ChesterCountyMedicineSpring2020 - 9

www.CHESTERCMS.org

month. Unrestrained by social isolation, the spread can be quick
and widespread.
As of May 1st, 2020, there have been greater than 3 million
cases of COVID-19 documented around the world up to this
point, and infection severity ranges from mild to severe. In a
report from the Chinese CDC that included about 44,500
cases: 81% were mild (no or mild pneumonia), 14% were severe
(with dyspnea, hypoxia or >50% lung involvement on imaging),
5% were critical (with respiratory failure, shock, or multiorgan
dysfunction), 2.3% were fatal. As you can see, mortality rate is
2-20%, so the majority of patients recover but some have rare
complications that can be life threatening. As of May 18, 2020
there has been almost 5 million cases. There have been over
300,000 fatal cases worldwide, and the U.S.A. alone has suffered
almost 100,000 deaths.
Severe illness can occur in any population, but the US Centers
for Disease Control and Prevention (CDC) has identified those
at higher risk for severe illness. Those comorbidities include:
hypertension, diabetes mellitus, chronic kidney disease, cancer,
obesity, chronic lung disease, liver disease, immunocompromising
conditions, and cardiovascular disease.
Complications are believed to be caused by cytokine release
syndrome or cytokine storm. This is when an infection triggers
the immune system to flood bloodstream with inflammatory
proteins, called cytokines. They can kill tissues and damage organs,
including: lungs, heart, and kidneys. Because of this storm,
Antileukine 6 inhibitors, like rheumatologic drugs (Sarilumab and
Remedesivir), have been tried as treatment. However, the jury is
still out on their success. In its mildest form, dry cough, low grade
fever, diarrhea, and chills are presenting symptoms (pictured at
right in Figure 3). Main complications are:
1. Respiratory Failure, which is the main cause of death,
especially in data from China. Damage to pulmonary alveoli
result in both reduced oxygen and accumulation of carbon
dioxide leading to severe pulmonary disease.
2. Pneumonia is a secondary manifestation that can result in
septic shock.
3. Acute Respiratory Distress Syndrome (ARDS) is another
possible major complication.
4. Acute Liver Injury can occur and will result in a rise in liver
enzymes.
5. Acute Kidney Failure, although not as common, may occur
and lead to chronic kidney disease, which potentially could 	
cause patients to require dialysis depending on severity.
6. Disseminated Intravascular Congestion (DIC) is currently
being seen, especially in New York cases, and can result in
organ failure and bleeding.
7. Rhabdomyolysis and muscle breakdown with tissue death
has also been observed in rare cases.

Figure 3: Coronavirus: The Facts.
Although respiratory illness is the most common clinical
manifestation of COVID-19, cardiovascular complications can
occur in about one fifth of cases. When they occur, prognosis can
be very poor. In one study there was almost 50% fatality, so we are
going to discuss cardiovascular complications more thoroughly.
Acute cardiac injury, defined as significant elevation of cardiac
troponins, is the most common cardiac abnormality seen in
COVID-19. It occurs in approximately 8-21% of all patients
through the mechanism of direct myocardial injury due to
viral involvement of cardiomyocytes and the effect of systemic
inflammation. The presence of pre-existing cardiovascular disease
and/or development of acute cardiac injury are associated with
significantly worse outcomes in COVID-19 patients.
Recent studies from Wuhan cohorts provide valuable
information about COVID-19. A cohort with 52 critically
ill patients revealed cardiac injury in 12% of patients. Worse
outcomes appear to be more prevalent in patients with
hypertension and diabetes mellitus (DM), possibly due to
overexpression of angiotensin-converting enzyme 2 (ACE2)
receptor in airway alveolar epithelial cells. Investigators suspect
that SARS-CoV-2 uses the ACE2 receptor to enter the lungs
in a mechanism similar to SARS-CoV. Several hypotheses have
been proposed to date regarding the net effect of ACEI/ARB on
COVID-19 infections. Positive effects include ACE2 receptor
blockade, disabling viral entry into the heart and lungs, and
an overall decrease in inflammation secondary to ACEI/ARB.
Negative effects include a possible retrograde feedback mechanism,
continued on next page >
SPRING 2020 | CHESTER COUNT Y Medicine 9
http://www.chestercms.org
ChesterCountyMedicineSpring2020

Table of Contents for the Digital Edition of ChesterCountyMedicineSpring2020
