With inputs from Dr Monica Vasudev

1009: Can the Virus Disrupt the Endocrine System?

Considering its effects on angiotensin-converting enzyme 2 (ACE2), researchers from Louisiana State University suggest that SARS-CoV-2 could potentially disrupt various endocrine functions throughout the body.

1010: Potential Treatments, but Hard to Test

Dipyridamole is a relatively cheap, FDA-approved drug given with blood thinners to prevent strokes. The drug could help patients with COVID-19.

1011: Researchers at Johns Hopkins wanted to test another cheap generic drug, prazosin, an alpha-blocker, which can prevent inflammatory surges.

1012: Oral petechial lesions, seen in some COVID-19 patients, in addition to skin rash exanthem, represents a new symptom of the virus. Researchers in Madrid examined the oral cavity of 21 patients with the virus who also had a skin rash. Investigators stated that the presence of enanthem in a patient with a skin rash was a useful finding that suggests a viral etiology rather than a drug reaction. The findings were published in a research letter in JAMA Dermatology. 

1012: Test to Guide Steroid Treatment: Hospitalized COVID-19 patients with high levels of inflammation may obtain significant benefit from dexamethasone and other steroids. Investigators at Albert Einstein College of Medicine and Montefiore Health System in the Bronx, New York, have suggested that patients with low levels of inflammation may have a significantly higher risk for severe outcomes with steroid use. C-reactive protein test can assist physicians in deciding which patients would likely benefit.

1013: Combination Therapy Suppresses Cytokine Storm: A new study has revealed that the combination of high-dose methylprednisolone and tocilizumab was associated with faster respiratory recovery, decreased odds of mechanical ventilation, and fewer in-hospital deaths among COVID-19 patients with a hyperinflammatory state known as a cytokine storm, in comparison with those given supportive care alone. Comparing the patients who received the treatments with historic controls, investigators noted that participants in the treatment group had a 79% increased likelihood of attaining at least a two-stage improvement in respiratory status.

1014: Bleeding complications linked to antithrombotic strategy used in non‐critically ill COVID-19 patients: [DG Alerts] A study published in the Journal of Thrombosis and Haemostasis challenge the current strategy of giving weight-adjusted doses of anticoagulants to non-critically ill patients with COVID-19 in the absence of thromboembolic complications. Investigators at University of Padua, Padua, Italy, noted that there has been increased awareness that low-dose anticoagulants may not be effective for prevention of thrombotic complications in the course of COVID-19, including the development of micro-thrombosis in the lung vessels. This has led several clinicians to consider the use of sub-therapeutic or even therapeutic doses of antithrombotic agents in all hospitalized patients, challenging their hemorrhagic potential. The results of their retrospective cohort study do not support this strategy.

Authors stated that as (sub)-therapeutic doses of antithrombotic drugs did not reduce the risk of fatal or non-fatal thrombotic complications while simultaneously increasing the hemorrhagic risk, their use in non-critically ill COVID-19 patients should be discouraged.

[SOURCE: Journal of Thrombosis and Haemostasis]

1015: Clinical improvement of severe COVID-19 pneumonia in a pregnant patient after cesarean delivery:  [DG Alerts] A case of COVID-19 in a pregnant patient with severe respiratory compromise was described in BMJ Case Reports. The patient’s clinical status significantly improved following cesarean delivery.

A 35-year-old gravida 10 para 7 at 29 3/7 weeks gestation presented to the labor and delivery unit with a 2-week history of cough and fever. The patient also reported dyspnea worsening with ambulation, myalgias and dysuria. On the day of presentation, she became increasingly hypoxic, and required 8 L/min of oxygen via nasal cannula. A COVID-19 nasopharyngeal PCR test on admission was positive; laboratory findings indicated lymphopenia and elevated LDH, D-dimer and C reactive protein (CRP). Chest X-ray findings were consistent with COVID-19, with extensive patchy airspace opacities in the middle and lower lung fields. 

The patient had to be taken to the SICU, where her condition deteriorated on day 2 with increasingly elevated oxygen requirements. On day 3, she was given tocilizumab 400 mg IV. Her respiratory status continued to worsen, and by day 5, she required 15 L/min of oxygen through a Venturi mask with desaturation of her SpO₂ to the low 80th percentile on ambulation.

Despite worsening respiratory status, the patient’s acute phase reactants showed considerable improvement. Her CRP came down from 179 mg/L at admission to 7.4 mg/L by day 5. Throughout her hospitalization in the SICU from days 2 to 9, the patient was afebrile but was visibly tachypneic with increased work of breathing. Her D-dimer level continued to rise, peaking at 3037 ng/mL. 

The patient needed 15 L/min of oxygen and had signs of clinical worsening with potential imminent need for intubation. Therefore, an interdisciplinary team opined to go ahead with cesarean delivery with neuraxial anesthesia, and possible intraoperative intubation if the patient was unable to tolerate prolonged supine position. 

The patient underwent an uncomplicated primary cesarean delivery at 30 5/7 weeks gestation with spinal anesthesia on day 10 of hospitalization, while being maintained on 15 L/min of oxygen during the procedure. There was no need for intubation. A male neonate was delivered whose chest X-ray on day of life 3 had no evidence of pulmonary disease. COVID-19 nasopharyngeal PCR testing collected 2 hours after delivery and on day of life 3 were also negative.

The patient’s clinical status exhibited rapid improvement postoperatively; she had a SpO2 to the low 90th percentile on room air at 2 hours post-cesarean, improving to 100% on 15 L/min of oxygen in the recovery room. Her cough and work of breathing also showed significant improvement. Her oxygen requirements gradually declined, and by postoperative day 2, she was weaned to 4 L/min of oxygen via nasal cannula. 

She was continued on therapeutic enoxaparin postpartum until a CT angiogram could be obtained, owing to the concern for a concomitant pulmonary embolism. Her CT angiogram was negative for pulmonary embolism, but consistent with COVID-19 infection. There were extensive bilateral patchy ground glass infiltrates and small consolidations. COVID-19 nasopharyngeal PCR tests came out positive on postoperative days 7, 8 and 9. The patient was discharged on postoperative day 9 as she had symptomatic improvement, saturating well on room air and meeting all postoperative milestones. Her COVID-19 test was negative on postoperative day 14.

In cases of severe respiratory distress from COVID-19 pneumonia, there may be a reversal in poor respiratory status after the physiological changes of pregnancy are removed.

This is probably the first case that cites the use of tocilizumab for COVID-19 infection in a pregnant patient. Tocilizumab exposure during pregnancy has mostly been studied in patients with severe rheumatologic diseases.

[SOURCE: BMJ Case Reports]

1016: Antibody levels in patients with mild COVID-19 seem to decline by half within 36 days, suggests new research. The research was conducted by F. Javier Ibarrondo, PhD, associate researcher at the David Geffen School of Medicine at University of California, Los Angeles (UCLA), and colleagues. It appeared online in a letter to the editor of The New England Journal of Medicine. (The original letter incorrectly calculated the half-life at 73 days.)

1017: Acute kidney injury is noted in a significant minority of patients with severe COVID-19, there was no evidence of the presence of SARS-CoV-2 in kidney biopsies from a small series of such patients.

The kidney biopsy research revealed that the kidney injury from COVID-19 virus occurs as a result of complications of the disease and not because of direct viral infection of the kidney. [Journal of the American Society of Nephrology]

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA