CME INDIA Presentation by Dr. N. K. Singh, MD, FICP, Director, Diabetes and Heart Research Centre, Dhanbad, Jharkhand, India. Editor, www.cmeindia.in.
“As we’ve moved from pandemic phase to endemic, how will we cope? Are we going to come to some sort of fraught truce with this virus? We haven’t figured out how to do that yet.” — Prof. William Schaffner
Lots of cases of COVID are now presenting like this:
One of my colleagues says
- I have covid in throat
- Cannot swallow sputum
- Fever has gone
- But never ever had such severe pain in throat
- Nothing is helping
- RT PCR POSITIVE
Dr. Nishith Kumar, Pulmonologist, Ranchi:
- There’s a definite surge in URTI cases in last couple of weeks.
- Patients are in general reluctant to get tested for Covid 19.
- There are many patients coming to my clinic with c/o sore throat/irritating cough.
- They typically give history that they suffered from influenza like illness 8-10 days back.
- Lozenges containing Benzocaine, menthol etc may offer some comfort.
- For post-viral persistent cough, a short course of inhaled corticosteroid+ bronchodilator generally solves the problem.
Dr. Atri Gangopadhyay Pulmonologist, Ranchi
- I have seen few cases. Tonsils (even unilateral) get enlarged and congested.
- Managing with Gargle and Steroid in specific cases.
- We can not isolate such cases without rtPCR positivity, but most do not get tested.
Dr. Ambrish Bhattacharya. Kolkata
- Same in Kolkata. But one additional problem.
- Half of the patients are not doing RT-PCR. Their justification is ….”we will do it if we need to get admitted”.
- Dry cough and lethargy persisting for 1 month.
Dr. Sourav Maiti, Neurosciences, Kolkata:
- True. The majority is taking the attitude of “it’s a common cold.”
Dr. S. K. Yadava, MD Med, Ajmer:
- These are throat related complaints. But myself and my colleague doctors have noticed about seven cases in last two months, who have been complaining Severe Right Shoulder pain. All these patients had COVID, within last one year, and were constantly suffering from tiredness & arthralgias. Now they have developed this Shoulder pain which is very Severe during night.
- Any other possibilities other than “Long Covid”? Not known?
Dr. Praveen Kulkarni, MD medicine Miraj, Maharashtra:
- Budecort nebulizer may reduce oedema and pain.
Dr. Anand, Hindu Rao Hosp., Delhi:
- Similar case was there in our hospital; laryngotracheobronchitis with dysphagia to even liquid. We gave him hydrocortisone and budesonide bd and other conservative management.
- Patient was able to tolerate soft diet on 3rd day. But patient didn’t continue his treatment because of demise of family member and we had to discharge him on request. But these medications worked for him.
Dr. Anil Motta, Sr. Consultant, Internal Medicine, Max, Delhi:
- Patients are coming with symptoms of fever and rhino pharyngitis. Seen about 8 pts in past 2 weeks. Three had similar problems in at least 2 more family members.
- Only one had odynophagia but was RTPCR negative. (ENT consult showed pharyngeal & oral ulcers)
- RAT was positive in 3 & RTPCR positive in 3.
- All improved with APC(Acetaminophen, phenylephrine,chlorpheniramine) Amoxiclav. (Given for 5 days)
- In nutshell, all improved without any progression of symptoms.
- Don’t know what strain it is.
Dr. Chandrakar Tarke Pulmonologist, Hyderabad:
- As of now, we are getting very few cases of COVID nowadays. Presentation similar to omicron variant.
Dr. Noni G. Singha Dibrugarh, Assam:
- Till now not much cases in my locality.
- Scattered one or two cases who travelled from Mumbai and Andhra Pradesh.
- Symptoms of RTI with Pain throat and body ache.
- One had severe conjunctivitis along with RTI.
CME INDIA Learning Points
- On May 22, The Indian SARS-CoV-2 Genomics Consortium (INSACOG) confirmed the first case of BA.4 and BA.5 variants of Covid-19 in India.
- At present BA.4 and BA.5 are sub-variants of the Omicron variant circulating globally.
- India’s dominant variant during the third wave was BA.2.
- A sore or scratchy throat that we might have dismissed just a few months ago as no big deal, is now considered as an early sign of omicron.
- This Omicron infection is unique in the sense that people who get it, they only know how distressing it is. Such painful sore throat was not the feature during Omicron wave in January 2022. At present, it is not known whether it is the same variant or a different one. There were some upper respiratory symptoms in delta and the other earlier variants, but not like we’re seeing now.
- Both Vaccinated and Unvaccinated are getting Omicron Sore Throat. Many people who took booster on time got it and suffered a lot.
- Although it is known that vaccine is really meant to protect from severe disease, present infection is behaving in the same magnitude in vaccinated with booster and unvaccinated, self-limiting . Mortality is unheard of.
- There is no data at present about exact variant and its long-term implications.
- There are cases, who got delta infection, Omicron infection in January 2022 and now this distressing sore throat associated Omicron. The new location is throat and makes it contagious but in most of cases Index Case is difficult to trace.
- Hot saline gargling may not bring relief. Lieleg et al. demonstrated that mucin in buffers with high salt concentration (0.3 M) increased the mucin barrier function and could block viral infection in vitro. Ramalingam et al. revealed that increasing concentration of sodium chloride (NaCl) enhanced the antiviral activity of epithelial cells through inhibition of RNA and DNA viral replications including human coronavirus.
- Conservative management is being applied but it is not able to bring relief in most cases.
- Many physicians are using systemic steroids, but no recommendations exist. Considering this unique presentation, studies are needed, what works and what not and why it has become so distressing.
References:
- Tiong, V., Hassandarvish, P., Bakar, S.A. et al. The effectiveness of various gargle formulations and salt water against SARS-CoV-2. Sci Rep 11, 20502 (2021). https://doi.org/10.1038/s41598-021-99866-w
- https://www.bmj.com/content/377/bmj.o892
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At GUWAHATI Assam recently I got one pt. with symptoms of influenza , fever body ache , sore throat. He was found Rt – PCR +ve ..He suffered immediately after he came from Delhi. I have got two more cases with URTI not responding to usual treatment with pain throat . One of them is a pt of HTN With type 2 DM. Rt PCR not yet done.
Omicron has a special predilection for throat. Viral Concentrations remain high in the throat for a longer duration. So the throat symptoms are worse and prolonged. RTPCR shows Lower Ct values.
But fortunately most patients improve without getting into pneumonia phase. Probably previous vaccination or infection is protective. But previous immunity offers no protection from Long Covid. Good numbers may come with Loss of Taste and/Smell or Brain fog fatigue