COVID19 presentations
The disease caused by a Corona Virus named SARS CoV-2, a positive sense RNA virus. The virus infection has different presentations in different patients.
o It is a viral disorder and is self-limiting in 90% of patients. If antivirals should be given are effective when administered within 48 hours.
o The virus behaves like HIV in some patients; if lymphopenia or reduced CD4 cell count, then give anti-HIV drugs.
o It produces hyperimmune inflammation, so if there are signs of hyper inflammation such as high ESR, CRP and ferritin, anti-inflammatory drugs such as HCQ, indomethacin, and steroids become important.
o It behaves like bacteria, so azithromycin can be given; azithromycin may cause cardiotoxicity, so doxycycline may be given. Actually in most cases of viral infections bacteria are secondary invaders but become the primary cause of death.
o It produces thrombo-inflammation; fibrinogen and d-dimer levels are raised then give anticoagulant – heparin, nafamostat, and steroids.
o It produces silent hypoxia; the oxygen level is very low, but the carbon dioxide level is normal; the person is conscious. The lung is compliant. In such patients, oxygen supplementation with high flow nasal cannula, BiPAP (if required), and ventilator (only 1%) can be of help.
o Cytokine storm and ARDS: this is a terminal illness and managed as per protocol for ARDS. Non-compliant lung and sudden death is the major outcome. Levilimab from Russia is a new drug that can be administered not only to patients already in a serious condition but used as a prophylactic to prevent the "cytokine storm" from occurring and allowing the patient to avoid intensive care and lung ventilation. It will go into the market under the brand LSIRA.https://www.eurekalert.org/pub_releases/2020-06/b-adf060920.php https://theprint.in/health/russia-approves-levilimab-for-treating-severe-covid-19-patients-says-it-reduces-death-risk/439094/ http://outbreaknewstoday.com/russia-covid-19-cases-top-500k-levilimab-approved-for-treatment-78666/
The SARS CoV-2 Coronavirus has a very wide spectrum of illness ranging from asymptomatic to cytokine storm. It has wide presentations, though the target organ is the lung.
The immunoinflammatory reaction primarily occurs in the lungs, but the manifestations of the thromboembolic phenomena have a very wide presentation.
In the initial stages, the patients have marked leukopenia; lymphopenia, in particular, is a predominant feature. The platelet count may be normal or slightly low, d-dimer and ferritin (acute phase reactants) levels are very high, parallel to high CRP and procalcitonin levels. The smear shows no evidence of DIC, the fibrinogen level is normal, PT and aPTT are either normal or slightly prolonged, but d-dimer is very high, LDH is very high.
Lung pathology and pathology in other organs show a hypercoagulable state with a thromboembolic phenomenon taking place. Microthrombi are being formed, like Thrombotic thrombocytopenic purpura (TTP) but it is not TTP as there is no evidence of purpura or thrombocytopenia.
As the disease advances, d-dimer and ferritin levels keep on increasing → multiorgan failure, then the platelet count falls very rapidly → PT and aPTT are prolonged. In the later stage, it is somewhat similar to DIC.
In the initial stage of the illness, the patient has a predominantly thromboembolic phenomenon, a hypercoagulable state due to immuno-inflammation. It mainly affects the lungs but can affect other organs also. Most patients do not have DIC like pictures in the initial stage of the illness (In DIC, fibrinogen levels should be low, PT and aPTT should be prolonged, peripheral smear should show microangiopathy). But when a patient develops multiorgan failure, a DIC-like picture is seen.
Monitoring: oxygen saturation, CO2; repeat CBC, platelets, d-dimer, ferritin, IL-6 every day or alternate days. Rapidly increasing levels are indicative of the worsening of patient condition. Act fast. A 3- to 4-fold rise in d-dimer means a critically ill patient, who may not survive.
Patients aged 60 years or above, or those who have comorbidities, are already decompensated to some extent. Survival is better in patients with no comorbidities.
Severe and persistent lymphopenia means that the virus is acting on the bone marrow and hematopoietic system. If neutropenia also occurs, this results in secondary infections. The virus has a more fulminant course in immunocompromised patients compared to those in whom the immune system is normal.
Cytokine levels are increased in these patients (TNF or IL-1, IL-6), the cytokines act on monocyte tissue factor expression, if they're acted upon by IL-1 and IL-6, they stimulate the coagulation pathway → prothrombin generation → thromboembolic phenomenon.
Multiple mechanisms are in play in the pathogenesis of a thromboembolic phenomenon.
Hypoxia is one of the factors stimulating hypercoagulation.
Nafamostat is an oral anticoagulant with antiviral activity. Maximum data available is on heparin and LMWH rather than nafamostat.
Kawasaki-like syndrome in children in the UK; similar data in India not available or published.
COVID toes and fingers are not an acute manifestation, they occur after the patient has recovered. Probably it is due to vasculitis persisting for some time after the disease has been taken care of.
Do tests: baseline, the next day, and then alternate days. If d-dimer is not increasing, then once every 3 days.
Hope for a Good Vaccine
Although many pharma companies are coming with claims of success of their vaccine and Italy (who believe that it is a non-viral disease) has claimed a few days back development of an effective SARSCoV-2 virus vaccine for COVID-19, the future of any vaccine as protector of humanity from COVID-19 is bleak. Covid19 antibody mapping in Wuhan (where disease precipitated in its worst form) indicated that vaccines may not be effective to protect you for long or at all and can not save you from 2nd or 3rd waves of COVID19. Only 4% of people had COVID19 antibodies after such a widespread occurrence of COVID in Wuhan. Similarly, in California, less than 20% of people could develop a protective immune response. In viral infections, the post-cure immune response is always better than afforded by any of the good vaccines. Thus you may imagine how good may be the eagerly awaited vaccines. Suppose you get an effective vaccine, how many doses will be required each year, it is a pertinent question in light of the reversal of illness in recovered patients reported first in South Korea and then almost from everywhere indicating a poor protective immune response. In India, we are not able to vaccinate about 20 crores of kids against polio, how will it be possible to vaccinate 138 crores with COVID-19 vaccine? Will the Indian economy can afford vaccination and treatment?
Besides, effective treatment of COVID-19 maybe with antiviral drugs. How many of Indians and people in the less developed world can afford that treatment?
Thus, if you want to fight with COVID19 than Be self-reliant. कोविड-19 से लड़ना है तो आत्मनिर्भर बनो
कोविड-19 से बचने के लिए यह सोच कर बैठना कि अगले 1 साल में अच्छी वैक्सीन और कोई दवा आ जाएगी बड़ी भारी भूल होगी क्योंकि बुहान में जहां यह बीमारी काफी विकराल रूप में फैली थी वहां भी इसके एंटीबॉडी चार परसेंट लोगों में भी नहीं मिले अर्थात दूसरी और तीसरी लहर आने से कोई रोक नहीं सकता वैसे भी कोविड-19 जाने के लिए आने वाली बीमारी नहीं है जिस बीमारी के लिए एंटीबॉडी बनने की दर इतनी कम हो और मृत्यु दर भी नाममात्र की वह बीमारी कभी जाती नहीं है
Don't wait for any good vaccine (it maybe by year-end) or any treatment as the majority of Indians fighting for food and treatment for minor ailments may not afford the luxury of using repeated shots of costly vaccines and treatments. Don't rely on that government to arrange for you all such vaccines and treatments as the government is already reached bankruptcy evident by the facts
1. Already cut the salaries and jobs in the public sector.
2. Already froze all community and public development programs.
3. Despite cheaper and cheaper petroleum all over the globe, we are burdened with ever-increasing diesel and petrol prices, etc.
4. Despite the fear of the spread of COVID19 through huddling, bars and liquor shops were the first to be opened.
5. In the country where half of the people are half fed the Mantra of Atmnirbhar is given i.e., you have to live and die at your own expense.
6. In the country where building mandir, masjid, statues, and monuments and advertisements of fake achievements are a priority and more important than the creation of jobs, hospitals, and education you need to be really Atmnirbhar.
7. The country which fights wars and enemies on social media and through bogus boycott appeals you really need to be Atmnirbhar.
Therefore, keep yourself educated, alert, and ready to fight COVID19 with the faith in your win.
अगर कोई वैक्सीन या दवा आ भी गई तो भारत के 90 परसेंट लोगों को उपलब्ध नहीं हो पाएगी वजह होगी उसकी कीमत और हमारी सरकार जो पहले से ही लगभग दिवालिया हो चुकी है आपकी कोई सहायता नहीं कर पाएगी. सरकार के दिवालियापन के लक्षण सर्वविदित है.
1. नौकरियां और नौकरी पहले ही बहुत कम हो चुकी है
2. सारे विकास कार्यों पर रोक लगा दी गई है सिवाय चुनाव के.
3. जब सारी दुनिया में तेल की कीमतें घट रही है हमारे यहां लगातार बढ़ रही है
4. यह जानते हुए भी की भीड़ बढ़ना और कोविड-19 बढ़ना साथ-साथ होगा सबसे पहले शराब खाने और ठेके खोल दिए गए हैं जिससे कि सरकार का खर्च चल सके
5. जहां पहले से ही लगभग आधी जनता भूखी है उस जनता को आत्मनिर्भर होने का मंत्र दे दिया गया है
6. जिस देश में मंदिर, मस्जिद, गुरुद्वारे, मूर्तियों का निर्माण और प्रचार विकास कार्यों और स्वास्थ्य एवं शिक्षा सुविधाओं से पहले आता हो उसके मानसिक दिवालियापन में कोई शक नहीं रहता
7. जिस देश में दुश्मनों से लड़ाई सोशल मीडिया पर प्रचार और बॉयकॉट की अपील से लड़ी जाए वहां ईश्वर भी कोई सहायता नहीं करते और आपको आत्मनिर्भर बनना ही पड़ता है. बाकी आपको कोविड-19 से 2020 के अंत तक (उसके बाद तो आपको इसके साथ रहने की आदत ही पड़ जाएगी) लड़ना है तो आत्मनिर्भर बनना है अपना ध्यान खुद रखना है आप को बचाने कोई नहीं आने वाला.
बाकी तो,
होई है वही जो राम रचि राखा
क्योंकि हम कुछ करने के लायक बचे ही नहीं हैं
भक्ति रस में डूबे हुए राष्ट्र को ईश्वर भी बचाने नहीं आएगा क्योंकि उसने इंसान को कर्म करने के लिए बनाया है भक्ति करने के लिए नहीं
Still, the more serious matter of concern is Environmental HealthMatter of concern for environmentalists and so-called sensible about COVID, a sociopolitical disorder caused by excessive diagnosis with ulterior motives is-
Who will estimate how much non-biodegradable and biologically hazardous waste had been generated worldwide out of testing, treatment (PPE, syringes, tubings, etc) and prevention measures (masks, PPE kits, gloves, disinfectants, sanitizers, automatic and semiautomatic dispensers, bottles, fruit and vegetable disinfecting/ decontaminating chemicals and many more to come) for COVID 19. It would also be interesting to hear from all the so-called experts, environmentalists, epidemiologists, and empathetic/self-declared sensible people on their somewhat educated estimates and somewhat fancy perspectives on the degradable/ nondegradable biologically hazardous and less hazardous and non-hazardous wastes ( eg., 0.1% of a or 500% of b and 1000% of c and so on and so forth). Who will account for???
