COVID 19 Updates

Today, Dr. Hakim is presenting a case of COVID-19 infection. We wanted to take this opportunity to give a general overview of COVID-19 and the available data. Just a quick disclaimer: we have extremely limited clinical experience in the treatment of COVID-19 and the following information is collected from various resources and articles. We anticipate that the details of COVID-19 will continue changing rapidly and the information here may become out of date very quickly.

ILLNESS SCRIPT:

Epidemiology: Median age is 47, slight male predominance (41.9% are female)

Symptoms and Signs of COVID-19: There are 7-9 large studies documenting signs and symptoms of COVID-19 infection with most data coming from China. The largest study, recently published in NEJM: Clinical Characteristics of Coronavirus Disease 2019 in China- W. Guan, Z. Ni, Yu Hu, et al. 

The most common symptoms of COVID-19 are fever and cough. These symptoms may not be present on admission. 

Systemic symptoms: Fever, fatigue, myalgias, anorexia, dizziness, headache

Respiratory symptoms: Dry cough, dyspnea, expectoration, pharyngalgia

GI symptoms: Diarrhea, nausea, vomiting, and abdominal pain

Capture

***There is no reliable way to distinguish influenza, other viral respiratory infections, and COVID-19 by symptoms alone. 

Incubation Period: median of 4 days, range up to 14 days

Lab Findings: White blood cell counts can vary!! Leukocytosis and leukopenia are reported.

  • Lymphopenia (absolute lymphocyte count <0.8) is the most common finding, but is extremely nonspecific as it occurs in many viral infections
  • Elevated LDH (>245), ferritin (>300), AST/ALT, troponin, and D-dimer (>1000) have all been reported
  • Procalcitonin is not elevated in most patients with COVID19 according to the Guan et al study cited above

Imaging: 

  • CXR may show infiltrates, but it really depends on the degree of respiratory symptoms
  • Chest CT most commonly shows bilateral peripheral ground-glass opacities (GGOs), and “crazy paving” in some instances
    • “Crazy paving”= GGOs with superimposed septal thickening
  • Imaging is NOT specific, but can add to your clinical picture and rule out non-pneumonia etiologies of respiratory distress

Diagnosis here at SCVMC:

  • ALL persons under investigation (PUIs) for COVID should be on airborne and contact precautions
  • Order Flu/RSV reflex to SARS-CoV2
  • Always notify Dr. Stephanie Chan and Dr. Jen Eng when COVID testing is sent via SecureChat message
  • If your patient is high risk or will need aerosolizing procedures (nebulized medications, sputum induction, open suctioning of airways, BIPAP/CPAP, HFNC, intubation, bronchoscopy), they should be admitted to a negative pressure room

Sensitivity and Specificity of Testing:

  • Sicker patients are thought to have higher viral loads and are more likely to have positive test results
  • Sensitivity is thought to be around 75% for swab PCR testing and there is evidence that CT scan may show disease sooner than PCR positivity. BAL has higher sensitivity than swab testing.
  • Repeat testing can be performed if necessary

Coinfection:

  • In China, the coinfection rate with COVID-19 and other viruses was thought to be low (1-5%), but data from Stanford University, show that >20% of patients had a coinfection with another virus

Key Resources for further COVID-19 Information:

UpToDate COVID19 article

EMCrit- Internet Book of Critical Care

MedCram.com COVID videos

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