% of cytomegalovirus and herpes simplex virus cases, and up to 25% of measles and human meta-pneumovirus cases. GGOs can be widespread in pneumocystis pneumonia, but, unlike in COVID-19, they tend to predominate in the upper lobes.

998: GGOs can also be common in hypersensitivity pneumonitis, lung injury from use of electronic cigarettes or vaping products, pulmonary edema, diffuse alveolar hemorrhage, pulmonary alveolar proteinosis, and eosinophilic pneumonia. But clinical features and GGO patterns are generally useful for differentiating these conditions from COVID-19.

999: Singapore scientists have uncovered T cell immunity specific to SARS-CoV-2 in recovered Covid-19 & SARS patients, and also in uninfected individuals. The study is published in Nature. T cells, along with antibodies, are part of the human immune response against viral infections. The T cells directly target and kill infected cells. In the study, the specific T cells were found in all subjects who recovered from SARS 17 years ago, and in over 50% of both SARS-CoV-1 and SARS-CoV-2 uninfected individuals tested. This suggests that a level of pre-existing SARS-CoV-2 immunity is present in the general population. They inferred that infection and exposure to coronaviruses induces long-lasting memory T cells, which could help in the management of the current pandemic. This could be due to cross-reactive immunity obtained from exposure to other coronaviruses, such as those causing the common cold. The researchers said it is important to understand if this could explain why some individuals are able to better control the infection. Source: Duke-NUS Medical School

1000: The incidence of stillbirth has increased since the COVID-19 pandemic began, according to a comparative study of pregnancy outcomes in a London hospital. This may have resulted from indirect effects such as reluctance to attend hospital when needed (e.g., with reduced fetal movements), fear of contracting infection, or not wanting to add to the National Health Service burden as reported by Dr Asma Khalil of St George's University of London in JAMA.


1001: A phase I/II trial of a vaccine against SARS-CoV-2 being developed by the University of Oxford has found that the vaccine is safe, causes few side effects, and induces strong immune responses. The early stage results, published in The Lancet, found that the candidate vaccine provoked a T-cell response peaking 14 days after vaccination, and an antibody response within 28 days. The trial, which has so far involved 1077 healthy adults, caused minor side effects when compared with a control group given a meningitis vaccine. Fatigue and headache were the most commonly reported reactions. However, there were no serious adverse events from the vaccine. The chimpanzee adenovirus viral vector vaccine (ChAdOx1) against the COVID-19 coronavirus is developed at Oxford University.

Phase II data on a competing vaccine from China, also using an adenovirus vector to deliver a gene encoding SARS-CoV-2 antigen, also indicated the product could be effective.
Phase I results on Moderna's mRNA vaccine published last week, all suggest that a vaccine -- and perhaps more than one -- to ameliorate the COVID-19 pandemic may soon be in reach.

159 CMAAO CORONA FACTS and MYTH COVID Dermatology Update

159 CMAAO CORONA FACTS and MYTH  COVID Dermatology Update

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

994: Update on Covid-19

IMA-CMAAO Webinar on “Dermatology Update and Covid-19”

18^th June, 2020

4-5pm

Participants

Dr KK Aggarwal, President CMAAO

Dr RV Asokan, Hony Secretary General IMA

Dr Ramesh K Datta, Hony Finance Secretary IMA

Dr Jayakrishnan Alapet

Dr Sanchita Sharma

Faculty

Dr Anil Ganjoo

Senior Dermatologist

Gujranwala, Delhi

·        The coronavirus has an affinity for the bronchial mucosal and the immune system. But the infection can also involve the cardiovascular system, liver and kidney.

·        Skin involvement may either be a direct manifestation of the disease such as skin rashes (primary cutaneous manifestations) or indirect manifestation due to the many processes associated with the disease (secondary cutaneous manifestations).

·        Skin rashes can be nonspecific and can be seen in any viral infection. But, during the pandemic, the dermatologist must keep in mind the likelihood of Covid presenting with skin manifestation, which can be the first symptom. Different types of skin lesions have been reported. It is important to be aware of the kind of rashes associated with Covid for timely diagnosis.

·        In a study from Italy, skin manifestations were seen in about one-fifth of patients with Covid-19. Eighteen of 88 patients (20.5%) had skin lesions: maculopapular rash (14), urticaria (3), chickenpox-like vesicles (1). Eight had skin rash at the onset of their illness, while the rest developed during their hospitalization (J Eur Acad Dermatol Venereol. March 26, 2020)

·        A patient presented with typical features of dengue fever in a hospital in Bangkok with skin rash, petechiae and thrombocytopenia. Covoid-19 was diagnosed only when this patient developed respiratory symptoms and subsequently tested positive for Covid-19.

·        A 67-year-old patient presented with symptoms of common cold, but no difficulty in breathing and developed a livedoid vascular rash (non pruritus, blanching) on right anterior thigh and hematuria. The rash and hematuria cleared up in 24 hours, but the patient tested positive for Covid-19.

·        Fatal Kawasaki-like disease has been reported in children; Covid toes have also been observed due to thromboembolic phenomenon (peripheral gangrene in digits or chill blain like lesions).

·        Patients with dermatological diseases might be at greater risk of developing the infection. 

·        Management of patients with diseases such as psoriasis, atopic dermatitis, lupus, scleroderma, which require immunosuppressants, is a concern. Stopping immunosuppressant or immunomodulator therapy is an easy decision in naïve patients, but is difficult as sudden withdrawal could make the disease more precarious and exaggerate response of cytokine storm. Tocilizumab is being used in Covid patients to reduce the host immune response and prevent severe lung damage.

·        Patients on immunosuppression therapy are vulnerable to severe Covid infection. Hence, they should be advised appropriate preventive measures.

·        The AAD (American Academy of Dermatology) and IADVL (Indian Association of Dermatologists, Venereologists and Leprologists) have give guidelines for the use of immunosuppressants and biologics during Covid-19.

·        IADVL guidelines: Decision to continue or start immunosuppressant in a patient with severe disease has to be made on cases to case basis. These patients are at an increased risk of severe coronavirus disease. Hence, patients on immunosuppressants including steroids, chemotherapy and biologics should be advised effective preventive strategies.

·        The International Psoriasis Council recommends stopping biologics in patients with Covid 19. Reduce steroids and other immunosuppressants to the lowest clinically effective dose for asymptomatic patients and who have not tested positive.

·        If the patient has been on long-term oral prednisolone, the target dose should be 7.5-10 mg/day to avoid manifest adrenal insufficienty.

·        The AAD recommends that patients should not stop biologics without consulting their doctors.

·        Hand eczema is quite common as a secondary cutaneous manifestation of Covid-19. It may occur due to too frequent handwashing, use of harsh detergents or prolonged use of latex gloves.

·        Use of N95 masks can cause contact irritant dermatitis of the nasal bridge, frictional dermatitis and postinflammatory hyperpigmentation.

·        PPEs can cause miliarial rash due to excessive sweating; they can also increase risk of developing fungal infections.

·        In a recent study from Wuhan of 700 healthcare workers, 526 reported skin problems. The most commonly affected areas were hands, nasal bridge, cheeks and forehead. Wearing protective equipment for longer than 6 hours resulted in greater degree of skin manifestations.

·        The general population can also develop skin problems during the pandemic. Excessive handwashing, as is advised for all, can cause xerosis and hand eczema. Wearing masks can cause facial rashes, contact allergies, pigmentation, frictional dermatitis; acne and seborrheic dermatitis can be aggravated.

·        Use of emollients, barrier creams, moisturizers can prevent such skin problems.