COVID-19 – Coronavirus Deep Dive

February 25, 2020

Written by Nicole McCoin

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Huang and colleagues have described the clinical presentation and course of illness for the 41 admitted patients who were identified as having lab-confirmed 2019-nCoV infection by January 2, 2020 to a designated hospital in Wuhan, China. At this point, be concerned in patients who have fever, cough, fatigue/myalgia, and pneumonia (particularly bilateral pneumonia).

Why does this matter?
Yesterday, we scratched the surface. Today we dive deep into the clinical aspects of COVID-19. We need to use this descriptive information to help us build our understanding of the virus so that we can do our best to identify and care for patients with potential cases. This post is longer than usual but needed for a worldwide public health threat.

Important Information:

What is 2019-nCoV (aka COVID-19)?

2019-nCoV is a novel betacoronavirus. Two other viruses in the same family are SARS-CoV and MERS-CoV. Although we understand SARS and MERS, there is no current published work about the human infection caused by the 2019-nCoV.

What were the demographics of the forty-one admitted 2019-nCoV patients included in this study?

• Most were men (30/41 patients; 73%)

• Median age = 49 years

• 13/41 patients (32%) had underlying disease (e.g. diabetes, hypertension, cardiovascular disease, COPD, cancer)

What kind of symptoms did the forty-one admitted 2019-nCoV patients included in this study have?

• Fever (40/41 patients; 98%)

• Cough (31/41 patients; 76%)

• Myalgia or Fatigue (18/41 patients; 44%)

• These three symptoms were the major ones. There were patients who had sputum production, headache, hemoptysis, and diarrhea; however, these symptoms were less common.

• Dyspnea occurred in 55% later in the course, with mean time to onset of dyspnea at 8 days.

What kind of laboratory abnormalities did the forty-one admitted 2019-nCoV patients included in this study have?

• Lymphopenia (lymphocyte count < 1.0 x 109/L) (26/41 patients; 63%). [Leukopenia can also be seen.]

• AST elevation (15/41 patients; 37%)

• The sicker patients who were admitted to the ICU were more likely to have lymphopenia; AST elevation; elevated D-dimer; elevated AST; elevated cardiac biomarkers; and elevated plasma levels of cytokines and chemokines including levels of  IL2, IL7, IL10, GSCF, IP10, MCP1, MIOP1A, and TNF alpha. Cytokine storm seemed to be associated with disease severity.

What kind of radiology abnormalities did the forty-one admitted 2019-nCoV patients included in this study have?

• Abnormalities in chest CT images in ALL patients

• Bilateral involvement on chest CT (40/41 patients; 98%)

• The sicker patients who were admitted to the ICU were more likely to have bilateral multilobular and subsegmental areas of consolidation (compared to non-ICU patients who tended to have bilateral ground glass opacities and subsegemental areas of consolidation).

What kind of time course did 2019-nCoV infection have in these forty-one admitted patients?

• Median time from symptom onset to hospital admission = 7 days

• Median time from symptom onset to dyspnea = 8 days

• Median time from symptom onset to ARDS = 9 days

• Median time from symptom onset to ICU admission = 10.5 days

• Median time from symptom onset to mechanical ventilation = 10.5 days

How many of these forty-one admitted 2019-nCoV patients had complications or death?

• Once again, all admitted patients had pneumonia.

• ARDS (12/41 patients; 29%)

• Acute cardiac injury (5/41 patients; 12%)

• Secondary infection (4/41 patients; 10%)

• Invasive mechanical ventilation (4/41 patients; 10%)

• ECMO (2/41 patients; 5%)

• ICU admission (13/41 patients; 32%)

• Death (6/41 patients; 15%) [For comparison, mortality rate is 10% for SARS-CoV and 37% for MERS-CoV.]

What did the authors NOT see with these forty-one admitted 2019-nCoV patients?

• No children or adolescents were among the 41 admitted, which the authors feel may be due to exposure bias.

• Not many upper respiratory tract symptoms such as rhinorrhea, sneezing, and sore throat, indicating that the target cells are likely in the lower airway.

• Not many GI symptoms (particularly less GI symptoms than their MERS and SARS counterparts)

• No rise in procalcitonin

What do we know about specific treatment for patients with 2019-nCoV thus far?

• Not much yet.

• In this study, the forty-one admitted patients received antibiotics and oseltamivir as it was also influenza season. Corticosteroids were given if severe community-acquired pneumonia was diagnosed. Oxygen was administered for hypoxemia. Supportive care measures were administered.

• In practice, further evidence is needed to determine if systemic corticosteroid treatment is indicated. No antiviral treatment for 2019-nCoV has yet been proven to be effective. The combination of lopinavir and ritonavir showed substantial clinical benefit in SARS-CoV. Remdesivir, which is a broad-spectrum antiviral nucleotide prodrug), has shown some promise with treatment of MERS-CoV and SARS-CoV. Once again, further evidence is needed to guide us in antiviral treatment.

There is a lot more to be discovered about 2019-nCoV. My advice is to stay well-informed using reputable sources of information, like the information from the CDC. Stay tuned…

Source
Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24.

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