My experience with COVID 19 infection and cytokine storm

Good morning to everyone

Myself Dr. Ram Bihade.

I have been treated for covid 19 pneumonia with cytokine storm. Today I have been discharged to home after 22 days. I intend to use this platform for sharing my experience.

I became symptomatic on 23 may evening, I had high grade fever and severe headache. 5 days earlier I had provided voluntary service in medicine opd of Akola GMC where a patient came after giving his swab in covid opd. I examined him with full precaution gloves, N95 and face shield and possibly he was the source of my infection, coz after that I quarantined myself at home . I did not come in contact with anybody till my symptoms began.

I contacted Dr. Pravin Shekokar who was posted at covid opd at that time and gave throat swab sample on 24 may. Since I was already taking Chloroquine prophylaxis, I started on oseltamivir, Azithromycin and antipyretics. Fever was above 102 farenheit

On 26 evening I requested Dr. Mantri sir to help me trace my report. He informed me it was positive and advised me to talk to Dr. Ashtaputre sir who on hearing my symptoms advised me to be admitted in ICU ward 29 sideroom .Around 9 pm I got admitted GMC ward as at that time Pvt setups were not allowed to admit COVID patients. I met Dr. Gupta sir there and he agreed to take care of all paperwork for me as I did not have report in my hand.

First set of investigations pointed that the infection might be relatively uncomplicated one everything(CBC, CRP, Ferretin, DDimer, PROCALCITONIN, Quantitative TROP I) normal except LDH of 577. (IL 6 levels were not done as it required minimum 6 days for report to arrive with lockdown in place and no local facility was available)

I was started on antibiotics vitamin C and zinc.

Fever persisted on 27/05 ranging 102- to 104 . Iv febrinil would just take the edge off for sometime, there was fatigue but not hindering daily activities.Oral paracetamol didn’t show any significant effect.

I monitored my tempreture myself because the non touch readers showed significantly lower value than my personal thermometer.

On 28/05 early morning I informed Dr. Ashtaputre sir about persistent fever and tachycardia and even more fatigue.Saturation was stable 98 at room air. He immediately started me on Piptaz TDS , methylprednisone 40 mg BD and Iv vitamin C. He also made sure that I recieved all the drugs in timely manner. Blood reports on 28/05 showed DDimer of more than 1000 and CRP of 10( normal value 6), rest of reports including serum Ferretin was normal. So LMWH injections were also started.

On 29/05 fever spikes reduced and requirement of febrinil went down. Maximum temperature was still 101 farenheit , tachycardia around 110 was still there. I felt symptomatically better probably due to reduced fever as a result of corticosteroids. I even walked for 30 mins without feeling much fatigue.

On 30/05 I woke up early with a fever of 102.5 farenheit. I realised something was not right with my condition. Fatigue was back but now with Oxygen saturation fluctuating between 93-96 . I was started on intermittent oxygen and I realised the day was eighth day of symptom and the time when things take turn for worse in symptomatic Covid. I was told to minimise my activities and stay on bed rest. Piperacillin Tazobactam was replaced with Meropenam. Fatigue was so bad that going to washroom felt like 100 meter dash.

I felt my strength decreasing and there was sense of impending doom. I reduced my activities to conserve energy. Increased the duration of proning and followed CARP protocol. Blood reports showed Ferretin of 310 ( upper normal for men 276) and DDimer had reduced to 510. Neutrophil to lymphocyte ratio was 4:1 which is one of the red flagsearlier it was less than 3:1

I also had been monitoring my NEWS score ( National early warning score) since admission. The score had jumped from 2 to 5 in one day. I discussed the matter with my PG batchmates friends , and concluded that this might be start of cytokine storm and I might require Tocilizumab. They also informed me that the drug was very difficult to get commercially and even in Pune they have started using Ulinastatin at some centres instead( which I did not want as comparative evidence was not as robust as Tocilizumab).

A word about my friends, they were concerned to the core I could feel it, but they wouldn’t hesitate to crack jokes at me or the disease, their light hearted notes added much needed balance to a serious situation, lucky to have them.

On 31/05 my clinical condition deteriorated furthur . I was not able to make it to washroom which was at hardly any distance and for that 3 mins trip I felt I would pass out. Checked oxygen saturation it was 85 at room air, continuous oxygen was started. Fatigue was so severe that I was hardly able to get up from my bed . Didn’t even have energy to open my tiffin and have food. Oxygen demand had increased significantly to about 10 litres a minute now. I felt clinically this is cytokine storm and I need Tocilizumab to fight it off. Also that being an experimental drug for Covid permission from Dr. Ashtaputre sir was must as he was the treating physician. I messaged Ashtaputre sir at 10.30am “Sir do we need Tocilizumab?”

He replied immediately that they are trying to procure it. My friend Dr. Zubin Sharma reached out to Dr. Kakrani sir our PG Professor and HOD, since I was fatigued even to talk on phone, I could barely type texts. They did discuss my whole case and also requested sir to arrange for Tocilizumab. Dr Zubin was also instrumental in going through Covid 19 research , despite his busy schedule and was my chief source of knowledge. I’ll be forever be indebted to him for all his help he provided during my illness. Dr Kakrani sir had a word with Dr Ashtaputre sir about my clinical condition. At 2.00 pm received news that Tocilizumab has been arranged from Yavatmal GMC and I will get it by night. This is one more thing for which I’ll forever be grateful to Dr. Kakrani sir for such timely help.

The day was very eventful everyone who saw me that day saw my clinical parameters and just assumed that I was depressed and so the condition is looking grim as clinical parameters and tests were not significantly deranged, well they were not but we did not have IL6 levels. I do not blame them they could not feel the fatigue which I was feeling. Most of them mistook my physical weakness as my mental weakness. The truth is my mind was clear as ever probably sharper.

Was I afraid ?- yes I was, there was fear of death, which I believe is the most powerful impulse of human spirit which helps us fight.

Was I depressed? – No chance. I knew exactly what I wanted and also knew how to get it . I don’t think a depressed person on 10 litres oxygen and continuous fever could think on these lines.

It’s okay to be afraid but it’s not okay to be depressed. Your mental state can make all the difference.

There were talks of shifting me to Nagpur /Pune/ aurangabad, the discussion I was not a part of. I just told my wife shift me only if Tocilizumab is available there or it is useless. She enquired in Nagpur GMC and IGMC but recieved news it was not available there at that time.

Anyways continuing with the story my sample for IL6 was sent to Mumbai before first dose of Tocilizumab. Results would arrive on 05/06.

It was first time Tocilizumab was being administered in GMC , practical experience with Tocilizumab was next to nothing. 10 minutes into the dose I had a reaction with full rigors and difficulty in breathing. I signalled one of the patients to call the doctor. Dr Kanjarkar sir came immediately administered treatment and I was out of the woods after sometime. I don’t know what the saturation was then but I felt like I have passed out. For timely treatment I will forever be grateful to Dr. Kanjarkar sir. Rest of the dose went on smoothly.

01/06. Fever had reduced. Fatigue was still present still barely able to talk full sentences. Still there was sense of impending doom. Tachycardia was persistent and wide variations in pulse were there even with change of posture. Daily activities had become even more difficult. Reports showed only increase in CRP rest parameters LDH , Ferretin DDimer everything normal. Oxygen requirement had gone upto 15 litres a minute.

I received second dose of Tocilizumab that day itself 12 hours after first dose. With a bad experience with first dose, I messaged Dr. Korde sir to be present nearby in case of any adverse drug reaction. Sir said we will be waiting outside don’t worry if anything occurs just ask anybody to dial my number and call me inside. With the grace of God nothing adverse happened.

02/06 Third dose of Tocilizumab was decided to be given judging from the clinical picture. Oxygen requirement were still 15 litres per minute

03/06 Fever was gone . Fatigue was slightly reduced. My wife had her second throat swab positive and even though she had mild symptoms. She decided to get admitted in with me. This really turned out to be blessing in disguise for me.

04/06 For first time since admission I felt really better. I had no fever ,no tachycardia, comparatively less fatigue. Only problem left was Oxygen requirement.

I was put on CPAP support with 70 percent Fio2.

05/06 The IL6 levels arrived and result shook me and everybody I shared the report with . It was a 400 times increase of the normal value. I thanked Almighty that I recieved Tocilizumab in time or everything could have been a disaster.

06/06- 12/06

Repeat throat swab came negative on 09/06. I was given a choice to get shifted to Ozone hospital as just it was a question of supplemental oxygen. The oxygen requirement went down steadily with spirometry , deep breathing exercises and CARP protocol. We both took discharge from GMC Akola on 12/06.

I shifted to Ozone hospital as still there was minimal oxygen requirement where I was for three days and took discharge when I was able to maintain steady SPO2 at room air with daily activities. Dr. Kishor Pachkor sir’s advice really eased the decision making process of weaning off from Oxygen.

Special thanks to Dr. Ashwin Bihade for providing timely blood reports throughout my hospital stay.

I intend to take a month’s break to work on my pulmonary rehabilitation and increasing exercise tolerance before resuming my duties.

Stay safe everybody because staying at home is not an option for medical community in this hour of need, except for senior members of our community who should step back from their service till a vaccine or cure is developed.

Some lessons I learnt

1. Never ignore red flags and clinical condition of the patient. Investigation reports cannot replace clinical judgement.

2. ARDS can be avoided with timely identification of cytokine storm.

3. NEWS scoring system can help to objectify clinical deterioration compulsorily should be used in every patient

4. IL 6 levels cannot be substituted by other markers.

5. Tocilizumab can work wonders if recieved timely and is not contraindicated. Due to short supply hospital should have it in their stock.

6. Never feel shy/ embarrassed to ask for help. There is plenty of help available from medical fraternity.

7. What doesn’t kill you makes you mentally stronger.

2 comments

  1. Deepa Rani · · Reply

    Very informative

    Like

  2. Dr Urvashi · · Reply

    Very much informative and inspirational

    Like

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