HOW CORONAVIRUS PRESENTS CLINICALLY . . . NOTES FROM THE 2020 INFECTIOUS DISEASE ASSOCIATION OF CALIFORNIA MEETING

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

I’m forwarding this important healthcare news about the most common presentation of coronavirus. It was obtained from a colleague who took notes from a meeting of the Infectious Disease Association of California dated March 7, 2020:

1. The most common presentation of COVID-19 was a one week prodrome of myaglias (muscle pain), malaise, cough, and low grade fevers gradually leading to more severe trouble breathing in the second week of illness. It is an average of 8 days to development of shortness of breath and average 9 days to onset of pneumonia/pneumonitis. This is not like influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (a low level of lymphocytes). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates on chest X-ray. Aside from that, the other markers (c-reactive protein, procalcitonin) were not as consistent.

2. Co-infection rate with other respiratory viruses like influenza or respiratory syncytial virus (RSV) is <=2%, interpret that to mean if you have a positive test for another respiratory virus, then you do not test for COVID-19. This is based on large dataset from China.

3. So far, there have been very few concurrent or subsequent bacterial infections, unlike influenza where secondary bacterial infections are common and a large source of additional morbidity and mortality.

4. Patients with underlying cardiopulmonary disease seem to progress with variable rates to Acute Respiratory Distress Syndrome (ARDS) and acute respiratory failure requiring Bilevel Positive Airway Pressure (BiPAP) then intubation. There may be a component of cardiomyopathy from direct viral infection as well. Intubation is considered “source control” equal to patient wearing a mask, greatly diminishing transmission risk. BiPAP is the opposite, and is an aerosol generating procedure and would require all going into the room to wear Powered Air-Purifying Respirators (PAPRs).

5. To date, patients with severe disease are most all (excepting those whose families didn’t sign consent) getting Remdesivir from Gilead through compassionate use. However, the expectation is that avenue for getting the drug will likely close shortly. It will be expected that patients would have to enroll in either Gilead’s randomized controlled trial (RCT) . . . (5 vs 10 days of Remdesivir) or the NIH’s “Adaptive” RCT (Remdesivir vs. placebo). Others have tried Kaletra, but didn’t seem to be much benefit.

6. If our local lab ran out of test kits we could use Quest labs to test. Their test is 24-48 hour turn-around-time. Both Quest and ordering physician would be required to notify Public Health immediately with any positive results. Ordering physician would be responsible for coordinating with the Health Department regarding isolation. Presumably, this would only affect inpatients though since we have decided not to collect specimens ordered by outpatient physicians.

7. At facilities that had significant numbers of exposed healthcare workers they did allow those with low and moderate risk exposures to return to work well before 14 days. Only healthcare workers (HCWs) with highest risk exposures were excluded for almost the full 14 days. After return to work, all wore surgical masks while at work until the 14 days period expired. All had temperature check and interview with employee health prior to start of work, also only until the end of the 14 days. Obviously, only asymptomatic individuals were allowed back.

8. Symptom onset is between 2-9 days post-exposure with median of 5 days. This is from a very large Chinese cohort.

9. Patients can shed RNA from 1-4 weeks after symptom resolution, but it is unknown if the presence of RNA equals presence of infectious virus. For now, COVID-19 patients are “cleared” of isolation once they have 2 consecutive negative RNA tests collected >24 hours apart.

10. All suggested ramping up alternatives to face-to-face visits, telemedicine, “car visits,” and telephone consultation hotlines.

11. Sutter Health and other larger hospital systems are using a variety of alternative respiratory triage at the Emergency Departments.

12. Health Departments (e.g. California Department of Public Health) state the Airborne Infection Isolation Room (AIIR) is the least important of all the suggested measures to reduce exposure. Contact and droplet isolation in a regular room is likely to be just as effective. One heavily affected hospital in the San Jose, California area is placing all “undifferentiated pneumonia” patients not meeting criteria for COVID testing in contact+droplet isolation for 2-3 days while seeing how they respond to empiric treatment and awaiting additional results.

As an internal medicine doctor and anesthesiologist, I see the information above as remarkable for several reasons:

How quickly the symptoms progress in susceptible patients from malaise and cough to respiratory failure and intubation; how difficult it may be to staff adequate numbers of nurses, physicians, and respiratory therapists if the ICU case numbers grow because these healthcare workers will be both at risk and deserving of quarantine themselves; the risk that healthcare workers will stay home because of fear, thus depleting the staff of hospitals; and the paucity of specific medical information the Centers for Disease Control and Prevention (CDC) has has chosen to release either to the medical community or to the public to date.