MEDICINE CASE DISCUSSION - COVID CASES
Online blended bimonthly assignment toward summative assessment for May 2021
Name: Sreshta
Roll no: 48
May 31 2021
I have been given the following cases to solve in an attempt to understand the topic of 'Patient clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and come up with a treatment plan.
This is the link to the questions asked regarding the cases:
http://medicinedepartment.blogspot.com/2021/05/covid-case-report-logs-from-may-2021.html?m=1
Below are my answers to the Medicine Assignment based on my comprehension of the cases.
9-1. COVID 19 WITH COMORBIDITY (PULMONOLOGY/RHEUMATOLOGY)
Link to pt details:
https://nikhilasampathkumar.blogspot.com/2021/05/covid-pneumonia-in-pre-existing-case-of.html
1) How does the pre-existing ILD determine the prognosis of this patient?
- The pre-existing ILD significantly worsens the prognosis of this covid patient.
- Interstitial lung disease is characterized by dyspnea, decreased pulmonary diffusing capacity, decreased FVC and TLC. The SpO2 of these patients is usually decreased due to increased A-a gradient
- A superimposed covid-19 infection in these cases can cause an acute exacerbation of symptoms such as dyspnea, decreasing levels of SpO2 further and faster than in Covid-19 patients without interstitial lung disease.
- Radiology (HRCT) usually shows the development of new pulmonary opacities and fibrosis.
Patient factors:
- Since this patient already had a reduced SpO2 of 90-92% (compared to the normal range of >96%) she is more susceptible to worsening of hypoxia and dyspnea unless immediate ventilator support is provided
- The patient reportedly did not have dyspnea prior to the covid infection but developed a grade 2 SOB
- ILD by itself makes the patient much more susceptible to acquiring Covid-19 infection.
Prognosis: Poor
Source: https://ejrnm.springeropen.com/articles/10.1186/s43055-021-00431-2
2) Why was she prescribed clexane (enoxaparin)?
- The main pathogenesis of systemic inflammation caused by Covid-19 is by inducing a cytokine storm that causes epithelial cell necrosis, increased vascular permeability, dysfunctional humoral and CMI which all collectively lead to acute lung injury and ARDS
- Of these cytokines, IL-6 is one that is the most important in determining the prognosis. IL-6 levels are highly elevated in patients with severe disease
- Enoxaparin is said to relieve and prevent inflammation produced by IL-6 by inactivating it by binding it with its non-anticoagulant fraction, especially in pulmonary epithelial cells.
- Moreover, patients with Covid-19 are more susceptible to the development of venous thromboembolism, which can be prevented by Enoxaparin (LMWH).
9-2. COVID 19 WITH DIABETES
Link to pt details:
https://nehapradeep99.blogspot.com/2021/05/a-50-year-old-female-with-viral.html
Since patient didn't show any previous characteristic diabetes signs, did the Covid-19 infection aggravate any underlying condition and cause the indolent diabetes to express itself? If so what could be the biochemical pathways that make it plausible?
- The patient may have already had slight hyperglycemia, owing to high HbA1c levels (7.1%), which may have aggravated due to COVID-19. The possible biochemical pathways include: [6]
2) Did the patient's diabetic condition influence the progression of her pneumonia?
- Yes, with DM or hypergycemia in patients leads to an increase in COVID-19 severity. Also, poor glycaemic control predicts an increased need for medications and hospitalizations, and increased mortality.
- In monocytes: elevated glucose levels increase SARS-CoV-2 replication, and glycolysis sustains SARS-CoV-2 replication via the production of mitochondrial reactive oxygen species and activation of hypoxia-inducible factor 1α. Therefore, hyperglycaemia supports viral proliferation.
3) What is the role of D Dimer in the monitoring of covid? Does it change management or would be considered overtesting?
- D- Dimer levels indicate the severity of COVID-19, pertaining to possible thrombotic complications- as D Dimer is formed post- fibrinolysis.
- D- Dimer does change the management, as D-Dimer levels above 2000ng/dl were found to have a direct link with increasing severity of COVID-19 [7]. Moreover, D- dimer levels would be helpful in fast diagnosis and prevention of thrombotic complications.
9-3. COVID 19 SEVERE
Link to pt details:
https://143vibhahegde.blogspot.com/2021/05/covid-in-26-yo-female.html
1. Why was this patient given noradrenaline?
- Following kidney failure, the patient had sudden and persistent hypotension. To combat this, the patient was given noradrenaline, a potent vasoconstrictor.
2. What is the reason behind testing for LDH levels in this patient?
- LDH (Lactate Dehydrogenase) catalyzes the conversion of lactate to pyruvate and back. Hence, an increase in LDH denotes some form of tissue damage. In this patient, an increase in LDH levels would denote inflammation, and a high increase would denote Multi-Organ Failure.
3. What is the reason for switching from BiPAP to mechanical ventilation with intubation in this patient? What advantages did it provide?
- Although BiPaP is a positive pressure system, unlike tracheal intubation, it does not send the air to the trachea and depends on the patient's ability to respire. In this patient, as SpO2 levels were dropping to 30% despite BiPAP, a more invasive method was required to push the air directly into the lungs- hence intubation was preferred.
9-4. COVID 19 MILD
Link to pt details:
https://gsuhithagnaneswar.blogspot.com/2021/05/29-year-old-male-patient-with-viral.html?m=1
1. Is the elevated ESR due to covid related inflammation?
- Erythrocyte sedimentation rate (ESR) is a blood test. It measures how quickly erythrocytes, or red blood cells, separate from a blood sample that has been treated so the blood will not clot.
- The sustained high level of ESR possibly brings a negative effect on COVID-19 patients' prognosis
- However, the elevation in esr cannot be explained based on the present knowledge of Covid
2. What was the reason for this patient's admission with mild covid? What are the challenges in home isolation and the harms of hospitalization?
- after 14 days of isolation, he got tested again for COVID-19 which was positive. He then developed fever for 4 days, cough which was productive for 4 days and shortness of breath grade 3 for 2 days. He also had fatigue. He lost the sense of taste and smell. Since the patient has an SOB of grade 3. This poses a challenge for home isolation.
- Patients with COVID-19 had almost 19 times the risk for acute respiratory distress syndrome (ARDS) than did patients with influenza, (adjusted risk ratio [aRR] = 18.60; 95% confidence interval [CI] = 12.40–28.00), and more than twice the risk for myocarditis (2.56; 1.17–5.59), deep vein thrombosis (2.81; 2.04–3.87), pulmonary embolism (2.10; 1.53–2.89), intracranial hemorrhage (2.85; 1.35–6.03), acute hepatitis/liver failure (3.13; 1.92–5.10), bacteremia (2.46; 1.91–3.18), and pressure ulcers (2.65; 2.14–3.27). The risks for exacerbations of asthma (0.27; 0.16–0.44) and chronic obstructive pulmonary disease (COPD) (0.37; 0.32–0.42) were lower among patients with COVID-19 than among those with influenza. The percentage of COVID-19 patients who died while hospitalized (21.0%) was more than five times that of influenza patients (3.8%), and the duration of hospitalization was almost three times longer for COVID-19 patients.
9-5. COVID 19 NAD COMORBIDITIES (ALTERED SENSORIUM, AZOTEMIA, HYPOKALEMA)
Link to pt details:
https://anuragreddy72.blogspot.com/2021/05/case-discussion-on-hypokalemic-periodic.html
1) What was the reason for the coma in this patient?
- The patient has a spo2 of 20%. This might have lead to cerebral hypoxia thus leading to coma.
- Also, low blood potassium can make you short of breath, as it can cause the heart to beat abnormally. This means less blood is pumped from your heart to the rest of your body
- Thus low spo2 and thus coma
2) What were the competency gaps in hospital 1 Team to manage this intubated comatose patient that he had to be sent to hospital 2? Why and how did hospital 2 make a diagnosis of hypokalemic periodic paralysis? Was the coma related?
- Hospital 1 might not have correlated Severe weakness of 4 limbs with low values of potassium which hospital 2 has diagnosed.
- Yes, coma is related to Hypokalemia periodic paralysis as it might have caused cerebral hypoxia.
3) How may covid 19 cause coma?
- After cessation of sedatives, the described cases all showed a prolonged comatose state.
- unconsciousness after prolonged periods of mechanical ventilation in the ICU.
9-6. COVID 19 WITH ALTERED SENSORIUM
Link to pt details:
https://vijaykumarkasturi.blogspot.com/2021/05/65-years-old-male-with-viral-pneumonia.html
1. What was the cause of his altered sensorium?
Can be any of the following reasons
- An altered state is any mental state(s), induced by various physiological( increased hospital stay), psychological( mental depression due to isolation), or pharmacological manoeuvres or agents( drugs of COVID)
2. What was the cause of death in this patient?
- This patient is an elderly chronic alcoholic and smoker.
- This might have delayed his healing process thus causing death
- Also, he had elevation LFT and RFT values
9-7. COVID 19 MODERATE WITH ICU PSYCHOSIS
Link to pt details:
What is the grade of pneumonia in her?
- Based on the CT severity score it can be said that the patients pneumonia is moderate.
What is the ideal day to start steroids in a patient with mild elevated serum markers for COVID ?
- It is best to start the treatment with dexamethasone before the onset of cytokine storm.
-The following can lead to ICU psychosis
- Sensory deprivation
- Sleep deprivation
- Stress
- Continuous light levels
- Continuous monitoring
- Lack of orientation
- pain
- drug reactions
- Infections
- metabolic disorders
- Dehydration
- Pirecetam improves memory and causes cognitive enhancement and also improves mood.
- Resperidone acts by decreasing the dopaminergic and seritonergic pathways in the brain
What all are the other means to manage such a case of psychosis?
- The management of ICU psychosis primarily depends on the cause. If it is sleep deprivation then hte patient should be provided a peaceful place to take rest.
- If it is due to underlying conditions like heart failure and dehydration then these should first be corrected.
- Haloperidol is a medication commonly used to manage ICU psychosis. Other common anti-psychotics can also be used.
What all should the patient and their attendants be careful about ( w.r.t. COVID )after the patient is discharged ?
- The patient is supposed to self isolate after they are discharged for another 7 days after discharge. If possible oxygen levels are to be monitored as well for the next 7 days. The patients and the patient's attenders should be on the look out for danger symptoms such as trouble breathing, chest pain, bluish discolouration of lips, confusion or inability to wake up.
What are the chances that this patient may go into long covid given that her "D Dimer" didn't come down during discharge?
- Long COVID is the persistence of symptoms such as cough, breathlessnes, headaches and chest pain weeks to months after discharge. People suffering from long COVID usually have elevated biomarkers such as elevated d dimer and CRP. As this patient has elevated d dimer levels at discharge there is a good chance that she could suffer from long COVID.
9-8. COVID 19 MODERATE
link to pt details:
1. Can psoriasis be a risk factor for a severe form of COVID?
- Elderly psoriasis patients and/or patients using conventional immunosuppressive regimens and biologic agents are at higher risk for infectious diseases.
- But the frequency of COVID-19 does not increase in patients using immunosuppressants, including those receiving biological therapy with a diagnosis of psoriasis
2. Can the increased use of immunomodulatory therapies cause further complications in the survivors?
- According to the present knowledge on Covid, there is no indication that people taking immunomodulatory drugs for other diagnosed conditions should be concerned that their medication increases their risk for severe COVID-19,"
- patients of Covid with greater fibrotic changes required more prolonged mechanical ventilation, and this, in turn, was associated with increased severity of systemic organ failure.
- Hence Mechanical ventilation is a risk factor.
9-9. COVID WITH DE NOVO DIABETES
Link to pt details:
Q1. What is the type of DM the patient has developed ?(is it the incidental finding of type 2 DM or virus induced type 1DM)?
- Incidental type 2 DM can be differentiated from de novo covid induced type 1 DM with the help of the HbAc1 levels.
- As HbAc1 levels are indicators of long term blood ssugar levels they are likely to be raised in pre existing DM that was incidentally discovered. But in case ofthe diabetes being de novo in nature then the HbAc1 levels are unlikely to be raised. As the patients HbAc1 levels are not raised we can not at this point determine if the patient has incedental discovered type 2 DM or Covid induced de novo DM.
Q2. Could it be steroid induced Diabetes in this patient?
- As the patient was given dexamethasone as a part of her treatment regimen it is possible that her elevated glucose levels are a result of steroid induced hyperglycemia.
9-10. COMPARINGTWO COVID PATIENTS WITH VARIABLE RECOVERY
Link to pt details:
Q1. What are the known factors driving early recovery in covid?
A. The following factors can play a role:
- Younger age ggroup
- shorter duration of fever
- No diabetes
- PaO2/FiO2 levels
- No comorbidities
9-11. COVID MODERATE WITH FIRST TIME DETECTED DIABETES
Link to pt details: https://rishithareddy30.blogspot.com/2021/05/covid-case-report.html
1) How is the diabetes related to the prognosis of COVID patients? What are the factors precipitating diabetes in a patient developing both covid as well as Diabetes for the first time?
- Hypertension and severe obesity are common comorbidities in patients with diabetes. It is unclear whether diabetes alone contributes to increased risk of morbidity and mortality related to COVID-19. have indicated that poorer glycemic control is associated with poorer outcomes in people with diabetes.
mechanisms that may increase the ability of COVID-19 to impact patients with diabetes:
- higher affinity cellular binding and efficient virus entry; decreased viral clearance; diminished T-cell function; increased susceptibility to hyperinflammation and cytokine storm; and the presence of cardiovascular disease
- pathogenetic link between diabetes and COVID-19. Both disease conditions involve inflammation with the release of inflammatory markers. The roles of angiotensin-converting enzyme molecule and dipeptidyl peptidase were explored to show their involvement in COVID-19 and diabetes. Pathogenetic mechanisms such as impaired immunity, microangiopathy, and glycemic variability may explain the effect of diabetes on recovery of COVID-19 patients. The effect of glucocorticoids and catecholamines, invasion of the pancreatic islet cells, drugs used in the treatment of COVID-19, and the lockdown policy may impact negatively on glycemic control of diabetic patients.
- Patients with diabetes mellitus have increased predisposition to viral and bacterial infections including those affecting the respiratory tract
- One of the mechanisms responsible for this predisposition is the “lazy” leukocyte syndrome, which represents impaired leukocyte function of phagocytosis (impaired immunity). This further emphasizes the likelihood of increased propensity of SARS-CoV-2 infections in diabetic cohorts
- Microangiopathy in diabetes mellitus also impairs lung compliance with consequent affectation of the gaseous exchange. This impairment may result in the proliferation of some respiratory pathogens including SARS-CoV-2
- There are respiratory changes in diabetic patients that affect lung volumes and pulmonary diffusing capacity
- Glycemic variability is a prognostic factor in diabetic patients with COVID-19 infection. Hyperglycemia worsens the outcome by the process of cytokine storm, endothelial dysfunction, and multiple organ injuries
- In the lungs, the primary target of COVID-19, hyperglycemia leads to a rapid deterioration in spirometric functions, especially decreased forced expiratory volume in 1 second and forced vital capacity.
- hyperglycemic states, there is elevated glucose concentration in the respiratory epithelium which may affect its innate immune capacity. Hypoglycemia also increases cardiovascular mortality by accentuating monocytes which are pro-inflammatory and enhancing platelet aggregation
- Severe hypoglycemia which may occur with strict glycemic control may worsen the overall mortality rate
- suboptimal glycemic control in COVID-19 patients is correlated with higher mortality rate
Effect of COVID-19 on Diabetes:
- COVID-19 infection compounds the stress of diabetes mellitus by releasing glucocorticoids and catecholamines into circulation. These worsen glycemic control and increase the formation of glycation end products in many organs and worsen prognosis
- The degree of inflammatory response to COVID-19 is more marked in diabetic patients than in nondiabetic cohorts
- showed that type 2 diabetic group had higher levels of inflammatory markers such as C-reactive protein and procalcitonin (57.0 and 33.3%) than the nondiabetic group (42.4 and 20.3%), respectively. Elevated C-reactive protein may serve as a marker for identifying those with high risk of death from COVID-19
- D-dimer which is a marker of coagulation status was also elevated in the diabetic group compared to the nondiabetic group
- The levels of these inflammatory markers have been correlated with the severity of COVID-19 infection.
2) Why couldn't the treating team start her on oral hypoglycemics earlier?
- To control the high range diabetes she is on insulin’s injections which have faster and effective action to control diabetes than oral hypoglycaemic drugs.
- Insulin exhibits inhibitory action on ADAM-17 [35]. ADAM-17 enhances the proteolytic shedding of the enzymatic active ecto-domain of ACE2. This may suggest that insulin increases the activity of ACE2 [35] and also increases the infectivity of SARS-CoV-2
- The beneficial effect of insulin may be related to its anti-inflammatory effect, which is by suppression of pro-inflammatory cytokines and increased immune mediators
- Insulin use has effective glycemic control.which benefits a better prognostic results.
9-12.MODERATE TO SEVERE COVID WITH PROLONGED HOSPITAL STAY
link to pt details:
1) What are the potential bio clinical markers in this patient that may have predicted the prolonged course of her illness?
-The potential biochemical markers in this patient are
-Elevated levels of
LFT- Total bilirubin : 1.24 mg/dl
- Direct bilirubin : 0.67 mg/dl
- SGOT : 73 units/ lit
- SGPT : 80 units/ lit
- ALP : 342 units/ lit
RFT Blood urea : 34 mg/dl
- Sodium : 150 meq/lit
- Potassium : 5.2 meq/lit
SERUM LDH 571 units/lit
FBS 332 mg /dl
9-13. SEVERE COVID WITH FIRST DIABETES
Link to pt details: https://vignatha45.blogspot.com/2021/05/58-years-female-patient-with-viral.html
What are the consequences of uncontrolled hyperglycemia in covid patients?
- Severe inflammatory changes in lungs in case of covid pneumonia.
- Delayed recovery of the patient .
- Since elevated blood sugar levels favors the virus growth and multiplication.
Does the significant rise in LDH suggests multiple organ failure?
- High LDH levels
- Extremely high levels of LDH could indicate severe disease or multiple organ failure. Because LDH is in so many tissues throughout the body, LDH levels alone won't be enough to determine the location and cause of tissue damage.
What is the cause of death in this case?
-Cause of death could be most probably due to:
- Severe covid pneumonia associated with uncontrolled hyperglycaemia
- Multiple organ failure
9-14. LONG COVIS WITH SLEEP DEPRIVATION AND ICU PSYCHOSIS
Link to pt details:
1)Which subtype of ICU psychosis did the patient land into according to his symptoms?
- Hyperactive delirium: Manifests as agitation, restlessness, refusal to cooperate with caregivers, unprovoked mood changes, hallucinations
2)What are the risk factors in the patient that has driven this case more towards ICU psychosis?
- Hypertension
- History of cerebrovascular accident (makes him more prone to a new one)
- Steroid use
- Sedative use (Gabapentin)
- COPD
- Sleep deprivation causing ICU psychosis
- ICU psychosis causing sleep deprivation
- ICU psychosis causing sleep deprivation is more likely in this patient
4) What are the drivers toward current persistent hypoxia and long covid in this patient?
- Elevated bio clinical markers like D-Dimer, LDH, Neutrophils, WBCs(absolute), IL-6, and CRP all contribute to persistent hypoxia and worsen the prognosis. In addition to this, ICU psychosis adds to the prolonged hospital stay.
9-15. MODERATE COVID WITH COMORBIDITY (TRUNCAL OBESITY AND RECENT HYPERGLYCEMIA)
Link to pt details:
1. As the patient is a non-diabetic, can the use of steroids cause a transient rise in blood glucose?
- Cortisol stimulates gluconeogenesis in the liver and inhibits glycogen synthesis, increasing blood glucose. Continuous treatment with corticosteroids can lead to elevated blood glucose titers even in non-diabetics.
2. If yes, can this transient rise lead to long-term complications of New-onset diabetes mellitus?
- It is still unclear if the alterations brought about by covid-19 in the glucose metabolism are permanent and persist or remit after the resolution of infection. There are ongoing studies that aim to answer these questions.
- Steroid diabetes is a term coined to describe diabetes mellitus arising as a result of glucocorticoid use for more than 50 years
3. How can this adversely affect the prognosis of the patient?
- Hyperglycemia in general is indicative of a poorer prognosis in a patient compared to covid patients with normal blood glucose levels.
- Oral hypoglycemics (such as sulfonylureas) are efficient at controlling blood glucose levels in non-diabetics who develop steroid-induced hyperglycemia. Most cases revert to normoglycemia after discontinuation of steroids.
- Fever in response to thrombophlebitis that is caused due to release of inflammatory mediators
- No, infusion thrombophlebitis is not grounds for discontinuation of infusions that are essential for the treatment of the case. Thrombophlebitis can be treated by local compressive dressings, NSAIDs (topical and/or systemic)
9-16. MILD TO MODERATE COVID WITH HYPERGLYCEMIA
Link to pt details:
1. What could be the possible factors implicated in elevated glycated HB ( HBA1c ) levels in a previously Non-Diabetic covid patient?
-The possible factors that could have led to precipitation of diabetes in a covid-19 patient are:
- Genetic susceptibility to diabetes
- Pre diabetic state
- Viral insult to the beta cells of the pancreas
- Stress hyperglycemia due to inflammation-induced insulin resistance
- High dose steroid usage
9-17. COVID 19 WITH HYPERTENSION COMORBIDITY
Link to pt details:
1)Does hypertension have any effect to do with the severity of the covid infection.If it is, Then how?
- Yes, hypertensive patients are at a higher risk of COVID 19 severity. It is already known that hypertension is assocatied with a weaker immune system and is seen in older patients which show bad prognosis when dealing with this infection. As there is a high risk of developing cardiovascular events as well as end organ failure.
2)what is the cause for pleural effusion to occur?
- Pneumonia caused due to COVID-19 infection lead to increase permeability of microvascular circulation which lead to pleural effusion(exudative type)
9-18.COVID 79 WITH MILD HYPOALBUMINEMIA
Link to pt details:
What is the reason for hypoalbuminemia in the patient?
- It may be due to pulmonary capillary leakage in the lungs, in response to epithelial endothelial damage due to covid infection.https://pubmed.ncbi.nlm.nih.gov/33411411/2.
- Yes, what the patient is experiencing is known as viral exanthem which is one of the cutaneous manifestations of COVID-19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549735/
What is the reason for Cardiomegaly?
- The most probable cause of that appearance is the AP view of the chest. When an anteroposterior view is taken, most times the CXR shows false cardiomegaly. To confirm the cardiomegaly a PA view of the chest must be taken.
- Another possible cause can be Direct Myocardial Cell Injury. The interaction of SARS-CoV-2 with ACE2 can cause changes to the ACE2 pathways, leading to acute injury of the lung, heart, and endothelial cells. A small number of case reports have indicated that SARS-CoV2 might directly infect the myocardium, causing viral myocarditis. However, in most cases, myocardial damage appeared to be caused by increased cardiometabolic demand associated with the systemic infection and ongoing hypoxia caused by severe pneumonia or ARDS. https://www.ncbi.nlm.nih.gov/books/NBK556152/
What other differential diagnoses could be drawn if the patient tested negative for covid infection?
Possible alternative diagnoses may include:
• Influenza
• Mycoplasma pneumonia
• Parainfluenza
• Respiratory syncytial virus
• Streptococcus pneumonia
• Other viral or bacterial pneumonia.
Why is there an elevated D-Dimer in covid infection? What other conditions show D-dimer elevation?
- It is well known that D-dimer is produced during fibrin breakdown and serve as a marker of fibrinolytic activity. A relationship between proinflammatory cytokines and markers of activation of the coagulation cascade, including D-dimer, has been demonstrated in critical patients or patients with sepsis. There is also evidence that under inflammatory conditions, the alveolar haemostatic balance is shifted towards a predominance of prothrombotic activity. In addition, pro-inflammatory cytokines may be involved in endothelial injury and may activate coagulation and inhibit fibrinolysis in patients with severe sepsis.
- D-dimer can be elevated such as in pregnancy, inflammation, malignancy, trauma, liver disease (decreased clearance), heart disease, sepsis or as a result of hemodialysis, CPR or recent surgery)
9-20. COVID 19 WITH FIRST TIME DIABETES
Link to pt details:
1)Can usage of steroids in diabetic Covid patients increases death rate because of the adverse effects of steroids???
- COVID-19 infection causes systemic inflammation and cytokine storm. In order to prevent these severe conditions steroids are used.
- A well-known adverse effect of steroid usage is the disruption in carbohydrate metabolism. It leads to hyperglycemia. When steroids are given to a diabetic COVID-19 patient utmost care must be taken. The patient should be shifted from oral anti diabetic drugs to s.c. insulin and blood sugars should be closely monitored. If possible, Tocilizumab should be used instead of steroids.
- Steroid usage in diabetic patient has shown a increase in death rate as it further decreases the immunity of the patient and make them prone to other opportunistic infections like mucormycosis leadth to inceased death rate.
2)Why many COVID patients are dying because of stroke though blood thinners are given prophylactically?
- In COVID-19 infection due to systemic inflammation and cytokine storm even when they are adequately managed, ae leading to damage of inner walls of small blood vessels of the brain. These blood vessels have very little or no collateral blood supply.
- Even though the patient is on blood thinners they cannot prevent this damage. When the blood viscocity becomes higher either due to dehydration or high LDL/cholesterol levels, these small blood vessels are blocked leading to stroke.
3)Does chronic alcoholism have effect on the out come of Covid infection?If yes,how?
- Yes, chronic alcoholism does worsen the prognosis of COVID-19 patient.
- One of the adverse effect of chronic alcoholism is its ill effect on innate as well as adaptive immunity.
- Reduced resistance to COVID-19 promotes progression of disease and leading to wrose prognosis
9-21. SEVERE COVID WITH DIABETES
Link to pt details:
1. What can be the causes of early progression and aggressive disease(Covid) among diabetics when compared to non diabetics?
- It is observed that there is a early as well as aggressive progression of COVID 19 in diabetics. This is attributed to interactions of several risk factors as well as hyperglycemia which is seen in diabetic patients. It modulates immune response as well as inflammatory responses thus predisposing individuals to lethal course of the disease.
2. In a patient with diabetes and steroid use what treatment regimen would improve the chances of recovery?
- Methylprednisolone from 40 mg/day to 160 mg/day for 6 days according to the weight and status of the patients. During this course of treatment, blood sugar should be closely monitored and patient should be shifted from oral anti diabetic drugs to insulin.
3.What effect does a history of CVA have on COVID prognosis?
- It is established that COVID-19 is associated with coagulopathy. In a patient who has a history of CVA are mostly old and have other co-morbidities which leads to severe course of the disease as well as poor prognosis.
9-23. COVID 19 WITH MULTIPLE COMORBIDITIES
Lik to pt details:
1)What do you think are the factors in this patient that are contributing to his increased severity of symptoms and infection?
- Old age
- Diabetes mellitus type 2
- Chronic kidney disease
- Bronchial asthama
2)Can you explain why the D dimer levels are increasing in this patient?
- It may be related to the viral life cycle. The apoptotic processes target the endothelial cells of the vasculature resulting in triggered coagulopathy and ultimately result in increased d-dimer levels
3)What were the treatment options taken up with falling oxygen saturation?
- Head elevation
- O2 supplementation
4)Can you think of an appropriate explanation as to why the patient has developed CKD, 2 years ago? (Note: Despite being on anti diabetic medication, there was no regular monitoring of blood sugar levels and hence no way to know for sure if it was being controlled or not)
- During the early stage diabetes, there is a increase in blood flow to the kidneys, which strains the glomeruli and lessenstheir ability to filter blood. High levels of glucose in the blood leads to accumulation of extra material in glomeruli. It increases the stress of glomeruli inturn leading to gradual and progressive scarring. Eventually leads to the development of CKD.
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