(Dysregulated hyperimmune response) to covid during 2nd to 5th week

Journal of American Medical Association (JAMA)

Clinical Spectrum of Covid Infection (Dysregulated hyperimmune response) during 2nd to 5th week

Salient features

• COVID-19 Infection is the best characterized by 3 illness periods. The first Phase is acute illness well known to us (fever, cough, dyspnoea) associated with RTPCR positivity . This can be followed by the other 2 illness periods

Post-acute Hyperinflammatory Illness

• This phase manifest approximately 2 to 5 weeks after onset .

• hyperinflammation can occur in organ systems distinct from those affected during COVID-19 and can begin after host clearance of SARS-CoV- 2 infection.

• During this phase patients may have cardiovascular and gastrointestinal manifestations as well as dermatological and mucocutaneous manifestations

• Laboratory testing reveal elevated inflammatory markers (C-reactive protein and ferritin levels), coagulopathy (eg, D-dimer), and elevated cardiac markers (eg, troponin level).

• Almost universally antibodies are positive, but many have negative RT-PCR test
Late inflammatory Sequelae

• In one study, 87% of previously hospitalized patients had 1 or more persistent symptoms (including fatigue, breathlessness, joint pain, and

chest pain) 60 days after the date of onset of symptoms.

My Take on the Subject

We Physicians have been perplexed with patients returning with increase in symptoms after initial successful treatment of Covid. These include resurgence of fever, breathlessness and at times requirement of ICU care. Also, we have seen acute myocardial infarctions(Heart attacks), strokes, Pulmonary embolisms and sudden deaths during this period . These clinical features are also at times associated with radiological deterioration on CT scan of the chest. The biomarkers including CRP, D-dimer, Ferritin, LDH are increased. Leucocytosis and lymphopenia are also common and in some patients RTPCR is also positive. This paper has coined the term `Post-acute Hyperinflammatory illness’. Recognition of this phase of illness would lead us to address this phase of illness with anti-inflammatory agents and other supportive therapies without loading patients with unnecessary high dose of expensive antibiotics.

We are alsoall observing long term symptoms such as fatigue, body aches, feverish feeling, depression- anxiety and sleep disturbances . Cause of this is ill understood.

The care of Patients with Covid must not stop at 2 weeks but should continue with judicious use of medication and supportive therapy which include physiotherapy and counselling

G C Khilnani

Chairman, PSRI Institute of Pulmonary, Critical Care and Sleep Medicine. Formerly Professor and Head Dept of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi

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