1066: Round Table Expert Zoom Meeting on “Post-COVID-19 Inflammation”

 22^nd August, 2020, 11am-12pm

Participants: Dr KK Aggarwal, Dr AK Agarwal, Dr Ashok Gupta, Dr JA Jayalal, Dr Atul Pandya, Dr Jayakrishnan Alapet, Dr Shantanu Tripathi, Prof Bejon Misra, Dr (Major) Prachi Garg, Ms Ira Gupta, Dr S Sharma

Key points from the discussion

• Delhi has seroprevalence of 28%, but asymptomatic persons with no increase in CRP/ESR do not develop antibodies. We have been able to tackle the disease in Delhi, Mumbai and Pune.
• In countries where 6 feet (2 m) social distancing is not possible, reduce the distance to 3 feet (1 m).
• The need of the hour is one vaccine, one movement. Polio has been almost eradicated because of global effort for one polio vaccine, but this is not the case with COVID-19.
• The government may revise its testing strategy to testing on demand.
• We should come out with a consensus statement regarding international travel stating under what conditions the 7-day quarantine could be exempted.
• COVID-19 disease has two phases: Viral phase and post-viral phase.
• Viral phase can be divided into aggressive phase and non-aggressive phase. About 33% of patients in non-aggressive phase go into post-viral phase, manifested as persistence of gene target positive for 120 days, fever, recurrent diarrhea, episodes of costochondritis, abdominal pain/nausea/vomiting, calf pain, rash, cystitis, lower abdominal pain, loss of smell/taste, etc.
• Pyrexia vs. thermia: pyrexia is because of the organism (first 9 days); thermia is not due to the virus (after 9 days), it is caused by thermodysregulation in the hypothalamus. The fever is low grade, appears after exertion, all inflammatory markers are normal.
• Phytoestrogens reduce IL-6; hence, soya, rich source of phytoestrogens can help.
• Some patients have post-COVID persistent inflammatory state – rising inflammatory markers or reducing but not rapidly.
• Do CRP as follow-up test. If normal, then IL-6 is normal; if high, then IL-6 is high. This means that the person can still go into delayed cytokine storm.
• After 9 days, even if no fever but raised CRP/ESR with/without increased IL-6: Curcumin (TNF-like activity), soya protein (reduces IL-6), NSAIDs (nimesulide, mefenamic acid, naproxen, indomethacin), hydroxychloroquine (discarded but re-emerging in post-COVID illness).
• If the patient develops symptoms again, e.g. diarrhea, with raised ESR/CRP, is it re-infection? We do not know.
• If first diagnosed as post-COVID illness after having missed earlier diagnosis, the prognosis may be unfavorable.
• In high prevalence area, both antigen and antibody tests should be done together.
• According to the CDC, the virus particle may be detected in the body for up to 120 days. This is persistent inflammation or the persistent virus particle, which is causing the inflammation.
• Do baseline CBC with ESR, CRP, IL-6, LDH, ferritin, D-dimer. A rapid rise in any of these is important.
• If CT scan is positive on Day 3 (pneumonitis) with more than 2-fold rise in CRP/ESR or rapid rise (>2-fold) in IL-6, this is the time to give remdesivir. If available, give it on Day 1, but definitely on Day 3 along with LMWH (to reduce thrombosis) and steroid (to reduce IL-6). Give heparin for 9 days, then shift to dabigatran/rivoraxaban x 40 days or even more, depending on the hypercoagulable state of the patient.
• Patients with GI symptoms (diarrhea) may have more severe disease and higher mortality.
• Off-label use is anecdotal evidence. Off-label use does not require trial; it is a shared decision made by the patient and all legal heirs and the doctor after informed consent. Consent may be routed through Ethics Committee if it is a hospital policy.
• If post-COVID patient needs oxygen, this means either resolving pneumonia or that the patient has developed lung fibrosis.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA