Nice post Dr Parveen Yograj. This Covid 19 effects every organ in the body and cause multi organ failure and death. Sars Cov-2 could directly infect the human kidney tubules and induce cytoplasmic tubular inclusions, a feature observed in virus induced nephropathies although Sars Cov-2 RNA is not found in kidney. Direct viral infection and replication in kidney plays a vital role and leads to AKI and hypotension, decreased kidney perfusion secondary to hemodynamic or hemostatic factors or associated with sepsis. The main binding site of Sars Cov-2 is ACE2 protein which is expressed more in kidneys much more than the lungs . Regardless of direct viral infection of kidney , Ang2 is likely increased in acute lung injury. ACE 2 is down regulated in AKI. This may lead to type 1 Angiotensin receptor activation as well as decreased Angiotensin formation and subsequent worsening of AKI. Thus the patients with CKD especially those with DKD who develop Covid 19 may be at higher risk of AkI because of baseline upregulation of ACE and downregulation of ACE2 ,a combination that primes the proinflammatory and profibrotic state in the kidneys. More than 40% of patients with Covid 19 have abnormal proteinuria to AKI. AKI is considered as marker of Covid 19 severity and negative prognostic factor for survival. AKI in COVID 19 patients is reversible or not , don't know because of very limited studies. Most of the cases with AKI in COVID 19 cases require dialysis,and renal replacement therapy and carries poor prognosis. A lot of research is going on this dangerous pandemic COVID 19.
Sir there is no theory to stop or put new hypertensive cases on ace or ARB rather new concept has come up to continue Arbs as ace2 inhhlitbion is acceptable As conjugation of covid19 protein with ace 2 protein doesnot affect the Ace or ARB in circulation rathe it holds the conversion of ang1 to -7 I was just on webinar by ipca moderator dr Bhandari cardiologist sms medical college jaipur
When the virus attacks the dynamic vital force tries to limit it to the least important organ of the organism, which may vary from person to person and that's why we see so many different systems getting affected. We even have found covid toes a skin condition in asymptomatic children. And many more can be correlated as the virus gets indigenous.
Is it advocable to hold ACE inhibitors at least in new HTN cases?
Tole of ACE Inhabitors is best justified in Coved 19...
Thank you for sharing this.. informative post
Very informative .
Very useful information with nice presentation
Cases that would interest you
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a patient came with c/o pain abd,fever 5-6 days..TLC increased,LFT and RFT deranged...Hb 6.5gm% ..BT was adviced and one unit of PRBC was transfused...1/2-1 hour after BT ,patient developed tachypnea,tachycardia..desaturated..put on mech vent with high PEEP...improved..may be case of TRALI...comments invited... both the xrays are 24 hour apart...Dr. Lalit Kumar2 Likes23 Answers
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In pathogenesis of COVID-19, hands play an important role by transporting virus from fomites mainly to nose and mouth. From mouth and nose virus spreads in the body. Saline wash of the nasal passage, mouth, and throat would probably eliminate or reduce viral load in the body mechanically at least in the initial stage of the pathogenesis. This could be similar to hand washing to contain the spread of the infection. Therefore, hypertonic saline gargles and nasal wash may work in preventing the disease and may also be useful in reducing nasopharyngeal viral load to provide symptomatic relief. Further, it may reduce viral shedding and reduce the transmission of the illness. This may break the chain of infection. COVID 19 disease is mild in eighty percent of patients and resolves spontaneously. Therefore, nasopharyngeal wash may be useful especially in subgroup of the population at high risk such as subjects with comorbid conditions and above 60 years of age. In this rapid systematic review to evaluate effect of nasopharyngeal wash majority of studies had methodological limitations. However, few studies using hypertonic saline gargles and nasal wash showed to prevent symptoms and reduce transmission, symptoms, need for symptomatic medication, and viral loads in patients of the common cold. Its utility, however, has to be studied for SARS-CoV-2 which has significant mutations from the coronaviruses that causes the common cold. Since it has been shown to work for a multitude of common viruses, logically, it should work for SARS-CoV-2 as well. The therapy could be studied as an easily available, and affordable add on modality to curb the transmission of the SARS-CoV-2. As we await definitive therapy to fight the pandemic this relative safe technique may give a ray of hope especially in prevention. COVID 19 infection starts in nasopharynx but involves lungs and other organs of the body. Therefore the effect of nasopharyngeal wash may have a limited action at nasopharynx; however, it may be more useful in prevention. The potential disadvantages of the nasal wash therapy are the discomfort in performing the procedure, however, in previous studies, it has been shown to be accepted in around 87% individuals. The second disadvantage would be the possible transmission of viral infection through the equipment used for the wash and the area where the procedure is performed. This limitation could be addressed easily by maintaining strict measures with each person use one's own equipment with no sharing amongst each other. Further, the washbasin/sink where the procedure is performed can be cleaned postprocedure. Certain precautions should be followed prior to the procedure including the use of clean water which can be ensured by boiling and subsequently cooling it. The technique of learning of nasopharyngeal wash should be supervised initially. To read more- http://www.lungindia.com/article.asp?issn=0970-2113;year=2020;volume=37;issue=3;spage=246;epage=251;aulast=SinghDr. Somesh Sharma19 Likes26 Answers
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77 yeas old female with a background notable of metastatic small bowel GIST. The patient is on chemotherapy, HTN, thyroidectomy, cholecystectomy presented with 10 day Hx of intermittent fevers, nonproductive cough, and increased Shortness of breath. PO2 8.8 on FiO2 0.85 on admission Admitted to ICU and Intubated Lung protective ventilation commenced but desaturated to 80% following RIJ CVC. Decompressed by the bedside and a CXR was performed that revealed large pneumothorax. The chest drain inserted with pneumothorax resolved gradually. 1 day after admission the admitting diagnosis was confirmed COVID-19. What are your experiences and knowledge of managing COVID-19 patients? Please discussDr. Harshita Jain3 Likes20 Answers
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THE COVID-19 SYMPTOMS WE DID NOT KNOW ABOUT As the pandemic spreads around the world, doctors are beginning to scope the coronavirus’s damage. Seen initially as a cause of viral pneumonia during the chaos of an explosion of cases in China, it’s now emerging as an enigmatic pathogen capable of harming the body in a myriad of unexpected, and sometimes lethal, ways. Clinical manifestations range from common cold-like symptoms and bronchitis to more severe disease such as pneumonia, severe acute respiratory distress syndrome, multi-organ failure and even death. The illness may occur as a direct result of viral infection, as well as the body’s response to it. Here’s a snapshot of some of the symptoms Covid-19 causes, including some you might not have heard about. Blood Fever and inflammation may disrupt blood vessels, rendering blood cells more prone to clumping while interfering with the body’s ability to dissolve clots. That may trigger a clotting cascade that can lead to blood-vessel blockages in tissues and organs throughout the body. Life-threatening clots in the arteries of the lung, known as pulmonary emboli, may occur even after symptoms of the infection have resolved. Damaged blood vessels may become leaky and prone to bleeding. In children, inflammation of veins and arteries triggered by excessive immune activation may cause an illness similar to Kawasaki disease, an inflammatory disorder. Brain Dysfunction in the lining of blood vessels and associated bleeding and clotting disorders may cause strokes and bleeding in the brain. Patients may also experience headache, dizziness, confusion, impaired consciousness, poor motor control, delirium and hallucinations. Eyes Red, puffy eyes, sometimes referred to as pink eye, may result from infection in the conjunctiva, the tissue that lines the inside of the eyelids and covers the white part of the eye. Gastrointestinal tract Infection of cells lining the digestive tract may cause diarrhea, nausea, vomiting and abdominal pain. Blood-vessel blockages caused by abnormal clotting have been found to damage the bowel, requiring emergency surgery and resection. Hands Prickling or burning sensation in the hands and limbs may indicate Guillain-Barré syndrome, a rare nervous-system disorder that may be triggered by aberrant immune responses to viral infection. Other symptoms of the syndrome include poor coordination, muscle weakness and temporary paralysis. Heart Cardiac injury, sometimes leading to irregular heartbeat, heart failure, and cardiac arrest, may occur as a result of excess strain, inflammation of the heart muscle and coronary artery, blood clots, and overwhelming multi-organ illness. Infection, fever, and inflammation in people with existing heart-vessel blockages may cause their fatty plaques to break off, blocking or stopping blood flow in organs and tissues. Limbs Obstructions in large blood vessels may cause insufficient flow, or acute ischemia, in the limbs. Severe vascular complications can be lethal. At least one reported cases resulted in lower limb amputation. Liver Liver dysfunction may occur as a direct result of the viral infection, or more likely because of immune-mediated, systemic inflammation and circulatory blockages cutting blood flow to the organ. Lungs The virus targets the epithelial cells that line and protect the respiratory tract as well as the walls of the tiny grape-like air sacs, or alveoli, through which gas exchange occurs to oxygenate the blood. Damage to alveoli and inflammation in the lungs can cause pneumonia, characterized by chest pain and shortness of breath. In severe cases, the lack of oxygen can trigger acute respiratory distress syndrome, leading to multi-organ-system failure. Kidneys Acute kidney injury may result from clots and impaired blood supply, or as a direct result of infection. Nose and tongue While the virus can cause the sneezing and runny nose typical of a common cold, it can also disrupt the olfactory system, causing an abrupt full or partial loss of the sense of smell known as anosmia. Taste may also become distorted in a condition known as dyguesia. Skin Hive-like rashes, small red dots and purplish discolorations on the legs and abdomen are part of a complex category of so-called paraviral dermatoses that may result from the body’s immune response to the virus or from benign, superficial blood-vessel damage beneath the skin. Toes Purple rashes that resemble chickenpox, measles or chilblains may appear on the feet, especially of children and younger adults.Dr. Prashant Ved17 Likes21 Answers
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The world is currently suffering from the outbreak of a pandemic caused by the severe acute respiratory syndrome coronavirus SARS-CoV-2 that causes the disease called COVID-19, first reported in Wuhan, Hubei Province, China on 31 December 2019. The most common comorbidities in one report were hypertension (30%), diabetes (19%), and coronary heart disease (8%). Another report showed that the most frequent comorbidities in patients with COVID-19 who developed the acute respiratory distress syndrome were hypertension (27%), diabetes (19%), and cardiovascular disease (6%). The frequency with which COVID-19 patients are hypertensive is not entirely surprising nor does it necessarily imply a causal relationship between hypertension and COVID-19 or its severity, since hypertension is exceedingly frequent in the elderly, and older people appear to be at particular risk of being infected with SARS-CoV-2 virus and of experiencing severe forms and complications of COVID-19. It is unclear whether uncontrolled blood pressure is a risk factor for acquiring COVID-19, or whether controlled blood pressure among patients with hypertension is or is not less of a risk factor. However, several organizations have already stressed the fact that blood pressure control remains an important consideration in order to reduce disease burden, even if it has no effect on susceptibility to the SARS-CoV-2 viral infection. In conclusion, there is as yet no evidence that hypertension is related to outcomes of COVID-19, or that ACE inhibitor or ARB use is harmful, or for that matter beneficial, during the COVID-19 pandemic. Use of these agents should be maintained for the control of blood pressure, and they should not be discontinued, at least on the basis of current evidence at this time. To read more-https://academic.oup.com/ajh/advance-article/doi/10.1093/ajh/hpaa057/5816609Dr. Somesh Sharma4 Likes2 Answers