960: Round Table Expert Zoom Meeting on “Unusual manifestations of Covid-19”

 27^th June, 2020, 11am-12noon

Participants: Dr KK Aggarwal, Dr AK Agarwal, Dr Shashank Joshi, Dr Ashok Gupta, Dr Suneela Garg, Dr JA Jayalal, Dr Jayakrishnan Alapet, Dr Atul Pandya, Dr TS Jain, Mrs Upasana Arora, Dr K Kalra, Ms Ira Gupta, Dr Sanchita Sharma

Key points from the discussion

• Many unusual symptoms of Covid-19 have been observed. These may differ even in different members of the same family.
• The CDC has recently added 3 new symptoms to its list of symptoms of coronavirus: Congestion or runny nose, nausea or vomiting and diarrhea.
• Isolated sudden loss of taste and/or smell is Covid, unless proved otherwise. However, bitter and sour tastes are retained. This symptom may be intermittent and may last for up to 2 months. It occurs more commonly in females. Such patients have not become serious.
• Isolated diarrhea may occur; the affected person may be a superspreader and may be the first person to be infected; more common in women. This is small intestine Covid. Such patients have not become serious.
• Constipation has been observed.
• Covid cystitis: low grade persistent fever or no fever, increased frequency of urination, urinalysis may show 50-60 pus cells, but culture is negative and total leukocyte count may be normal. No antibiotics are needed as it resolves spontaneously.
• If the patient comes before 9 days, this is acute viral response. If the patient comes after 9 days and is not hospitalized, this is post-Covid syndrome, which may manifest as low grade exertional afternoon rise of temperature or chills without rigors x 6 weeks. Give high doses of vitamin C, D and zinc x 3 days OR give colchicine or hydroxychloroquine (HCQ) twice daily. This fever is because the virus causes some thermostat dysregulation.
• Neurological complications like encephalitis, meningoencephalitis have been observed in ICU patients. Prognosis is not good.
• Skin lesions may occur – small blister/s, scratch-like lesion, bruise; more in females.
• Eye involvement: Conjunctivitis may occur.
• Covid toes, presenting as gout-like symptoms. Such patients may test negative in the beginning, but may test positive later.
• Covid may present as calf pain (muscle pain - myositis), which responds only to mefenamic acid, naproxen, nimesulide or indomethacin.
• Leukocyte count <1000 signifies serious illness; high monocyte count is a new observation - may be indicative of prolonged inflammatory response.
• SLE-like manifestations may be seen (high ESR, low CRP).
• If CRP >100, such patients invariably have pneumonia; get a CT chest done for these patients.
• Backache, which responds to naproxen; ISA (inflammatory spondyloarthropathy)-like or Behcet’s-like or Ritter-like phenomenon.
• Other symptoms such as tinnitus, persistent sore throat, nausea and vomiting, exertional tachycardia, urinary pain, menstrual pain have also been seen.
• A new phenomenon of delayed hypoxia has been observed by Day 15-17 with sudden deterioration; all high risk patients must be given anti-thrombotic treatment, DVT prophylaxis to prevent delayed hypoxia.
• In Tamil Nadu, almost all deaths have been occurring early morning; hence, absolute bed rest for all patients. Most patients have sympathetic overactivity - hypoxia, exertional tachycardia, which can precipitate early morning acute myocardial infarction. Ivabradine may be considered in patients with exertional tachycardia.
• ENT manifestations: Herpes zoster oticus, Ramsay Hunt syndrome, anosmia, acute peritonsillitis.
• Covid-19 spares joints and larynx.
• Coinfections of dengue, chikungunya, TB may occur. This may be a dangerous combination.
• Covid positive patients have false positive Typhidot due to cross reaction.
• If a Covid-positive patient has symptoms like joint pain, retro-orbital headache, laryngitis, exertional tachycardia, look for coinfections or underlying disease, e.g., if retro-orbital headache, look for co-existing dengue; if exertional tachycardia, look for underlying coronary artery disease; if persistent shortness of breath, look for small airway obstruction.
• Do not ignore isolated skin manifestations, even small rashes. These should be investigated as first sign of Covid infection.
• RT PCR test may be positive for up to 50 days; but the patient becomes non-contagious after 9 days as the virus becomes non-replicating.
• Covid-19 causes lymphopenia, low CD4 count (HIV-like symptoms). A question was raised that could diarrhea, aseptic cystitis, ear manifestations, secondary viral manifestations be a presentation of low CD4 count? If yes, there may be an upsurge of lymphoma cases. Patients with low CD4 count should be given combination of lopinavir and ritonavir.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA