welcome to another MedCram COVID-19 update we are headed to a half a million
total confirmed worldwide over 20,000 deaths and 115 thousand total recovered
with most of that growth outside of China at this point if we look at the
world ometer website most of the deaths that are occurring are in Italy and
Spain with the United States starting to move up as well the number of new cases
in Italy looks as though it might have peaked will have to see more in the
future in terms of its direction while the total deaths in Italy continued to
escalate over in the United States the total number of cases continues to grow
total number of deaths is over a thousand here in the United States
already New York City seems to be the epicenter of what's going on here in the
states and they are predicting that the peak number is still about two to three
weeks away in New York and remember that New York is ahead of just about
everybody else of course if we were able to flatten the curve then that's gonna
delay that even more but hopefully the peak won't be as high okay I want to
talk to you about a couple of updates in terms of signs and symptoms this is from
the American Academy of Ophthalmology which is warning us that there have been
several reports that the virus may cause conjunctivitis and possibly be
transmitted by aerosol contact with the conjunctiva and the Academy is
recommending protection from the mouth nose and eyes when caring for patients
potentially infected with SARS Cove - also there are recommendations there on
how to sterilize the equipment that's used the other name for conjunctivitis
is pinkeye it's not uncommon to have conjunctivitis when you have an upper
respiratory viral infection so be aware of that the other sign in symptom is
related to the loss of smell as a marker of Cova 19 infection this is a letter
that was written by the president of the ear nose and throat Association in the
UK dar Kumar and he's talking here about
post-viral anosmia that by itself is not unusual what they're seeing however is
they're seeing a huge rise in the number of patients that are complaining of the
inability to temporarily smell after a viral infection they mentioned here that
in South Korea where testing has been more widespread 30% of patients testing
positive have had anosmia as their major presenting symptom in otherwise mild
cases on the flip side of that they're also noticing that patients without any
other signs or symptoms consistent with asymptomatic kovat 19 are presenting
with the only sign being anosmia and that may be suggestive of an
asymptomatic infection with covin 19 and he's talking about him personally having
seen four patients in one week all under the age of 40 and otherwise asymptomatic
except for recent onset and nas mia and he usually sees only about once a month
so this is something to be on the lookout for he also has some
recommendations at the bottom of the letter he says that there is potential
that if any adult with anosmia but no other symptoms was asked to self
quarantine for seven days in addition to the current symptom criteria used to
trigger quarantine we might be able to reduce the number of otherwise
asymptomatic individuals who continue to act as vectors not realizing the need to
self isolate it would also be an important trigger for healthcare
personnel to employ full PPE or personal protective equipment and help to counter
the higher rates of infection found amongst ENT surgeons compared to our
other health care workers and of course we'll put links to these articles as
well as other ones in the description below so we're going to talk about the
immune system as promised and remember what we talked about how a good immune
system in both of these situations could help not only the person having the good
immune system but also reducing the number of people going into our
healthcare system so here is what is represented as the population at whole
and then there is a certain amount that will catch the infection which is here
infection and then about 80 percent those people will not need to go to the
hospital because they have a sufficient immune system but the 20% here we could
improve and perhaps if we had a good immune system we might be able to not
even become infected in the first place and we talked about in our last update
what they were doing by giving a BCG vaccine even if there were given one
earlier life to give another one they're hoping to see that their immune system
will be heightened not just against tuberculosis as it's designed for but
also an improvement in your innate immune system so that's your lymphocytes
your leukocytes your natural killer cells your neutrophils etc what is it
that we can do to improve our own immune system so the first thing I want to talk
about is fever fever is one of those signs that you get when you have a viral
infection and it's one of those things that you might see also with kovat 19
although it's not universal so here's a paper that was published in 2017 looking
at the presence of fever in adults versus children and one of the things in
the article that's interesting to note is they looked at a number of different
viruses and you can see here for corona virus if we were to take this as a
representative of the current kovat 19 cases only two out of seven cases
presented with fever giving it about a twenty eight percent incidence of fever
in the discussion they say here we have shown using prospectively collected data
that the rate of fever in adults with confirmed viral respiratory infections
is much lower than described in children nevertheless it is present and it would
behoove us to take a look at the mechanisms of fever both in adults and
children so here's another paper that was published in the world Journal of
Clinical Pediatrics back in 2012 titled fever management evidence versus current
practice and I found it to be a very good source of some interesting studies
regarding fever and under the heading that says evidence that fever is
beneficial they had a number of points it talks about fever having an adverse
effect on back tear on viruses how it improves the activity
of a lot of signaling like interleukin 1 also cells that are involved in the
immune system that we've talked about including T cells B cells and antibody
production a lot of these things are mediated at temperatures that are just
above normal around 38 39 40 degrees centigrade 38 degrees correlates to
about 100 point 4 there's also some studies here that show that interferon
which is of course in antiviral agents has enhanced antiviral activity above 40
degrees centigrade so there are a number of references here and I'll include all
of those papers in the description below in those references we can see here in
vitro that as we increase the temperature here on the x axis the
percent yield in this case of poliovirus starts to drop similarly if we look at
the development of poliovirus at 37 degrees centigrade in that paper it was
quite prolific over a period of time repeat the experiment here at 40 degrees
centigrade there is a precipitous drop again these aren't in vitro studies so
let's look at some human studies so while there have been a lot of bacterial
studies I wanted to highlight a viral study with Rhino virus which is a virus
that causes a common cold as well this paper was published back in 1990 there
was 56 healthy subjects and all of them had Rhino virus introduced into them but
then there were forearms there was an aspirin arm there was a Tylenol arm
there was an ibuprofen arm and then there was a placebo arm and in each of
these arms they measured something called a serum neutralizing antibody
response so we're looking for the antibody response after these people
that were infected with Rhino virus and what they found is that in the aspirin
and in the tylenol group these together were statistically significantly lower
in terms of that antibody response when it was compared to placebo and that
p-value was less than point zero five
and what we're finding more and more of recently is that temperature is
intricately related to the immune function of the cell here's a paper that
was published in 2018 that shows that temperature regulates certain cellular
messaging systems that allow the immune system to respond to infections this
signaling pathway known as NF kappa-b is a signaling mechanism that allows the
cell to respond to these infections and it was recently highlighted in an
article in medical news today a signaling pathway called nuclear factor
Kappa B plays an important role in the inflammation response in the context of
infection or disease this protein helps the expression and the production of
certain immune cells these proteins respond to the presence of viral or
bacterial molecules in the system and that is when they start switching
relevant genes related to the immune response at the cellular level they also
note here that this NF kappa-b becomes more active at higher
temperatures and less active at lower temperatures so the question is is it
the fever that's causing the NF Kappa beta to go up or is it the NF Kappa beta
that's causing the fever well they did some experiments and they found this
protein called the a20 protein is what tells the NF kappa-b
protein to go up and so if you knock out this a 20 then that is gonna prevent the
NF kappa-b from activating and when it doesn't it's no longer going to be doing
the things that it needs to do to augment the immune system so in essence
fever somehow stimulates a twenty which then stimulates NF kappa-b an NF kappa B
is essential for immune system how do we deal with fever well remember what we
talked about a couple of lectures ago we have something called arachidonic acid
which is converted into prostaglandin and specifically prostaglandin e2 that's
mediated through something called the - enzyme and what are one of the big
inhibitors of the cox-2 enzyme but NSAIDs remember what NSAIDs are aspirin
ibuprofen and indomethacin so because of this in other studies many scientists
and many practitioners especially in the pediatric population are advocating that
fevers based on known viral infections shouldn't be treated just based on the
number itself and the fact that the temperature is elevated that in fact the
fever may actually be beneficial to the recovery of the patients and unless the
fever is excessive or the patient's dehydrated or there's lethargy which
means that the patient doesn't want to move very much then fever shouldn't be
treated couple of points here to remember number one a fever is not
hyperthermia hyperthermia is what one might get if they were running on a very
hot day and their temperature was 105 106 107 those are clearly very dangerous
temperatures and they need to be treated aggressively otherwise someone could die
but in the sense where there is a viral infection and a fever is being caused
and there's no other complication as a result of that fever there is a question
about whether or not that fever should be treated the other point I want to
make and it's very important is that there are a number of adults in this
country that are on aspirin for very good reasons and this is not a reason to
stop it you should never stop any medication without consulting your
physician there are people with stents people with
strokes for which aspirin is life-saving not to mention that people take
ibuprofen and in the medicine for rheumatological conditions as well I'm
simply saying that perhaps an elevated temperature in your body may be part of
the solution to getting better over the viral infection and not part of the
problem I would be interested in your comments below regarding this issue I
think one of the conclusions that I draw from this is that there is a benefit in
infectious disease to having an elevated body temperature okay we'll see if our
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