CME INDIA Presentation by Dr. B. B. Rewari MD, FRCP(Ireland), FICP, FIACM, FIAMS, FIMSA, FCCP, FGSI, MPH. Former Regional Advisor, Hepatitis, HIV, STI WHO SEARO Clinical Professor, Global health, University of Washington, USA. Former Professor of Medicine, PGIMER & RML Hospital, New Delhi, Vice Dean, Indian College of Physicians.
Key facts about HIV
- HIV is a major global public health issue, having claimed 40.4 million lives so far.
- There are an estimated 39 million people living with HIV at the end of 2022, two thirds of whom (25.6 million) are in the WHO African Region.
- In 2022, 630,000 people died from HIV-related causes and 1.3 million people newly acquired HIV.
- HIV is a retrovirus, from lentiviridae family, that attacks the immune system leading to AIDS.
- There is no cure for HIV infection. However, with access to effective HIV prevention, diagnosis, treatment and care, including for opportunistic infections, HIV infection has become a manageable chronic health condition, enabling people living with HIV to lead long and healthy lives.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
- COVID – 19 is a disease caused by SARS-CoV2 virus.
- Corona virus caused:
- Severe Acute Respiratory Syndrome (SARS) in 2003.
- Middle Eastern Respiratory Syndrome (MERS) in 2012.
- The first cases were identified in people with pneumonia in Wuhan, China, in late December 2019.
- The World Health Organization (WHO) declared the situation a pandemic on 11 March 2020 signifying:
- Widespread human-to-human spread through droplets
Post COVID – 19 syndrome
- Various terms have been used post-COVID conditions, long-haul COVID, chronic COVID, post COVID-19 syndrome, and Post acute sequelae of SARS CoV-2 infection (PASC).
- Long COVID, the term favored by research agencies
- According to the World Health Organisation “Post COVID – 19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID – 19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis.”
- According to CDC, “Post-COVID Conditions” is an umbrella term for the wide range of physical and mental health consequences experienced by some patients.
Post COVID-19 syndrome: According to MOHFW, Govt. of India
Post COVID – 19 syndrome: pathophysiology
People more likely to develop Long-COVID
- People who had a severe COVID – 19 infection especially if they were hospitalised or needed intensive care.
- People who have underlying conditions –diabetes, Bronchial asthma, ILD, Preexisting anxiety and depressive symptoms.
- People who did not get COVID-19 vaccines.
- People who experience multisystem inflammatory syndrome (MIS) during or after COVID – 19 illness.
- Some people are affected by health inequities including people from racial or ethnic minority groups and people with disabilities–female sex, older and middle age, lower socioeconomic status and poor access to healthcare.
Post COVID – 19 syndrome: Prevalence
- Cohort studies, epidemiologic studies and systematic reviews suggest that up to 70% of individuals experience some form of Long COVID following SARSCoV-2 infection, with smaller proportions (5–10%) experiencing severe, debilitating forms of this condition.
- According to some studies conducted in India, 30-40% of the patients discharged after COVID related hospitalization had persistent symptoms.
- 18% of the symptoms resolved within 4 weeks.
- Most common symptoms reported were:
- Shortness of breath
Post COVID – 19 syndrome: mechanism
Post COVID – 19 syndrome: Common symptoms
Respiratory system bears the maximum brunt of the damage due to infection and which may persist for several weeks.
Most common symptoms reported are:
- Chest pain
- Have been reported in symptomatic and asymptomatic
Pulmonary abnormalities seen after post covid are:
- Diffuse lung disease (inflammatory and/or fibrotic)
- Respiratory muscle weakness (due to mechanical ventilation)
- Sequelae of pulmonary thromboembolism
- Pulmonary infections (mycosis)
Pulmonary complications: Who are at risk?
- Age > 60 years
- Comorbidities – Diabetes Mellitus/ Hypertension/ Coronary Artery Disease
- Pre-existing respiratory disease (e.g.: Asthma, Chronic obstructive pulmonary disease, interstitial lung disease)
- Requiring Oxygen therapy at home
- Patient who required Mechanical Ventilation/ Non-Invasive Ventilation during the acute COVID – 19 illness
- COVID – 19 infection is an inflammatory and hypercoagulable state leading to a higher risk of thromboembolic events
- Symptoms: chest pain, severe dyspnoea, dizziness
- Can be confused with myocardial infarction, pericardial tamponade
- Investigations to be done
- Electrocardiogram (ECG)
- Arterial Blood Gas (ABG)
- Chest X-Ray (mostly normal)
- Therapeutic anticoagulants should be started
- The minimum duration of such treatment should be 03 months
Post-COVID Diffuse Lung Disease
- Lung parenchymal changes in post covid can be of an inflammatory pathology or pulmonary fibrosis
- CT scan can be helpful to check for the extent and type of such abnormalities
- In most patients, the abnormalities resolve by itself
- Management should be handled by specialists
- 20-30% of patients who have been hospitalised because of severe covid infection have elevated troponin levels, venous thromboembolism, arrhythmias and heart failure
- Elevated troponin level – poor prognosis
- Various mechanisms have been proposed
- Direct cardiomyocyte damage
- Damage secondary to hypoxia
- Microvascular dysfunction
- Cytokine storm
- Disorder of cardiac rhythm
- Usually there is an underlying cause
- Palpitations in Post-COVID syndrome could be due to:
- Inappropriate sinus tachycardia
- Postural orthostatic tachycardia syndrome
- Ventricular arrhythmias consequent to myocardial fibrosis and scarring
- Investigations: ECG
- Management: treat the underlying cause
Do’s and Don’ts – Post Covid
Do’s during Post Covid period
|Restructure routines at home.|
|Greater emphasis on healthy weight.|
|Moderate intensity exercise (30 minutes per day- 5 times a week).|
|Avoid alcohol, No smoking or tobacco products.|
|Vaccination after 03 months post recovery if not vaccinated prior.|
|Important to control co-morbidities.|
|Practice meditation, Yoga within your tolerance.|
Don’ts during Post Covid period
|Persistent symptoms (such as fatigue, cough, breathlessness, fever): limit activity to 60% of maximum heart rate (220- age in years) until 2-3 weeks after symptoms resolve.|
|Intense cardiovascular exercise in known cardiac patients and all cardiovascular training in case of athletes to be avoided for 3 months.|
|Do not ignore warning signs such as highgrade fever, oxygen saturation< 93%, chest pain, dizziness, syncope or palpitations.|
|Direct effects:||Indirect effects:|
|Endothelial damage due to viral entry|
Neurological complications and management
- Cognitive Impairment (brain fog)
- Guillain Barre Syndrome
- Status Epilepticus
- Sleep Disorders
- Loss of smell and taste
- Direct invasion of CNS by virus and neurodegeneration – SARSCOV 2 has a high affinity for ACE 2 receptors which are expressed in neurons and glial cells.
- Weak immunologic response and incomplete virus eradication results in ongoing inflammation Dysregulated immune response.
- Symptoms are triggered or worsened by upright posture.
- Can be evaluated via the head-up tilt test.
|Condition||Response to head-up tilt table test|
|Postural Orthostatic Tachycardia Syndrome (POTS||Heart rate increases (at least 30 beats/min) within first 10 minutes of testing with no change in blood pressure (no hypotension)|
|Orthostatic hypotension||Blood pressure falls (SBP by 20 mm Hg or more, or DBP by 10 mm Hg or more) with no increase in heart rate|
|Vasovagal syncope||Blood pressure drops with decrease in heart rate (Abnormal increase in parasympathetic activity)|
- Reported in 14% of infected patients
- Frequency comes down from time of admission to 06 months
- Attacks maybe more frequent and pain last longer.
Tension-type headache common
- Migraine headache is less common
- Patients with pre-existing migraine may see an increase in frequency
Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life.
- It can be from mild to severe.
- With mild impairment, people may begin to notice changes in cognitive functions, but still be able to do their everyday activities.
- Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently.
- It lowers work function and leads to poorer quality of life in the affected people.
- Reported in 12 -50% of patients.
- Can persist for more than a year.
- Common symptoms:
- Brain fog: feeling mentally slow, fuzzy, or spaced out.
- Impaired attention.
- Poor concentration.
- Poor and short-term memory loss.
Avoid rapidly moving from lying or sitting to a standing position (rise slowly after lying down – sit for a while before standing).
Guillain Barre Syndrome
- Commonest neuromuscular complication in long covid
- Often appears within 05 – 10 days after COVID-19 diagnosis, but can also develop after a few weeks
- Acute inflammatory demyelinating polyneuropathy is the most common form of GBS
- Commonly caused by an immune reaction following exposure to virus, 2/3rd of cases report a history of infection prior to the onset of symptoms
- Cardiovascular complications and respiratory insufficiency leads to critical care admission
- Rapid deterioration to respiratory failure can happen
- Nerve conduction studies can be done to check for demyelination
- CSF analysis can exclude infectious pathology. Helps in detecting cytoalbuminous dissociation (characteristic of GBS)
- Treatment does not differ from the usual treatment
- Regular monitoring of vital capacity should be done to detect respiratory failure
- IV immunoglobulins or plasma exchange can be helpful
- Supportive measures to protect the airway
Associated with severe course of disease
- Ischemic stroke more common
- Intracerebral haemorrhage less common
- Activation of the coagulation system
- Disseminated intravascular coagulation
- Vascular complications as an expression of severe organ damage
- Various type of sleep disorders have been reported
- Obstructed sleep-disordered breathing
- Reported in 30% of patients
- Home apnoea test or Polysomnography can be done to check for sleep apnoea
- Insomnia can be assessed with Insomnia severity Index or Pittsburgh sleep quality index
If sleep-disordered breathing is diagnosed then positive airway pressure or oral appliance therapy may be helpful
- Low dose Melatonin can be tried 2 hours before bedtime
- Cognitive behavioural therapy for insomnia
- Relaxation therapy
Loss of smell and taste
- Post COVID infection can lead to altered or complete loss of smell and taste
- According to a few studies, 23% had anosmia and 15% had ageusia
- Usually occurs during the acute phase and persists in 1/3rd of patient
- Median recovery duration is 31 days
- Symptoms can persist up to a year
- Long term effect can lead to loss of appetite, anxiety and depression
- Quality of life can be assessed by a questionnaire of olfactory disorders
- Unrelating exhaustion and a constant state of weariness that reduces a person’s energy, motivation, and concentration
- Shares characteristics with chronic fatigue syndrome after other serious conditions like SARS, MERS
- Post viral fatigue is considered subacute form of Chronic Fatigue Syndrome
- It’s different to ordinary tiredness
- Can be cognitive and physical in nature
Look out for:
- Profound fatigue not relieved by rest
- Discomfort or aggravation after physical exertion
- Unrefreshing sleep
- Cognitive impairment
- Substantial impairment in the ability to perform activities
- The symptoms are for more than 06 months
Gastrointestinal symptoms are common after recovery from COVID – 19 Common symptoms:
|Loss of appetite (anorexia)|
Nausea and vomiting
|Altered taste (dysgeusia)|
Secondary bacterial infection (Clostridium Difficile)
Common Side effects of COVID – 19 drugs
|Drug||Class||GI Side eFFECTS|
|Azithromycin||Antibiotic||Diarrhoea, Cholestatic hepatitis, Nausea, Pain abdomen|
|Hydroxychloroquine||Antimalarial||Abdominal pain, anorexia, diarrhoea, nausea, vomiting|
|Lopinavir||Anti-Viral||Dysgeusia, nausea, vomiting, pain abdomen, diarrhoea, elevated amylase and lipase|
|Favipiravir||Anti-Viral||Nausea, vomiting, diarrhoea, transaminitis|
Common symptoms in COVID – 19 infection and hospitalised patients
- Hydration level
- Hemodynamic status
- Drug intake
- Pre-existing diarrhoea
- Relationship to COVID – 19 illness
- Infectious causes
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