coronavirus are now more appropriately it's called sars-cov-2 - - that's the name of the
virus that's responsible for the covid 19 outbreak Wuhan China is the epicenter of this epidemic but
some experts like dr. Anthony Falchi of formerly the CDC now NIH is saying that we're on the verge
of a pandemic now before I get to the autopsy results of this patient with covid 19 illness
it's important to understand the context of the numbers that we're talking about it's important to
understand the total number of people infected how many people have pneumonia how many people have a
RDS and how many people have died when looking at the numbers we should realize that they're almost
certainly being underreported in China and there's multiple reasons for this but I'm not going to get
into that right now although these numbers are not concrete numbers it's what we have to go by
this point also up to this point there hasn't been any pathology reported on the disease because of
limited access to autopsy and biopsy results so these are the latest numbers as of February 18th
553 p.m. that's when I'm recording this video so the total number of confirmed cases seventy five
thousand one hundred fifty two vast majority are in mainland China on the Diamond Princess cruise
ship they had 542 cases that brought in fourteen new cases to the US previously the US was fifteen
but now it's 14 plus 15 gives you 29 the total number of deaths so far 2007 total number of
recovered 14,000 352 now based on the number of studies that are out there about 15 the 20% or
so of infected patients have pneumonia and the number for ARDS is less than that because not
all the pneumonia patients are getting aired yes that numbers probably around 5% would be my guess
so the number of deaths would be even less than that 5% and that percentage is calculated to be
around 2% or so but again we don't have all the numbers these aren't concrete numbers and these
are estimates so new studies are coming out this week and we're gonna learn a lot more about this
virus but finally we now have a new case report study in Lancet respiratory medicine this was
published February 17th and this has autopsy result for a patient who actually died of covid 19
so this case is based on pathological findings of covid 19 associated with acute respiratory distress syndrome or ARDS
for short the patient is a 50 year old man from China who visited Wuhan
January 8th to January 12th On January 14th he developed a dry cough and some mild chills so
this is considered day 1 of his illness however he didn't initially seek medical attention and
he kept working until January 21st he then went to a medical clinic on January 21st because by
that time he had developing worsening symptoms he had fever chills fatigue cough and shortness
of breath so here's his chest x-ray when he first presented on January 22nd day 9 of his illness the
Beijing Centers for Disease Control confirmed by reverse transcriptase real-time PCR assay that the
patient had covid 19 he was immediately admitted to the isolation ward and received supplemental
oxygen through a facemask this is not the actual patient but I wanted to give you a visual of what
I'm talking about here he was given several different medications which included inhaled
version of interferon alpha to be IO pin of air + ritonavir as antiviral therapy and moxifloxacin to
prevent secondary bacterial infection he was also given a steroid methylprednisolone also known as
solu-medrol to attenuate lung inflammation and more on this in a little bit now let's take a
look at his lab results so far you may notice that his WBC count is white blood cell count
was low and specifically his lymphocytes are low and this is what we call lymphopenia this is not
uncommon with some viral infections some other labs that stood out here are elevated ast and
elevated LDH the elevated ast indicates some kind of liver injury there's lots of different causes
of that including viral infections including medication on day 12 of his illness after his
initial presentation his symptoms did not improve other than his fever but he was given medication
for that presumably acetaminophen his chest x-ray on day 12 showed progressive bilateral
infiltrates he repeatedly refused ventilator support in the intensive care unit apparently
because he had claustrophobia and therefore he absolutely refused to be intubated so instead of
being intubated with mechanical ventilation he received high flow nasal cannula oxygen therapy
the amount was 60% concentration with a flow rate of 40 liters per minute so he's not maxed out
on the high flow nasal cannula settings at this point on day 13 of his illness his symptoms had
still not improved but oxygen saturation remained above 95% generally speaking you want the oxygen
saturation to be above 92% maybe above 94% but that's a generalization now fast forward to day
14 of his illness and his shortness of breath and oxygen saturation worsened despite receiving high
flow nasal cannula oxygen therapy that was turned up to the max with a hundred percent concentration
and a flow rate of 40 liters per minute his oxygen saturation decreased to 60% and the patient had a
cardiac arrest at that point he was intubated with mechanical ventilation during his cardiac arrest
where he's having chest compressions and he was given epinephrine unfortunately they weren't able
to revive him they soon did an autopsy after his death and the biopsy samples were taken from his
heart from his liver and from his lung his heart was essentially normal the liver biopsy of this
patient showed moderate microvascular steatosis and mild lobular and portal activity indicating
that this injury could have been from the virus itself the Tsarskoe v2 virus or it could be from
medication effect or it could be a combination of both and now to the lung biopsy histological
examination of lung tissue showed diffuse alveolar damage with cellular fibro mix soit
exudates along with desquamation of nuuma sites in hyaline membrane formation now that's a lot of
medical jargon these findings are consistent with acute respiratory distress syndrome interstitial
mononuclear inflammatory infiltrates dominated by lymphocytes were found in both lungs they were
multinucleated syncytial cells and a typical large alveoli characterized with prominent nucleoli
consistent with cytopathic viral-like changes so in english basically the findings were consistent
with viral infection in the alveolar areas these pathological features of covid 19 greatly
resembled those of the Tsar's and MERS coronavirus --is now let's talk about giving someone
methylprednisolone or solu-medrol for acute lung infection it's typically reserved for someone
who has severe ARDS which this patient ended up having it's someone difficult to tell exactly when
he developed erred yes because you need certain criteria but appears he went into areas around day
12 of his illness his chest x-ray on day 8 day 10 and day 12 are here you'll notice that on day 12
it's pretty obvious that he has bilateral patchy opacities meaning bilateral fluffy infiltrates
part of the other criteria for ARDS is having a low po2 to fio2 ratio essentially this is a
measure of the ratio of the amount of oxygen you inhale compared to the amount of oxygen you end up
getting into your blood a low ratio indicates that the lungs are doing a poor job of moving
the oxygen from the air you inhale into your bloodstream patients with ARDS have a ratio of
less than 300 and severe ARDS is when it's less than 100 it's a little bit hard to determine this
patients ratio based on the limited details in this case report but it can be safe to assume that
his ARDS was severe before his death based on his oxygenation levels check out my video on ARDS
for a deep dive into how we diagnose and manage patients with aired yes now this patient refused
a breathing tube with mechanical ventilation if he was intubated sooner rather than later would that
have changed the outcome it's hard to know it's possible he still would have had the same outcome
but I can tell you that it's chances of survival would have been higher had he been intubated
sooner rather than later and the reason is we can do things that have proven to reduce mortality in
patients with severe ARDS like this patient I do occasionally have patients who need intubation but
they refuse it unless they stop breathing and or their heart stops they say well if I stop
breathing and my heart stops then go ahead and do CPR and put the breathing tube in but short of
that I don't want the breathing tube I explain to them that the prognosis is better if we intubate
you sooner rather than later most patients at that point have to decide or a family member
will decide for them if they can't make decisions on their own they have to decide whether they want
to be a DNI meeting do not intubate or do they want the breathing to the pitch in this case
didn't get intubated until after his breathing and his heart stopped when you get to that point
the prognosis is essentially zero now there are more and more studies coming out this week about
co vid 19 and they're coming from credible medical journals like the New England Journal of Medicine
Lancet and major JAMA and others so I'm gonna be on the lookout for these studies if there's
a particular Covid 19 topic you want me to make a video on let me know in the comments below and
I'll do my best to make a video on that so if you like this video it helped me if you clicked
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