Clinical time course of COVID-19, its neurological manifestation and some thoughts on its management

COVID-19 has become a global pandemic. Its clinical course and temporal profile has not been well described. Since the outbreak, the disease is known for its respiratory symptoms including fever and coughing. It is also widely known for its higher mortality than common influenza and elderly has more severity. However, we have found that many patients had neurological symptoms in their early stages, and ischaemic stroke often happened around 2 weeks after the onset of infection. Our findings have important clinical significance. If these neurological symptoms are present, test for COVID-19 may be warranted. We have found that COVID-19 runs its course in two phases, the initial incubation phase and later clinical symptomatic phase. The initial incubation phase is about 3–5 days, during which the virus is attempting to seed at the most peripheral and inferior parts of the lungs. Since it is a RNA virus, it may take several days to replicate to a significant amount and cause organ damages. One laboratory sign of early infection without fever and cough during this phase is the development of lymphopenia. Once clinical symptoms are onset, the patients may begin with neurological symptoms first. When neurological symptoms occur, complete blood count and lymphocyte count should be checked routinely. Mucosa is rich in angiotensin-converting enzyme 2 (ACE 2) receptors, and the virus enters the host via eyes, nose and mouth. In severe patients, retaining CO2 is a challenging problem. Due to extensive damage to the lungs, gas exchange becomes difficult. Frequent checking of arterial blood gas is needed to monitor PCO2 levels. Only using pulse oximeter to monitor PO2 may be misleading. Currently, the treatment and vaccine for COVID-19 is under development. Those principles have been so effective to manage patients in our clinical practice: Be vigilant of neurological symptoms with low lymphocyte count and if they occur, consider CT of chest and test for COVID-19. If symptoms detected and nucleic acid is positive, start prescribing Arbidol or hydrochloroquine as treatment daily and quarantine in a hospital ward. Management of neurological symptoms continued. Mild patients cannot go home but be quarantined somewhere else. About 20% of them will turn into severe cases. More than a week later if fever and lung infections happen, broad-spectrum antibiotics should be started when either sputum or blood cultures are positive, with or without elevated C reactive protein level. When D-dimer is elevated, systemic anticoagulation is indicated. Antiplatelet therapy will fail. Monitor arterial blood gas often and be aware of hypercapnia from the retention of PCO2. Ventilator support when PO2 is low and PCO2 is high. Consider intravenous immunoglobulin at the later phase. To Read more- https://svn.bmj.com/content/early/2020/05/07/svn-2020-000398

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