Novel coronavirus-19

Novel COVID-19
Dr.Amit Goyal
Government Medical College
Amritsar

Introduction
• Coronaviruses are important human and animal pathogens.
• At the end of 2019, a novel coronavirus was identified as the
cause of a cluster of pneumonia cases in Wuhan, a city in the
Hubei Province of China.
• It rapidly spread, resulting in an epidemic throughout China,
followed by an increasing number of cases in other countries
throughout the world.
• In February 2020, the World Health Organization designated
the disease COVID-19, which stands for coronavirus disease
2019 .
• The virus that causes COVID-19 is designated severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2); previously,
it was referred to as 2019-nCoV.

• Full-genome sequencing and phylogenic analysis indicated
that the coronavirus that causes COVID-19 is a
betacoronavirus in the same subgenus as the severe acute
respiratory syndrome (SARS) virus (as well as several bat
coronaviruses), but in a different clade
• the virus has been shown to use the same receptor as sars,
the angiotensin-converting enzyme 2 (ACE2), for cell entry
• The Middle East respiratory syndrome (MERS) virus,
another betacoronavirus, appears more distantly related.
The closest RNA sequence similarity is to two bat
coronaviruses, and it appears likely that bats are the
primary source; whether COVID-19 virus is transmitted
directly from bats or through some other mechanism (eg,
through an intermediate host) is unknown

• Transmission — Understanding of the transmission risk
is incomplete. Epidemiologic investigation in Wuhan at
the beginning of the outbreak identified an initial
association with a seafood market that sold live
animals, where most patients had worked or visited
and which was subsequently closed for disinfection .
However, as the outbreak progressed, person-to-
person spread became the main mode of transmission.
• Person-to-person spread of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) is thought to
occur mainly via respiratory droplet

• Incubation period — The incubation period for
COVID-19 is thought to be within 14 days
following exposure, with most cases occurring
approximately four to five days after exposure.
• The median incubation period was four days.
• Individuals of any age can acquire severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2)
infection, although adults of middle age and
older are most commonly affected.

Clinical Feature
• Initial presentation — Pneumonia appears to be the most frequent serious
manifestation of infection, characterized primarily by fever, cough, dyspnea, and
bilateral infiltrates on chest imaging . There are no specific clinical features that
can yet reliably distinguish COVID-19 from other viral respiratory infections.
• The most common clinical features at the onset of illness were:
• ●Fever
• ●Fatigue
• ●Dry cough
• ●Anorexia
• ●Myalgias
• ●Dyspnea
• ●Sputum production
• Other, less common symptoms have included headache, sore throat, and
rhinorrhea. In addition to respiratory symptoms, gastrointestinal symptoms (eg,
nausea and diarrhea)

• Spectrum of illness severity — The spectrum of symptomatic
infection ranges from mild to critical; most infections are not
severe. Specifically, in a report from the Chinese Center for Disease
Control and Prevention that included approximately 44,500
confirmed infections with an estimation of disease severity:
• ●Mild (no or mild pneumonia) was reported in 81 percent.
• ●Severe disease (eg, with dyspnea, hypoxia, or >50 percent lung
involvement on imaging within 24 to 48 hours) was reported in 14
percent.
• ●Critical disease (eg, with respiratory failure, shock, or multiorgan
dysfunction) was reported in 5 percent.
• ●The overall case fatality rate was 2.3 percent; no deaths were
reported amon

Complication
• Acute respiratory distress syndrome (ARDS) is
a major complication in patients with severe
disease.
• Other complications have included
arrhythmias, acute cardiac injury, and shock.
• According to the WHO, recovery time appears
to be around two weeks for mild infections
and three to six weeks for severe disease.

Diagnosis
• Laboratory findings — In patients with COVID-19, the white blood
cell count can vary. Leukopenia, leukocytosis, and lymphopenia
have been reported, although lymphopenia appears most common.
• Elevated lactate dehydrogenase and ferritin levels are common
• Elevated aminotransferase levels have also been described. On
admission, many patients with pneumonia have normal serum
procalcitonin levels; however, in those requiring intensive care unit
(ICU) care, they are more likely to be elevated.
• High D-dimer levels and more severe lymphopenia have been
associated with mortality.

Imaging Studies
• CXR: Hazy bilateral, peripheral opacities.
• CECT Chest: Chest CT may be helpful in making the
diagnosis, in patients with COVID-19 most commonly
demonstrates ground-glass opacification with or without
consolidative abnormalities, consistent with viral
pneumonia.
• Less common findings include pleural thickening, pleural
effusion, and lymphadenopathy.
• Lung USG-It shows -B lines,
• -Irregular,Thickenend Pleural lines
• -Sonographic Findings of Lung
Consolidation

Chest X-ray shows multifocal patchy
peripheral
consolidations in bilateral lungs
CECT Chest shows Bilateral Ground glass Opacities

Evaluation
• Clinical suspicion and criteria for testing — The approach to initial
management should focus on early recognition of suspect cases,
immediate isolation, and institution of infection control measures.
• At present, the possibility of COVID-19 should be considered primarily in
patients with fever and/or respiratory tract symptoms (eg, cough,
dyspnea) who have had any of the following in the prior 14 days:
●Close contact with a confirmed or suspected case of COVID-19, including
through work in health care settings. Close contact includes being within
approximately six feet (about two meters) of a patient for a prolonged
period of time while not wearing personal protective equipment or having
direct contact with infectious secretions while not wearing personal
protective equipment.
●Residence in or travel to areas where widespread community transmission
has been reported (eg, China, South Korea, most of Europe [including
Italy], Iran, Japan).
●Potential exposure through attendance at events or spending time in
specific settings where COVID-19 cases have been report

• Laboratory testing — Patients who meet the criteria for suspect cases, as discussed
above, should undergo testing for SARS-CoV-2 (the virus that causes COVID-19.
• CDC recommends collection of a nasopharyngeal swab specimen to test for SARS-
CoV-2 . An oropharyngeal swab can be collected but is not essential; if collected, it
should be placed in the same container as the nasopharyngeal specimen.
• Sputum should only be collected from patients with productive cough; induction of
sputum is not indicated.
• SARS-CoV-2 RNA is detected by reverse-transcription polymerase chain reaction (RT-
PCR).A positive test for SARS-CoV-2 confirms the diagnosis of COVID-19.
• If initial testing is negative but the suspicion for COVID-19 remains, the WHO
recommends resampling and testing from multiple respiratory tract sites .
• Negative RT-PCR tests on oropharyngeal swabs despite CT findings suggestive of
viral pneumonia have been reported in some patients who ultimately tested positive
for SARS-CoV-2.

Management
• Site of care
• Home care — Home management is
appropriate for patients with mild infection
who can be adequately isolated in the
outpatient setting. Management of such
patients should focus on prevention of
transmission to others, and monitoring for
clinical deterioration, which should prompt
hospitalization.

• Hospital care —
• Patients with severe disease often need
oxygenation support.
• High-flow oxygen and noninvasive positive
pressure ventilation have been used, but the
safety of these measures is uncertain, and
they should be considered aerosol-generating
procedures that warrant specific isolation
precautions.

• Role of glucocorticoids — Glucocorticoids have limited
role in management of COVID-19.The WHO and CDC
recommend glucocorticoids not be used in patients
with COVID-19 pneumonia unless there are other
indications (eg, exacerbation of chronic obstructive
pulmonary disease).
• Glucocorticoids have been associated with an
increased risk for mortality in patients with influenza
and delayed viral clearance in patients with Middle East
respiratory syndrome coronavirus (MERS-CoV)
infection.

• Investigational agents — A number of investigational agents are being
explored for antiviral treatment of COVID-19,
• ●Remdesivir –Remdesivir is a novel nucleotide analogue that has activity
against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in
vitro and related coronaviruses (including SARS and MERS-CoV) both in
vitro and in animal studies . Several randomized trials are underway to
evaluate the efficacy of remdesivir for moderate or severe COVID-19 .
• ●Chloroquine/hydroxychloroquine – Both chloroquine and
hydroxychloroquine inhibit SARS-CoV-2 , although hydroxychloroquine
appears to have more potent antiviral activity .
• ●Lopinavir-ritonavir – This combined protease inhibitor, which has
primarily been used for HIV infection, has in vitro activity against the
SARS-CoV . and appears to have some activity against MERS-CoV in animal
studies
• ●Tocilizumab – Treatment guidelines from China's National Health
Commission include the IL-6 inhibitor tocilizumab for patients with severe
COVID-19 and elevated IL-6 levels; the agent is be

Prevention
• Infection control to limit transmission is an essential
component of care in patients with suspected or
documented COVID-19.
• Individuals with suspected infection in the community
should be advised to wear a medical mask to contain
their respiratory secretions prior to seeking medical
attention.
• The WHO recommends standard, contact, and droplet
precautions (ie, gown, gloves, and mask), with eye or
face protection. The addition of airborne precautions
(ie, respirator) is warranted during aerosol-generating
procedures (as detailed below).

• Preventing exposure in the community — The following general
measures are recommended to reduce transmission of infection:
●Diligent hand washing, particularly after touching surfaces in
public. Use of hand sanitizer that contains at least 60 percent
alcohol is a reasonable alternative if the hands are not visibly dirty.
• ●Respiratory hygiene (eg, covering the cough or sneeze).
• ●Avoiding touching the face (in particular eyes, nose, and mouth).
• ●Avoiding crowds (particularly in poorly ventilated spaces) if
possible and avoiding close contact with ill individuals.
• ●Cleaning and disinfecting objects and surfaces that are frequently
touched.

Prognosis
• Age and Comorbidities(DM,COPD,CVD) are
signficant predictors of poor clinical
outcome,admission SOFA score also predicts
mortality.
• Lab Findings also predict mortality:
Increase d-Dimer
Increase Ferritin
Troponin
Cardiac Myoglobin

Special Situation
• Pregnant women — Minimal information is available regarding COVID-19
during pregnancy. Intrauterine or perinatal transmission has not been
identified .
• In two reports including a total of 18 pregnant women with suspected or
confirmed COVID-19 pneumonia, there was no laboratory evidence of
transmission of the virus to the neonate. However, neonatal cases of
infection have been documented. In one case, the diagnosis was made at
day 17 of life after close contact with the infant's mother.
• The approach to prevention, evaluation, diagnosis, and treatment of
pregnant women with suspected COVID-19 should be similar to that in
non pregnant individuals , with consideration that pregnant women with
other potentially severe respiratory infections, such as influenza, severe
acute respiratory syndrome (SARS)-CoV, or Middle East respiratory
syndrome (MERS)-CoV, appear to be more vulnerable to developing severe
disease.

• Additionally, the American College of Obstetricians and
Gynecologists (ACOG) specifies that infants born to
mothers with confirmed COVID-19 should be considered a
patient under investigation and appropriately isolated and
evaluated.
• It is unknown whether the virus can be transmitted through
breast milk; however, droplet transmission could occur
through close contact during breastfeeding. ACOG
recommends that mothers with confirmed COVID-19 or
symptomatic mothers with suspected COVID-19 take
precautions to prevent transmission to the infant during
breastfeeding (including assiduous hand hygiene and using
a facemask) or consider having a different individual feed
expressed breast milk to the infant.

Novel coronavirus-19

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