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CMAAO Coronavirus Facts and Myth Buster 69

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Dr KK Aggarwal    22 April 2020

(With regular inputs from Dr Monica Vasudev)

Poison centers see 20% spike in calls related to cleaners, disinfectants

Poison centers in the United States have seen over 20% rise in calls for exposures to cleaners and disinfectants during the first 3 months this year compared with the same time period in 2019, according to a new MMWR report.

What is the link

The spike is likely related to the COVID-19 pandemic. As per the report, there were 45,550 exposure calls in the U.S. related to cleaners and disinfectants from January to March which is 20.4% more than the first 3 months in 2019 and 16.4% more than in the year 2018.

What is the main poisoning

Among cleaners, exposure to bleaches has been reported to account for the largest percentage of the increase compared to 2019. Nonalcohol-based disinfectants and hand sanitizers have been accountable for the largest percentage of the increase among disinfectants.

The CDC recommends that people should clean and disinfect high-touch surfaces to help mitigate the transmission of SARS-CoV-2 viruses, but with precautions.

The report revealed that children aged 5 years or below consistently represented at large percentage of calls during the study periods in all 3 years. The MMWR report described two cases:

  1. A preschool-age child was hospitalized in the pediatric ICU after ingesting an unknown amount of ethanol-based hand sanitizer, resulting in a blood alcohol level about 3 1/2 times the legal limit for driving in most states.
  2. In another case, a woman experienced difficulty breathing and called 911 after mixing bleach, vinegar and hot waterin her sink to clean produce. Both patients recovered.

[Reference: Chang A, et al. MMWR Morb Mortal Wkly Rep. 2020; doi:10.15585/mmwr.mm6916e1.]

How is bleach harmful

  1. Bleach is caustic
  2. It is important to dilute bleach and make sure that its not used at full-strength and is not to be mixed with other solutions and chemicals.
  3. Never mix bleach with ammonia. When mixed with bleach, ammonia converts the chlorine in bleach to chloramine gas. Breathing in the fumes can lead to coughing, shortness of breath, and pneumonia.
  4. Never mix acidic compoundssuch as vinegar or window cleaner with bleach. They will generate chlorine gas. Excessive exposure to the gas can cause chest pain, vomiting, and even death.
  5. Do not mix Alcohol as it converts to chloroform when mixed with bleach. Breathing in chloroform can cause fatigue, dizziness, and fainting.

Patients with COVID-19 who had ST-segment elevation had a poor prognosis

NEJM-DG Alerts: Sripal Bangalore, MD, New York University Grossman School of Medicine, identified 18 patients with COVID-19 and ST-segment elevation treated at 6 New York City hospitals.  The median age of the patients was 63 years, 83% were men, 33% had chest pain around the time of ST-segment elevation, 65% had hypertension, 41% had hypercholesterolemia, 35% had diabetes, and 18% had a history of coronary artery disease. Of these patients, 10 (56%) had ST-segment elevation at the time of presentation, and the other 8 patients developed it during hospitalization (median, 6 days). 

Among 14 (78%) patients with focal ST-segment elevation, 5 (36%) reported normal left ventricular ejection fraction (1 with regional wall-motion abnormality) and 8 (57%) reported a reduced left ventricular ejection fraction (5 with regional wall-motion abnormalities). One patient did not undergo an echocardiogram. Of 4 patients with diffuse ST-segment elevation, 3 (75%) had a normal left ventricular ejection fraction and normal wall motion while 1 patient had a left ventricular ejection fraction of 10% with global hypokinesis.

Half of the patients underwent coronary angiography. Of these, 6 had obstructive disease and 5 (56%) underwent percutaneous coronary intervention (1 after the administration of fibrinolytic agents).

The 8 patients (44%) with a clinical diagnosis of myocardial infarction had higher median peak troponin and d-dimer levels (1,909 vs 858 ng/ml) compared to the 10 (56%) patients with noncoronary myocardial injury. Overall, 13 (72%) patients died in the hospital [4 with myocardial infarction and 9 with noncoronary myocardial injury].

Conclusion of the study: These COVID-19 patients with ST-segment elevation had variability in presentation, high prevalence of nonobstructive disease, and a poor prognosis. All 18 patients were shown to have raised d-dimer levels. In a previous study, on the other hand, in patients presenting with ST-segment elevation myocardial infarction, 64% had normal d-dimer levels. Myocardial injury in patients with COVID-19 could be attributed to plaque rupture, cytokine storm, hypoxic injury, coronary spasm, microthrombi, or direct endothelial or vascular injury.

Another study, published in the Journal of Thrombosis and Haemostasis, showed that D‐dimer levels on admission predicted in‐hospital mortality in patients with COVID-19.

Litao Zhang, and Xinsheng Yan, Wuhan Asia Heart Hospital, Wuhan, China, and colleagues analyzed data from 343 patients with COVID-19 treated at Wuhan Asia General Hospital from January 12, 2020, to March 15, 2020. Of the patients, 67 had D-dimer levels ≥2.0 µg/ml and 267 had D‐dimer levels <2.0 µg/ml on admission.

A total of 13 deaths occurred during hospitalization -- 12 deaths among patients with D-dimer levels ≥2.0 µg/ml and 1 in a patient with D-dimer levels <2.0 µg/ml (hazard ratio = 51.5; P < 0.001).

The optimum cut-off value of D‐dimer to predict in‐hospital mortality was 2.0 µg/ml with a sensitivity of 92.3% and a specificity of 83.3%.

Compared to patients with D-dimer levels <2.0 µg/ml, patients with D-dimer levels ≥2.0 µg/ml reported a higher incidence of underlying diseases, such as diabetes, hypertension, coronary heart disease, and history of stroke. They were also found to have lower levels of lymphocyte, hemoglobin, platelet count, and higher levels of neutrophil, C-reactive protein, and prothrombin time.

D‐dimer on admission >2.0µg/mL could effectively predict in‐hospital mortality and improve the management in patients with COVID-19, the authors concluded.

A case report published in the American Journal of Perinatology suggests possible vertical transmission of SARS-CoV-2

DG alerts: Maria Claudia Alzamora, MD, British American Hospital, Lima, Peru, and colleagues describe the case of a pregnant woman aged 41 years with diabetes presenting with a 4-day history of malaise, low-grade fever, and progressive shortness of breath. A nasopharyngeal swab came out positive for COVID-19; however, serology was negative. The patient developed respiratory failure requiring mechanical ventilation on day 5 of disease onset.

The patient underwent a cesarean delivery, followed by neonatal isolation immediately after birth, without delayed cord clamping or skin-to-skin contact.

The nasopharyngeal swab of the neonate, 16 hours after delivery, was positive for SARS-CoV-2 RT-PCR, and immunoglobulin (Ig)-M and IgG for SARS-CoV-2 came as negative. Maternal IgM and IgG were positive on postpartum day 4 (day 9 after symptom onset).

This is the earliest reported positive polymerase chain reaction in the neonate. It raises concern about vertical transmission. Pregnant women should be considered as a high-risk group and efforts should be made to minimize exposures for these reasons.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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