Coronavirus

What is Coronavirus disease( COVID19)?

• Newly discovered corona virus is a highly infectious virus. It spreads through droplets of saliva, discharge from the nose, cough or sneeze of an infected person.
• Majority of people have only mild respiratory symptoms such as sore throat, dry cough,headache, bodyache, fever or loss of taste/smell.  Some people may not have symptoms but they can still spread virus through saliva/nasal discharge.
• People with preexisting illness such as diabetes, heart disease, high BP, lung disease can have severe respiratory symptoms/ shortness of breath.
• Elderly(>60 year) people are at high risk of developing serious illness/death.
• Children are least affected, they are not at risk of developing serious disease.
• Any one with symptoms of covid19 must wear a mask and isolate themselves from others for atleast 2 weeks.

Pathophysiology:

• Virus enters our body through inhalation by nose. It stays in the lining of nose and throat in the surface receptor called ACE2 and replicate (7,8). During this stage we get fever,sore throat, body pain. If our immunity is strong enough, then we will get cured without any further progression. In some people virus goes down through wind pipe in to the lungs and alveoli, and pneumonia develops. So, cough and difficulty in breathing starts. Oxygen and other supportive treatments are needed. In some people its very severe where whole lungs gets infiltrated with fluid filled pus (ARDS-acute respiratory distress syndrome) and patients needs to be on ventilator to support breathing in intensive care setting. 
• ACE2 receptors are also present in Gastrointestinal lining (can cause diarrhoea), Blood vessels (hypotention / thrombosis), kidney (renal failure), and brain (encephalitis).

Among patients who are positive for COVID19, their symptoms/severity of disease can be categorized in 3 level.

1. Mild (75%): These people only have symptoms of cough, cold and fever in mild degree. They just need supportive care. No hospitalization needed.

Category 2 and 3 needs hospitalization(25%).

2. Moderate(15-20%) : These people have shortness of breath along with other symptoms. Their oxygen saturation is low. They need to get admitted to the hospital and need intra-nasal oxygen support. But, usually gets better in 3-4 days and can be safely discharged home with isolation order. 

3. Severe(10-15%): These people have difficulty in breathing and requires intubation and to be on Ventilator support (artificial respiration support) as their lungs get infiltrated. They can get cured in 7-10 days or they can become worse. There is possibility of severe progression of disease and development of stroke, heart attack, GI bleeding or severe hypotention which can lead to death. 

{% are calculated based on data at CDC and WHO. (1,2,3)}

Prevention: 

• Wear face mask to protect yourself and others. (2) It reduce touching of mouth and nose and less chances of spread. Any face mask is better than none. Someone posted this on facebook.

• This shows any type of face mask is better than none. 
• A systematic review by Maclntyre at el.(4) of 19 studies about face mask shows following findings:

-  Wearing mask can be beneficial to prevent community spread
- Mask is beneficial to Healthcare worker when worn continuously during the shift.

• Frequent hand washing with soap and water kills virus on surface of hand. 
  
  
  
• Avoid touching nose/ rubbing eyes/ eat without washing hands with soap and water. 
• Use hand sanitizer (>60% alcohol) in absence of soap and water

Other alternative possible preventive measures/ measure that boost immunity:

• Drinking a glass of Hot water everyday as a first drink in the morning
• Eating food/fruits that have high antioxidents such as Oranges, blueberry, amla(indian Gooseberry), ginger, and turmeric.

Treatment:

-For mild cases no treatment needed. For moderate cases observation and nasal oxygen is given.
- Serious cases need ventilation support and ICU level care.

1. Hydroxychloroquine :

Its the gold standerd medicine for treatment of malaria and its prophylaxis. In previous SARS outbreak it showed effective in laboratory study. Its in debate weather or not to use this drug for prophylaxis and treatment of covid19 (5). It goes in acidic environment/ in lysosomes and increase the pH. That's how it prevents virus replication and decrease inflammation. While arrythmia is one of its side effect which debates its use, its wide spread use in tropical county should allow them to consider it as a cheaper prophylactic alternative against Covid19.

As an inference, any person who have previously tolerated chloroquine (example:malaria prophylaxis/ other use) and doesn't have any heart problems, should take it as covid19 prophylaxis if they are health care workers or have Covid-19 positive family members. 

2. Antivirals:

a. Ramdesivir: used in Ebola virus: Showed efficacy in monkeys and later in human trials. Its broad spectrum antiviral against RNA viruses. Its more effective than lopinavir in decreasing lung pathology, improve pulmonary function and decreasing viral load.

b. Lopinavir/Ritonavir: 2-10% Decreased death rate in animal model.Not very effective

3. Streroids:
It is not shown to be beneficial in previous covid19 like infection like MERS, instead it showed to be harmful in critical patients. But, several recent study showed short course of steroid might be beneficial in moderate to severe cases of Covid 19.


Reference:

1.https://www1.nyc.gov/site/doh/covid/covid-19-data.page
2.https://www.worldometers.info/coronavirus/
3.https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
4. MacIntyre CR, Chughtai AA. A rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patients [published online ahead of print, 2020 Apr 30]. Int J Nurs Stud. 2020;108:103629. doi:10.1016/j.ijnurstu.2020.103629
5. Pal A, Pawar A, Goswami K, Sharma P, Prasad R. Hydroxychloroquine and Covid-19: A Cellular and Molecular Biology Based Update [published online ahead of print, 2020 Jun 10]. Indian J Clin Biochem. 2020;1‐11. doi:10.1007/s12291-020-00900-x
6.Zhai P, Ding Y, Wu X, Long J, Zhong Y, Li Y. The epidemiology, diagnosis and treatment of COVID-19. Int J Antimicrob Agents. 2020;55(5):105955. doi:10.1016/j.ijantimicag.2020.105955
7. https://www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes
8. Zemlin AE, Wiese OJ. Coronavirus disease 2019 (COVID-19) and the renin-angiotensin system: A closer look at angiotensin-converting enzyme 2 (ACE2) [published online ahead of print, 2020 Jun 2]. Ann Clin Biochem. 2020;4563220928361. doi:10.1177/0004563220928361
9. https://health.clevelandclinic.org/heres-the-damage-coronavirus-covid-19-can-do-to-your-lungs/

Viral Infection/ Cold/ Flu

What is flu? Its a viral respiratory illness caused by influenza virus. Symptoms: High Fever, runny nose, cough, body ache, tiredness, headache, diarrhea/ vomiting. Highly contagious, one can spread it 1 day before they got sick to 7 days after. Fever can last from 2-7 days.

Complications: mainly small children and elderly patients, get coughing with breathing problem. Mainly due to flu pneumonia or association with other bacterial infections.

Common cold: Viral infection other than by influenza virus. Mainly present as runny nose, sore throat and cough

Season: From late October to early March is a time frame when most of people get sick from flu or other viruses.

Why in winter? Its a myth that flu is caused by cold temperature. Cold is only favoring factor, but it is caused by a influenza virus.
- Influenza virus survive longer on surface in cold & dry temperature. they love cold and dry weather. 
- Lack of sunlight or staying more indoor decrease our immunity( ability to fight infection)
- Lack of fresh air circulation in house due to closed door and windows cause high possibility of spread of infection from one to another.

What helps to avoid flu?
- Stay warm and hydrated
- Use Humidifier 
- Go out in sunlight
- Open doors and window for few minutes during day time every day 
- Flu vaccine: Helps to avoid complications of flu, it takes a week or two to get its effect. So take flu shot early in cold season.
- Frequent hand washing and covering mouth while coughing help decrease its spread

Who need treatment with antivirals? 

High risk individuals, Children<5 years or people>65 year, people with diabetes, heart disease or asthma. Antivirals shortens course of disease by couple of days and may help prevent complications/ hospitalization

Weather its influenza or corona virus or other respiratory virus, not all the people who get exposed get symptomatic. Why? because they had flu vaccine/ they are more active, hydrated and stay more in sunlight or in area with good fresh air movement. This is true with any virus or bacteria. Get vaccine if available, and stay in sunlight with fresh air circulation.


Other sources of reading:

https://www.cdc.gov/flu/symptoms/symptoms.htm

http://sitn.hms.harvard.edu/flash/2014/the-reason-for-the-season-why-flu-strikes-in-winter/

https://www.cdc.gov/flu/highrisk/pregnant.htm

Headache

Headache is a feeling of pain/heaviness in the head.

Types of Headache, causes and modality to help reduce it:

Most Common type of Headache: 

1. Tension Headache:

Mild to Moderate pain that comes and go over time. Mainly felt pain / heaviness over frontal region. Its most common type of headache. Occurs mainly due to
- Emotional Stress
- Fasting
- Lack of sleep
- strong smell : ex.perfume, smoking, smoke
- noise
- weather change
- gas trouble/ certain food
- overuse of phone, TV,laptop
*Try avoiding situation that gives you headache. Coffee+ Tynelol might help.

2. Migraine Headache:

Throbbing headache lasting couple hours to days, and reappears few times every month. Usually associated with sensitivity to light, noise or smell.  Sometime patient may experience paralysis like symptoms with migraine headache.

*Avoid triggers such as fasting, lack of sleep, noise. Tynelol extrastength, Ibuprofen / other medicine recommended by physician can help


3. Cluster Headache:

Intense peircing pain behind the eye. Associated with tear, red eye. last for 15min-2hours, for 2- 3 times a day for many days. May associated with sweating. Comes at the same time each day. Triggers: trigeminal neuralgia/smoke/ allergies/sinusitis. *Avoid / treat triggers.

Other Causes of Headache:

1. New / change in Eye number/glasses

It usually causes bitemporal (on side) headache. It is usually associated with difficulty reading small letter from distant/ headache after reading books. Mainly caused by refractive errors.
*Mostly patient need new glasses and check up with ophthalmologist.

2. Drug withdrawal:

ex. Missing a daily dose of Alcohol, Coffee, Tea. Nitrate withdrawal(medicine to treat angina).

3.  Hormonal changes/ cyclic headache

Women may experience headache couple of days before starting of menstrual period every month. *Ibuprofen might help.

4.  Infection in sinus/denture:

A. Frontal sinusitis following cold, or other upper respiratory diseases. *Needs antibiotic treatments under physician's direction
B.: Dental infection: associated with dental pain. *Need antibiotics and dental check up

5. Dehydration: 

Drink water, and Oral re-hydration solution with electrolytic powder helps.

6. Fever: 

Tynelol/ controlling fever helps.



Causes of Headache that needs immediate medical attention: 

1. High blood pressure:

Patient known to have blood pressure on medicine, complain of headache in the middle of the head/vertex (pounding headache). H/o skipping medicine or + of pedal edema. This kind of headache usually is caused by high blood pressure. + very high blood pressure(>180mmhg) with nausea suggest developing encephalopathy. *Blood pressure control is needed under physician guidance.

2. Glucoma:

High fluid pressure in eye chamber can damage optic nerve. Associated with vision changes, halos, eye pain, and nausea and headache. Immediate opthalmologist / eye dr. attention needed to prevent blindness. Eye drops and medicine to decrease fluid production/ increase drainage in eye chambers helps. 

3. Intracranial causes: Headache is always associate with nausea and or vomiting

A: Meningitis: infection of covering of brain. Associated with fever, neck stiffness and nausea/vomiting. *Treated with intravenous antibiotics.
B: Intracranial Bleeding (Subarrachnoid hemorrhage): These are the worst headache of one's life, associated with nausea /vomiting, later neck stiffness. Usually patient has history of high blood pressure. *Patient is usually admitted to ICU for care.
C: brain mass/ tumor: Associated with nausea, vomiting and weight loss. *Surgical removal needed depend on type of mass.
D: ventricular enlargement (hydrocephalus): Due to blockage of CSF drainage due to mass or bleeding. Associate with nausea, drowsiness and gait changes/fall. *Surgeon usually puts a EVD(type of tube to drain excessive fluid)
E: blocked vain in head, stroke 
*Medical care with neurologist/ neurosurgeon needed for all intracranial issues

4. Post Lumber puncture Headache:

This occurs post spinal tap due to CSF leak. Severe Headache occurs on getting up from bed. Lying down in bed helps. *Usually complete bed rest for few days and or placing a patch in the leak needed.

5. Inflammation of temporal artery:

Headache on temporal region with thick pulsatile artery. Associated with loss of appetite, fever, pain in jaw on chewing and vision changes. It needed immediate attention as it can lead to blindness. * Need treatment with steroids.

Referances: 
https://www.medicinenet.com/headache/article.htm
https://www.webmd.com/migraines-headaches/migraines-headaches-basics#1
https://www.health.harvard.edu/pain/headache-when-to-worry-what-to-do