CME INDIA Presentation by Admin.
Real case scenarios now bring agony to physicians. Which way to move and what dangers are still largely understood?
CME INDIA discussion:
Dr Ambrish Mithal, DM Endo, Delhi: According to friends in the US – No Azithromycin. No ivermectin. No Favipiravir. HCQ was there. Gone now. Only steroids, blood thinners and Remdesivir. The latter in very selected cases. We are starting steroids too early. For almost all.
Dr Zarir Udwadia article in a newspaper sparks discussion:
(Source: www.indianexpress.com)
He says :
In conclusion, six months into the pandemic, we must therefore acknowledge four facts:
1. There are few proven treatments for COVID-19 to date, and most will help sicker patients. Dexamethasone, remdesivir, and blood thinners are all proving beneficial: each under very specific circumstances.
2. The majority of patients will get well on their own without any treatment. In most, a healthy immune system will mount its own defence against the virus and overcome the disease. It is, however, said that physicians in India have always felt compelled to prescribe medications to their patients, because patients expect it. This is a self-fulfilling prophecy. As with other bad habits during the pandemic, now is a good time to break it, once and for all.
3. Most current COVID drug studies are anecdotal reports or observational studies, which are not the same as, and inferior to, randomised controlled trials (RCTs) where impact on the disease is studied in two comparable groups with and without intervention. The mere announcement of a trial, anywhere in the world, even if an RCT, is not a green light for us to start prescribing these medications in the desperate hope that they will work.
4. Some of the drugs in current use are likely to end up doing more harm than good. Now, more than ever, let us not abandon the primary Hippocratic injunction of Medicine: ‘primum non nocere’ — first, do no harm.
Dr Nandini Rastogi, Diabetologist, Kanpur: Why does ICMR not pay heed to this?
Dr Ambrish Mithal, DM Endo, Delhi: Even today – a diabetic with fever, no other symptoms. All inflammatory markers fine. O2 normal. No breathlessness. Day 5. Started on steroids, azithromycin and Ivermectin today. Don’t know what to do. But I am not convinced he needs all these drugs if he has no increase in inflammatory markers.
Dr N K Singh: Utter confusion. We all are doing same. Article points important issues. Big Concern is this: Day 5 is THE crucial day in COVID phase (Lancet. 2020;395(10229):1054-62). In the COVID phase, Day 3 is the day when pneumonia may develop. If steroids and dabigatran are not started by Day 5, the illness may become serious. By Day 5, diagnosis pneumonia must be made to reduce mortality. (Expert opinion)
And with this fear, when CT not universally available, D DIMER, IL6 -not possible, physicians are tempted to use and I think, there is no way out. In the majority, patients may experience mild symptoms, they do not require hospital admission and the patient must be isolated. Crux of problem is that some of the patients may develop severe symptoms, such as COVID-19 pneumonia, respiratory distress, and septic shock, and till now we do not know the ways to predict it.
Like this… Let us see this case:
Dr Sangita Kamath, Internist, Jamshedpur: 63 yrs., male, no comorbid condition was admitted on 7th Sept for fever, cough of 3 days.
1st Chest Xray /7/9/20:
Hemodynamically stable. SPo2 on air 96 percent. CXR clear. RAT (Rapid Antigen Test) on 7th – POSITIVE. Rxed With Doxy, Ivermectin, Steroids, Inj Loparin, Inj Cefepime. In Isolation Ward.
On 22nd September, turned RAT negative. Was totally asymptomatic by 24th September & discharged on tab Acitrom, tab Prednisolone & others.
On 25th September, came back with fever, cough & breathing difficulty. SpO2 on air 86 percent. CXR now showing bilateral COVID pneumonia.
RAT Negative which is done in Emergency room. Still patient was sent to Suspect Ward.
Rt-PCR sent the next day in view of high index of suspicion – Now POSITIVE. HRCT thorax will be done. Inflammatory markers at present not available.
Questions:
- What went wrong?
- Is it reinfection?
- Is there anything like post COVID ARDS, developing 18 days after illness?
So, in spite of taking Acitrom and Prednisolone, things went wrong.
CME INDIA Discussion:
Dr Manish Ranjan, Cardiologist, Asansol, WB: Re-infection seems unlikely. May be due to early initiation of steroid there is delayed viral clearance. RAT false negative.
Dr Raju Sharma, Internist, Jamshedpur: Is it due to sepsis or coagulopathy? So, we should look at CBC CRP, Procalcitonin d dimer.
Dr Durgesh Sharma, MD Medicine, Agra: Secondary infection/ pneumonitis should be kept in mind. Sputum staining, C/S may help, HRCT chest. Reinfection may be commented only after 90 days.
Dr Rajneesh Tyagi, Physician, Noida, UP: Exactly.
Dr Vivek Gumber, Resident Smbt Medical College, Nashik: Cytokine storm have been reported as late as 3rd week. If it is 18 day still there are high chances patient may have landed in delayed cytokine storm.
Dr N K Singh: My points:
1. Cannot be reinfection.
2. Delayed cytokinesis storm – Possibility exists.
3. Sepsis may be. Needs-Inflammatory markers and HRCT.
Dr P R Parthsarathy, Chennai: The first episode did not show any + features of COVID – except for RAT being +ve. Maybe it’s false +, & the patient had developed an infection only later – as evidenced by x-ray features. HRCT might have helped in the initial admission. Reinfection can be thought of only later & that too by genomic studies.
Dr Vivek Gumber, Resident Smbt Medical College, Nashik: Yes, it is possible easily many times rapid antigen can be falsely positive.
Dr P R Parthsarathy, Chennai: RAT being – be with RT PCR being +ve show the unreliability of RAT. RAT kits are from different manufacturers. it’s easily possible.
Dr Jagdeeshan, Chennai: RAT can give false negative. But it has high specificity, so false positives are rare.
Dr Bhanu Pratap Singh, Physician, Siwan, Bihar: As per me, there was no need to start steroids unless pulmonary involvement or raised inflammatory markers.
Dr Pranab Kanti Datta, Agartala: In practice once confirmed, treatment of viral pneumonia includes steroid.
Dr Somnath, Hyderabad: Was steroid indicated in proven viral pneumonia? Curious to know before COVID. If yes, then why not in COVID pneumonia?
CME INDIA Learning Points:
- Day 90 is the day after which the word COVID ends (CDC Duration of isolation and precautions for adults with COVID-19). It becomes a non-COVID illness after 90 days. After 90 days, it is a new disease and not written as post-COVID. Updated Sept. 10, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
- Delayed occurrence of cytokine storm have been reported. There is no unified standard for the diagnosis of COVID‐19 associated with CSS. Followings have been suggested:
- A sudden or rapid progression with multiple organ involvement (such as liver, cardiac or renal injury);
- The significant decline of peripheral blood lymphocyte counts;
- The significant elevation of systematic inflammatory indicators (such as CRP, serum ferritin, erythrocyte sedimentation rate); and (iv) the elevation of multiple cytokines, such as IL‐1β, IL‐2R, IL‐6, IFN‐γ, IP‐10, MCP‐1, TNF‐α and MIP1a.
- In this case, many unusual things are not fully answerable. There is suspicion on first RAT positivity. Anticoagulants and steroids were given post discharge. Still recent deterioration needs proper investigations.
- In most of mild cases and even with normal inflammatory markers, we do not know what works and what not. But, at present, most important things are to watch for abnormal findings and be liberal to advice for HRCT at 3 to 5 days. If pulmonary involvement is significant, delay in starting LMWH and steroids, even with normal inflammatory markers is the emerging expert opinion and must be followed.
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Cytokine storm is most likely the cause of late onset pneumonia…however patient was on steroid…was admitted in hospital with exposure to multiple pathogens…secondary infection as cause of pneumonia cannot be ruled out…and the case should be treated as usual pneumonia in day to day practice…it may be wiser decision to forget temporarily that patient is or still having Corona virus in the system
We have a problem, the Virus must have multiplied in the gap when the patient recovers.