COVID-19

This presentation discusses COVID-19. It covers etiology, epidemiology, pathophysiology, clinical features, diagnosis, clinical management and treatment of COVID-19. It also discusses the effects of COVID-19 on pregnancy,how it manifests and how it is diagnosed and how it is managed. Hope this will help you.

1. COVID-19 Dr.Muhammad Zaid Shaukat

2. COVID-19 Coronaviruses belong to the “Coronaviridae family”, which causes various diseases, from the common cold to SARS and MERS. The coronavirus is naturally prevalent in mammals and birds. So far, six human-transmitted coronaviruses have been discovered. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in December 2019 in Wuhan, China.

3. COVID-19

4. EPIDEMIOLOGY EPIDEMIOLOGY INDICATORS DESCRIPTION AGE Increased risk with 60+ age.Cases range from 2 to 72 years. Elderly with morbid conditions (Hypertension, diabetes, chronic kidney disease). SEX Males mostly affected MORTALITY High mortality from 60 to 80 years. Increased mortality in 60+ years of age. INCUBATION PERIOD Symptoms may appear from 2 to 14 days after exposure.

5. PATHOPHYSIOLOGY The S glycoprotein of the newly discovered SARS-CoV-2 is composed of two subunits, S1 and S2, and is commonly represented as a sword-like spike. Angiotensin-converting enzyme 2 (ACE2) receptors in mammalian lung cells act as recipients of the S-spike protein, releasing endogenous viral RNA genetic material into host cells. One of the crucial functions of angiotensin-converting enzymes (ACE2) is to regulate the renin–angiotensin system (RAS). In general, the angiotensin-converting enzyme 2 (ACE2) acts as a cell surface receptor and causes SARS-CoV-2 to enter host cells and plasma and is expressed in organs such as the lungs, kidneys, and heart. Moreover, one of the reasons for the development of COVID-19 is the disturbance of the ACE/ACE2 balance and the activation of RAAS by SARS-CoV-2, especially in patients with underlying cardiovascular disease problems, hypertension, and diabetes.

6. ACE2 expression in alveolar epithelial cells types 1 and 2 in the human lung is much higher than elsewhere in the body.According to research, the level of ACE2 expressions in men is much higher than in women in alveolar cells. Moreover, in their alveolar cells, ACE2 expression levels in Asians are much higher than in whites and African-Americans. It is stated that Increasing ACE2 expression due to SARS-CoV-2 virus binding via spike protein could lead to alveolar cell damage and followed by systemic reactions and even death.

7. CYTOKINE STORM 1)Infection of lung cells by COVID-19. 2)Cytokine production through virus detection by immune cells (macrophages). 3)Creating a cycle of inflammation in lung cells by further uptake of immune cells (white blood cells) through the cytokine phenomenon. 4)Fibrin formation and further damage. 5)Filling of the lung cavities due to the infiltration of fluids into the weak blood vessels, followed by respiratory damage.

8. CLINICAL FEATURES Symptoms of COVID-19 disease vary from patient to patient. Sometimes it may be asymptomatic. Typically, in the early stages of COVID-19 infection, the most common infection symptoms can be fever, dry cough, and tiredness. Less common symptoms are nausea or vomiting, muscle or joint pain, sore throat, loss of sense of smell or taste or both, nasal congestion, conjunctivitis, headache, different types of skin rashes, diarrhea, shivering, and dizziness. In the disease’s progression stages, the patient will face severe shortness of breath, decdecreased blood oxygen (hypoxia), destruction of the lungs,and several organs dysfunction. More severe and rare neurological complications such as stroke, encephalitis, delirium, and nerve damage are other complications of COVID-19.

9. SYMPTOMS Cough Fever Shortness Of Breath Sore Throat MOST COMMON SYMPTOMS LESS COMMON SYMPTOMS SEVERE SYMPTOMS •DRY COUGH •FEVER •TIREDENESS •GASTROINTESTINAL PROBLEMS •NAUSEA & DIARRHEA •SORE THROAT •HEART ATTACK •SHORTNESS OF BREATH •CEREBRAL HEMORRHAGE

10. COVID-19 MODES OF TRANSMISSION

11. C lose contact and respiratory droplets are one of the main ways of transmission. Therefore, the relevant experts strongly advised maintaining social distance and using a mask. Touching the face’s T-zone after contact with contaminated surfaces is also a mode of transmission that emphasizes the need for hand hygiene and handwashing. Other routes of transmission are through contaminated surfaces as well as airborne, fecal-oral transmission. MODES OF TRANSMISSION

12. PREVENTION Social Distancing 2 m Indoors: prevent close contact with sick people and maintain a distance of 6 feet Outdoors: Maintain a 6-foot distance between yourself and people.

13. PREVENTION FACE MASK Prevent the high prevalence and infection of the virus by masks.Due to the transmission of COVID-19 disease to others even if there are no symptoms.The necessity of wearing masks in public areas and around people in society due to the difficulty of observing social distancing. 2 m SOCIAL DISTANCING Maintain distance of 6ft(2m). CLEAN & DISINFECT Do NOT touch contaminated surfaces AND regularly clean, and disinfect surfaces that are frequently touched, such as telephones, keyboards, light switches, handles, faucets, sinks, toilets, tables, door buttons, and countertops. HAND SANITIZER Washing hands for at least 60 s with soap and water.Before and after touching face.When leave a public place.After coughing, blowing your nose, and sneezing

14. DIAGNOSIS 1. RT-PCR METHOD One of the most important ways to detect the SARS-CoV-2 virus in upper and lower respiratory specimens is the Real-Time Reverse Transcriptase (RT)–PCR Diagnostic Panel. The basis of the PCR is copying the RNA and DNA structure of the sample, which can diagnose infectious origin and various genetic and blood diseases.

15. Position the patient in a comfortable position. 3.3.3 Tilt the patient’s head back at a 70-degree angle. Rotate the swab gently through 180 degrees to make sure adequate specimen is obtained. Leave the swab in place for 2-3 seconds to ensure absorbance of secretions. NASOPHARYNGEAL SWAB <15 min OROPHARYNGEAL SWAB Press the outer two-thirds of the tongue down with a tongue depressor, making the tonsils and the posterior wall of the throat visible. 3.4.3 Insert swab, avoiding touching the teeth, tongue, or the depressor. 3.4.4 Rub the swab over both tonsillar pillars and posterior oropharynx. This will cause the patient to gag briefl

16. 2 . CT SCAN Computed tomography (CT) is a suitable diagnostic method that sheds light on several stages of disease diagnosis and development.CT imaging can help to reveal the abnormalities caused by COVID-19. In about 85% of patients with superimposed irregular lines and interfaces, Chest CT in COVID-19 pneumonia cases shows bilateral, peripheral, and basal predominant ground glass opacities (GGOs) and/or consolidation . CT SCAN FOR COVID POSTIVE(TOP) AND FOR NON-COVID(BOTTOM)

17. CLINICAL MANAGEMENT & TREATMENT

18. Supportive care The mainstay of management for COVID-19 is oxygen therapy via nasal cannula or face mask. If available high flow oxygen can also be used to maintain saturation. All patients with low saturations should be placed in the prone position. For those not intubated, voluntary awake prone positioning should be encouraged for as long as the patient can manage. For patients on the ventilator, 12 to 15 hours of prone positioning should be attempted. Specific Therapy Steroids All patients requiring oxygen should be started on steroids. The steroids recommended include dexamethasone or methylprednisone. The choice of steroid used is at the discretion of the clinician. However, dexamethasone is cheaper, easier to use in the outpatient setting and has more potent glucocorticoid (anti-inflammatory) activity). On the other hand, methylprednisonemay be superior in patients in shock due to its mineralocorticoid activity. In patients with severe and critical disease, intravenous steroids are preferred. Treatment should continue for 5 days. However, this may be prolonged in case of prolonged hypoxia.Dose: 6mg per day of dexamethasone (oral or intravenous) 0.5 to 1 mg/kg/d of methylprednisone

19. Anticoagulation As patients with COVID-19 may be hypercoagulable, anticoagulation plays an important role in therapy. For all doses mentioned below, adjustment will be required in case of renal impairment or morbid obesity (BMI ≥ 40kg/m2 )If the patient was already on oral anticoagulation for another indication (such as atrial fibrillation): • In moderate disease: Continue same • In severe/critical: Consider switching to parenteral therapy If the patient was not on anticoagulation at the time of admission • In moderate disease: Start standard DVT prophylaxis (enoxaparin 40 mg once daily once daily) • If severe disease: Start aggressive prophylaxis (enoxaparin 40 mg every 12 hourly) Indications for therapeutic anticoagulation (any of the following): • Documented presence of thromboembolic disease (such as ultrasound doppler or CT for PE) • Strong suspicion for thromboembolic disease when investigation cannot be done • D-Dimers over 3 times upper limit normal

20. Remdesivir Indication : Moderate and severe COVID requiring oxygen therapy regardless of if CRS(CYTOKINE Release Syndrome) is present. This can also be given in critical COVID, however, with the available data, it is unlikely to be of benefit in this patient population. Dose : 200 mg IV on day 1 followed by then 100 mg IV daily on days 2-5 Tocilizumab Reserved for patients in whom worsening occurs despite steroids or those who present as severe/critical disease in CRS. As tocilizumab greatly increases the risk of secondary infection, only use in cases of confirmed CRS Dose : 4 to 8 mg/kg iv. Not over 800mg (maximum). Can repeat in 12 hours once only Contraindications : Active TB Zoster Sepsis and positive blood culture Suspected GI perforation Multiple Sclerosis Allergy to Tocilizumab ALT > 5 times or Bilirubin > 2 ANC <2000 or Thrombocytopenia <50 Pregnancy (relative contraindication)

21. ANTIBIOTICS Antibiotics should only be used in cases where a bacterial infection is suspected, for example in cases with an elevated white cell count (in the absence of steroid) or procalcitonin. There is no role of prophylactic antibiotics to prevent a secondary infection. VACCINE A vaccine is a biological product that produces an acquired active immunity against a specific microbial disease. Vaccines are very vital to save the lives of millions of people every year. The primary function of vaccines is to train and prepare the immune system to identify and fight the target viruses and bacteria.

22. EFFECTS OF COVID IN PREGNANCY Due to the complications of COVID-19, pregnant women are expected to be at risk of developing severe COVID-19 compared to non-pregnant women. It should be noted that the easy spread of viral respiratory diseases, such as influenza, during pregnancy indicates that pregnant women are more vulnerable to COVID-19 and require more medical care. Generally, mechanical and physiological changes in pregnancy gained susceptibility to COVID-19, significantly when it affects cardiorespiratory and gravida, and it increases the rate of progression in respiratory failure. Due to physiological changes in the immune and cardiopulmonary system in pregnant women (e.g., improved diaphragm, increased oxygen consumption and respiratory mucosal oedema), they are very susceptible to respiratory pathogens severe pneumonia.Additionally, pregnant people with COVID-19 might be at increased risk of adverse pregnancy outcomes, such as preterm births. A wide range of vaccines is routinely and safely administered during pregnancy. As mentioned in the vaccine section, Pfizer-BioNTech vaccines are an effective vaccine against COVID-19.

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