(With inputs from Dr Monica Vasudeva)

791: Why sudden deaths after cure

In one of the countries amongst 200 people who were suffering from coronavirus, 20 died days after discharge. In the post-mortem, it was found that the active virus was still present in their body.  We all know that virus can remain active in the nasal cavity for up to 28 days and in the stool for 3 months. Once the RT PCR is negative, it does not mean that the virus has gone as RT PCR can have 33% false negative in the first test and 15 to 20% false negative with the second test. Also, if the second sample is not a lower respiratory tract sample, the false negative rates are higher.

Therefore the dictum is that positive cases undergo 14 days of isolation followed by 14 days of quarantine and another 14 days of monitoring.

10% of these cases develop heart involvement and these are the cases which can have sudden death even after discharge. The classical example is the Italian doctor who died after discharge because of a heart attack in Jaipur.

792: False dawn recovery haunts virus survivors who fall sick again

A month after Mirabai Nicholson-McKellar, 35-year-old filmmaker, was infected with the coronavirus, she developed shortness of breath followed by chest pains. A visit to the emergency room and a second test for COVID-19 gave another positive result. Just three days earlier, she’d been cleared by health authorities in Australia’s New South Wales state and was allowed to end her home quarantine after 72 hours without symptoms.

Her experience is an addition to a growing number of reports of patients appearing to have a reactivation of symptoms, testing positive again, or even potentially being reinfected. Incidents like these don’t align with the generally accepted understanding of how virus infections work and spread. This is called false-dawn phenomenon.

Why do symptoms re-emerge in some people, and whether the patients experience reinfection or if the virus persists for weeks. One of the possibilities is that COVID-19 causes blood clots that may cause potentially dangerous complications unless treated with anticoagulant medications, said Edwin J.R. van Beek, chair of clinical radiology at the University of Edinburgh’s Queens Medical Research Institute.

South Korean researchers have also offered some clues as they reported that the so-called nucleic acid tests might be positive based on the detection of dead viral particles that could give the false impression that a patient is still infectious when they’re actually not.

793: Why people are leaving from one state to another

When we talked to people who are leaving Delhi to go to their native places, they said they know that the restrictions of lockdown are easing down but to maintain a social distance of 3 feet they will have to vacate their residence where they are sharing a single room with 10 other people and also at the place where they work, social distancing will not be possible unless they lay off 30 to 40% of the people. Therefore, the only answer for them is to go back from Delhi.

794: Is it ok to raise cess on alcohol

The Delhi government decision of putting cess on alcohol and extra GST on petrol and kerosene is not understandable. The reason given is to maintain social distancing and recover the losses, they must increase the cess so that less people buy. But this would mean that all sectors of the society which have lost money in the lockdown are free to increase their charges. If private medical establishments were adding PPE charges, I could have understood but not the government.

Putting extra GST and increasing the charges of petrol and diesel does not make any sense and will not be taken up in a good taste by the community as all over the world, the charges are going down.

795: India in top 5

The number of new cases in India in last one day was approximately 4000. With this, India comes in the top 5 countries having largest number of cases on a single day. USA tops the list with 24000, Russia is second with 10000 and Brazil third with 7000 cases. India shares this number with UK, both with approximately 4000 new cases in one day.

796:  Sudden rise a concern

Sudden rise of cases at the end of the lockdown is a matter of concern. On an average, it takes 5.2 days for symptoms to manifest. This would mean these cases have acquired the infection at least five days before the lockdown was eased out. The actual rise, if any, because of the lock down release will be evident only after another five to seven days.

797:  India is missing the cases

Time to Death is 14 days

Death Rate = Number of deaths today/Number of cases 14 days back

Deaths on 4^th May: 1566, number of cases on 20^th: 1239: death rate 6%

15% of serious patients will die

Number of deaths on a given day x 85 = number of serious patients 14 days before  

Number of deaths 100 today would mean 666 serious cases 14 days before

On 20^th we should have had 666 serious cases

For every 100 cases, 15% would be serious cases

No. of actual expected cases on 20^th:  4440

Actual cases: 1239

Cases Missed: 3201 > 75%

>90% of people are symptomatic within 2 weeks of infection, with fatalities occurring on average 2 weeks after that

 798: We Cannot Let the Cure Be Worse Than the Problem Itself

A bit of death is the unavoidable price of economic revitalization. Georgia’s Republican governor, Brian Kemp, has reopened his state despite a severe outbreak. The lockdowns can’t last forever.

799: COVID Dermatology

Two case reports published in JAMA Dermatology prompted an accompanying editorial urging dermatologists to participate in the characterization and management of skin complications associated with COVID-19 infection. [Medscape]

800:  CDC 10 Clinical Tips on COVID-19 for Healthcare Providers Involved in Patient Care

Treatment and Prophylaxis

1. The NIH has developed guidance on treatment, to be regularly updated as new evidence on the safety and efficacy of drugs and therapeutics becomes available from clinical trials and research publications.
2. No FDA-approved post-exposure prophylaxis currently exists for people who may have been exposed to COVID-19. 

Symptoms and Diagnosis

3. Non-respiratory symptoms of COVID-19, such as gastrointestinal (e.g., nausea, diarrhea) or neurologic symptoms (e.g., anosmia, ageusia, headache), might appear before fever and lower respiratory tract symptoms (e.g., cough and shortness of breath).
4. Children with COVID-19 may have fever and cough at symptom onset as often as adult patients. Although most children with COVID-19 have not had severe illness, a high index of suspicion is required for SARS-CoV-2 infection in children, particularly infants and children with underlying conditions.
5. CT scans should not be used to screen for COVID-19 or as a first-line test to diagnose COVID-19. CT should be used sparingly, reserved for hospitalized, symptomatic patients with specific clinical indications for CT.

Co-Infections

6. Patients can be infected with more than one virus at the same time. Coinfections with other respiratory viruses in people with COVID-19 have been reported. Identification of infection with one respiratory virus does not exclude SARS-CoV-2 virus infection.
7. Several patients with COVID-19 have been reported as presenting with concurrent community-acquired bacterial pneumonia. Decisions to administer antibiotics to COVID-19 patients should be guided by the likelihood of bacterial infection (community-acquired or hospital-acquired), illness severity, and antimicrobial stewardship issues.

Severe Illness

8. Be aware of the potential for some patients to rapidly deteriorate one week after illness onset.
9. The median time to acute respiratory distress syndrome (ARDS) varies from 8 to 12 days.
10. Lymphopenia, neutrophilia, elevated serum alanine aminotransferase and aspartate aminotransferase levels, elevated lactate dehydrogenase, high CRP, and high ferritin levels may be associated with greater illness severity.

 [CDC]

Dr KK Aggarwal

President CMAAO, HCFI, Past National President IMA, Chief Editor Medtalks