overview of covid 19

1. ‫الرحيم‬‫الرحمن‬‫هللا‬‫بسم‬
(ْ‫م‬ِ‫ه‬ِ‫س‬ُ‫ف‬ْ‫ن‬َ‫أ‬ ‫ي‬ِ‫ف‬َ‫و‬ ِ‫اق‬َ‫ف‬ ْ‫اْل‬ ‫ي‬ِ‫ف‬ ‫ا‬َ‫ن‬ِ‫ت‬‫ا‬َ‫ي‬‫آ‬ ْ‫م‬ِ‫ه‬‫ي‬ ِ‫ر‬ُ‫ن‬َ‫س‬‫ا‬ ُُ‫ى‬‫ن‬َ‫أ‬ ْ‫م‬ُ‫ه‬ََ ََ‫ى‬‫ي‬َََ‫ت‬َ‫ي‬ ‫ى‬‫ت‬ََُّ‫ق‬َََْ)
((Soon will We show them our Signs in the (furthest)
regions (of the earth), and in their own souls, until it
becomes manifest to them that this is the Truth))
Fussilat: Verse 54

2. Prof. Ibrahim Fadl M, MD.
Associate prof. of Anesthesiology & Intensive Care
Al- Azher University,New Damietta

4. Definition
Coronavirus disease 2019 (COVID-19)
 a potentially severe acute respiratory infection caused
by ; severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2).
The virus was identified as the cause of an outbreak of
pneumonia of unknown cause in Wuhan City, Hubei
Province, China, in December 2019.[1]
C/P ; ranging from a mild common cold-like illness, to
a severe viral pneumonia leading to ARDS that is
potentially fatal.

5. Epidemiology
WHO was informed of 44 cases of pneumonia of
unknown microbial aetiology associated with
Wuhan City, China on 31 December 2019.
 Most of the patients in the outbreak reported a
link to a large seafood & live animal market
(Huanan South China Seafood Market).[2]
The outbreak spread rapidly from a single city to
an entire country in only 30 days.[3]
At least 20 countries have reported local
transmission (as of 1 March 2020)

6. Epidemiology
The majority of confirmed cases (87%) were
aged 30 to 79 years,
1% were aged 9 years or younger,
1% were aged 10 to 19 years, &
3% were aged 80 years or older.
Approximately 51% of patients were male &
49% were female.
Nearly 4% of cases were in health care
workers.[11]

10. Aetiology
Severe acute respiratory
syndrome coronavirus 2
(SARS-CoV-2) is a
previously unknown
betacoronavirus
that was discovered in
bronchoalveolar lavage
samples taken from clusters
of patients who presented
with pneumonia of
unknown cause in Wuhan
City, Hubei Province,
China, in December 2019.[1]

11.  Most of coronaviruses cause mild symptoms in humans but
there are 3 serious strains of coronaviruses:
1- Severe Acute Respiratory Syndrome (SARS-COV) ⟹
outbreak in 2003 in china
2- Middle East Respiratory Syndrome (MERS-COV) ⟹
outbreak in 2012 in KSA
3- Novel coronavirus 2019 (COVID-19) = Severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) ⟹
outbreak in DEC 2019 in china

12. Pathophysiology
The incubation period ; 1 to 14 days (4_5 d) [4 ]
Transmission may be possible during the incubation
period [5 ]
Reproductive Number (R₀); the number of people who
acquire the infection from an infected person, is
approximately 2.2. [6]
the virus may be able to bind to the angiotensin-
converting enzyme-2 (ACE2) receptor in humans,
which suggests that it may have a similar
pathogenesis to SARS.[7]

13. Pathophysiology
a unique structural feature of the spike
glycoprotein receptor binding domain of SARS-CoV-
2 (which is responsible for the entry of the virus
into host cells) confers potentially higher binding
affinity for ACE2 on host cells compared to SARS-
CoV.[8]
High viral loads have been detected in nasal &
throat swabs soon after symptom onset.
An asymptomatic patient was found to have a
similar viral load compared with symptomatic
patients.[9]

15. :Primary prevention
I. General prevention measures
II. Medical masks
III. Screening ; People travelling from areas with a high
risk of infection
IV. Vaccine ;
 There is currently no vaccine available.
 Vaccines are in development, but it may take up to 12
months before a vaccine is available. [10]
 An mRNA vaccine (mRNA-1273) has been shipped to the
National Institute of Allergy and Infectious Diseases for
phase I clinical trials in the US, with an estimated start date
of 6 March 2020.[11]

16. General prevention measures
 The only way to prevent infection is to avoid exposure to the
virus :[12][13]
 Wash hands ( with soap and water or an alcohol-based hand sanitiser)
 avoid touching the eyes, nose, and mouth with unwashed hands
 Avoid close contact with people ( maintain a distance of at least 1
metre [3 feet]),
 Practice respiratory hygiene (cover mouth and nose when coughing
or sneezing, discard tissue immediately in a closed bin, & wash hands)
 Seek medical care early if they have a fever, cough, & difficulty
breathing, & share their previous travel and contact history with their
healthcare provider
 Avoid direct unprotected contact with live animals and surfaces
in contact with live animals when visiting live markets in affected
areas
 Avoid the consumption of raw or undercooked animal products,
& handle raw meat, milk, or animal organs with care .

17. :Secondary prevention
I. Early recognition of new cases is the
cornerstone of prevention of transmission.
II. Immediately isolate all suspected & confirmed
cases & implement recommended infection
prevention and control procedures according to
local protocols, including standard precautions at all
times, & contact, droplet, & airborne precautions
while the patient is symptomatic. [14]
III. Report all suspected & confirmed cases to your
local health authorities

18. Case history

19. Case history;
A 30-year-old man presents to his general practitioner
on 14 January 2020 with a bad cough. He has
had the cough for 4 days and now feels a little short of
breath. He also has a headache and reports that
his muscles ache.
On examimation, his pulse is 100 bpm and his
temperature is 38.5°C (101.3°F).
The patient reports that he returned from a business
trip in China 6 days ago.

20. Step-by-step diagnostic approach
 Early recognition &rapid diagnosis are essential to
prevent transmission & provide supportive care in a timely
manner.
 Have a high index of clinical suspicion for COVID-19 in
all patients who present with fever &/or respiratory
symptoms & who report a travel history to an affected area
 History
 Take a detailed history
 close contact with infected individual
 Travel history is key; residence in/travel to affected area 14
days prior to symptom onset

21. Infection prevention & control
I. Triage all patients on admission and immediately
isolate all suspected & confirmed cases .
II. Implement infection prevention & control
procedures.
III. Screening questionnaires may be helpful.
IV. WHO recommends the following basic principles: [14]
 Immediately isolate all suspected cases in a separate
area from other patients
 Implement standard precautions at all times:
• Practice hand and respiratory hygiene
• Offer a medical mask to patients who can tolerate one
• Wear personal protective equipment (PPE)
• Prevent needle stick & sharps injury
• Practice safe waste management, environmental cleaning,
& sterilisation of patient care equipment & linen.

22. Infection prevention & control
 Implement additional contact and droplet precautions
until the patient is asymptomatic:
 Place patients in adequately ventilated single rooms; when single
rooms are not available, place all suspected cases together in the
same ward
 Wear a medical mask, gloves, an appropriate gown, and eye/facial
protection (e.g., goggles or a face shield)
 Use single-use or disposable equipment
 Consider limiting the number of healthcare workers, family
members, and visitors in contact with the patient, ensuring
optimal patient care and psychosocial support for the patient
 Consider placing patients in negative pressure rooms, if available
 Implement airborne precautions when performing aerosol-
generating procedures
 All specimens collected for laboratory investigations
should be regarded as potentially infectious.

23. Clinical presentation
The clinical presentation → viral pneumonia .
 The severity of illness ranges from mild to severe;
80% of patients present with mild illness,
14% present with severe illness, &
5% present with critical illness.
 Illness severity is associated with older age & the
presence of underlying health conditions.[3]
 90% of patients present with more than one symptom &
15% of patients present with fever, cough, and dyspnoea.[15]

24. Clinical presentation
The most common
symptoms are: [15]
Less common symptoms
i. Fever
ii. Cough
iii. Dyspnoea
iv. Myalgia
v. Fatigue.
i. Anorexia
ii. Sputum production
iii. Sore throat
iv. Confusion
v. Dizziness
vi. Headache
vii. Rhinorrhoea
viii. Chest pain
ix. Haemoptysis
x. Diarrhoea
xi. Nausea/vomiting
xii. Abdominal pain

25. Initial investigations
ResultTest
may show low oxygen saturation (SpO₂ <90%)pulse oximetry
may show low partial oxygen pressureABG
leukopenia; lymphopenia( ~ 80% )
±leukocytosis
Mild thrombocytopenia (rarely <100⟹poor
prognostic sign
CBC
elevated D-dimer;
prolonged prothrombin time
coagulation screen
elevated liver transaminases;
decreased albumin;
renal impairment
comprehensive
metabolic panel

26. Initial investigations
ResultTest
 COVID-19 does not ↑the procalcitonin.
 ↑ procalcitonin ⟹ alternative diagnosis (e.g.
pure bacterial pneumonia).
 In COVID-19 ↑ procalcitonin ⟹ a superimposed
bacterial infection
 may be elevated
procalcitonin
 may be elevatedCRP
 may be elevated
lactate
dehydrogenase
 may be elevatedcreatine kinase
 may be elevatedserum troponin level

27. Initial investigations
ResultTest
negative for bacterial infection
blood & sputum
C/S
 positive for severe acute respiratory
syndrome coronavirus 2 (SARS CoV-2) viral
RNA;
 negative for influenza A and B viruses and
other respiratory pathogens
real-time reverse
transcription
polymerase chain
reaction (RT- PCR)
 Unilateral lung infiltrates are found in 25%
of patients,
 bilateral lung infiltrates are found in 75% of
patients
chest x-ray
bilateral ground-glass opacity or
consolidation
CT chest

28.  Peripheral & bilaterally opacifications in CXR

30.  CT abnormalities are more likely to be; bilateral, a peripheral
distribution, & involve the lower lobes.
 Less common findings ; pleural thickening, pleural effusion &
lymphadenopathy

32. Normal CT chest in early COVID -19

34. CXR & CT in COVID-19
I. Use CXR as standard chest imaging.
II. CT Chest ; only when it would make a difference to
care .
III. CT scan rooms ; carefully cleaned every time after
an infected patient is scanned & it will take longer
than normal to complete each study.
IV. CXR findings – ground glass changes, occasional
consolidation, bilateral and peripheral patterns.
V. Severity of respiratory illness is directly
proportional to how extensively the lungs affected

35. Differential diagnosis
Differentiating testsDifferentiating signs /
symptoms
Condition
RT-PCR : positive for
MERS-CoV viral RNA.
1. Lack of travel history to affected
areas, or of close contact with an
infected person in the 14 days prior
to symptom onset.
2. GIT symptoms 7&URT symptoms
appear to be less common in COVID-
19 .. [15]
1- Middle East
respiratory
syndrome
(MERS)
RT-PCR: positive for
SARS-CoV viral RNA.
There have been no cases of SARS
reported since 2004.
+ 1 & 2
2- Severe acute
respiratory
syndrome
(SARS)
RT-PCR: positive for
influenza A or B viral
RNA.
sore throat is less common in
COVID19. [15]
 + 1
3- Influenza
infection
RT-PCR: positive for
causative organism, or
negative for SARS-
CoV-2 viral RNA
sore throat is less common in
COVID19. [15]
 + 1
4- Common
cold

36. Differential diagnosis
Differentiating testsDifferentiating signs /
symptoms
Condition
RT-PCR: positive for H7-
specific viral RNA.
 May be difficult to differentiate
 Close contact with infected birds
,or living in an area when avian
influenza is endemic.
 sore throat is less common
5- Avian influenza
A (H7N9)
virus infection
RT-PCR: positive for H5N1
viral RNA
 + 1
 Close contact with infected birds ,or
living in an area when avian influenza is
endemic.
 sore throat is less common
6- Avian influenza
A (H5N1)
virus infection
Blood or sputum culture :
positive for causative
organism.
1-………7- Community-
acquired
pneumonia
 CXR: fibronodular opacities in
upper lobes with or without
cavitation; atypical pattern
includes opacities in middle or
lower lobes, or hilar or
paratracheal lymphadenopathy,
and/or pleural effusion.
 Sputum acid-fast bacilli
 Molecular testing: positive for
Mycoplasma tuberculosis .
History of symptoms is usually
longer.
 Presence of night sweats and
weight loss may help to differentiate
8- Pulmonary
tuberculosis

38. Clinical Classification of COVID-19
I. Mild ; (symptoms are mild & no pneumonia
manifestations)
II. Moderate ; (fever + respiratory symptoms, etc. +
pneumonia manifestations can be seen in imaging).
III. Severe ;
• RR > 30/min
• SPo2- <93%
• PaO2/FiO2 <300
• Lung infiltrates >50% within 24- 48 hours
IV. Critical ;
• Respiratory failure (need of MV)
• Septic shock
• MODS

39. Therapeutics/treatment options
OF COVID 19
Isolation of patients
At present, there are no specific antiviral drugs or
vaccine against COVID- 19 infection for potential
therapy of humans.
The only option available is ; using broad-
spectrum antiviral drugs like Nucleoside
analogues & also HIV-protease inhibitors that
could attenuate virus infection until the specific
antiviral becomes available [16]

40. There are no proven or approved treatments
for COVID-19.
The following treatment plan is suggested on;
the on the basis of information available till
date on various investigational treatment
approaches.

41. Treatment Options - COVID 19

PLAN
SEVERITY OF
ILLNESS
i. Outpatient care
ii. Strict Home Quarantine monitored by
government/health authorities
iii. Supportive care
iv. Assess patient’s clinical condition via telephonic
conversation/ using telemedicine facility
Mild illness
without any
risk factors/
Comorbidities
i. Admit in Hospital isolation room
ii. Supportive care
iii. Start empirical antibiotics (per local CAP
guidelines)
iv. Oseltamivir 75/150mg BD
v. Consider starting
Hydroxychloroquine Or
Lopinavir/Ritonavir (If evident risk factors for
progression of disease are present)
Moderate
Illness:
• Dyspnoea
• Hypoeximia
• Infiltrates/
consolidation
on CXR/CT
scan

42. Treatment Options - COVID 19

PLAN
SEVERITY OF
ILLNESS
i. Remdesivir (for compassionate use only)
ii. Tocilizumab can be considered (check IL-6 level
prior to starting Tocilizumab). Especially in
patients with evidence of cytokine release
syndrome.
iii. Continue IV antibiotics & supportive care
iv. Rule out VAP/ catheter related infections & other
secondary bacterial/viral/fungal infections
v. Always keep in mind the to rule out DD of non–
resolving pneumonia
vi. MV: follow ARDS Net protocol strategy
vii. Consider ECMO if need arises
viii. Refractory or progressive cases in ICU: Interferon
beta B1 can be considered. However it should be
combined with an anti-viral (Lopinavir/Ritonavir) &
hydroxychloquine
Critical
Illness:
• MV patient’s
• Multi lobar/
bilateral lung
consolidation
Careful using these
drugs in patients
with multi
organ damage

43. ANTI-VIRAL THERAPY
No anti-viral therapy has been proven to work for
COVID-19 in humans.
INDICATIONS FOR ANTI-VIRAL THERAPY;
Retrospective data from SARS suggests that earlier
treatment (e.g. within 1-2 days of admission) may be
more effective than reserving therapy until severe organ
failures occur (Chan 2003).
The vast majority of patients will do fine without
any therapy, so in most cases there's no need for
antiviral therapy.

44. REMDESIVIR (compassionate use only)
i. Investigational antiviral drug with reported in vitro
activity against SARS-CoV-2
ii. No published phase 3 trials
iii. Mechanism of action: Extrapolated from MERS CoV
iv. Premature termination of viral RNA transcription
v. Has been found to reduce pulmonary pathology in in vitro
studies
vi. Remdesivir cannot be used in combination with other
experimental antiviral agents
vii. Tried in Ebola virus too
viii. Side effects- Hepatotoxicity
ix. Dose: Adult: 200mg IV on day 1(loading dose) followed
by 100mg IV OD x 9 days.
x. Pediatric: < 40 kg: 5 mg/kg IV on day 1, then 2.5 mg/kg
IV q24h

45. Oseltamivir
Neuraminidase enzyme inhibitor in influenza
Not seen in SARS CoV2
No trials on COVID-19
Many patients with similar presentation of
COVID 19 might be influenza
Hence better to give the drug to avoid
patient worsening due to influenza
Dose: 150mg BD x 5 days

46. Lopinavir/Ritonavir (29)
 In vitro reduces replication by 50% in MERS corona
virus
 Definite efficacy not proven
 WHO has mentioned as an agent that can be tried
 May be also tried in combination with Interferon alpha or
Ribavirin
 Potent CYP3A4 inhibitor – monitor for drug interactions
 Oral and liquid formulation is available
 Dose: Adult: 400/100mg PO Q12h
 Pediatric: Pediatric (based on lopinavir): Oral solution

47. INTERFERONS
 IFN-α2a, IFN-α2b orIFN-β1a
 SARS CoV2 attenuates the interferon (IFN)
response of the innate immune system
 Impair the antiviral adaptive type 1 T-
helper cell
 But in vitro effects hasn’t been fully shown
to be working

48. CHLOROQUINE/HYDROXYCHLOROQUINE
Mechanism;
i. Hampers the low pH dependant steps of viral replication
ii. Interference with the cellular receptor ACE2 (potentially
making it particularly effective against SARS & COVID-19)
No renal or hepatic dose adjustments necessary
Side effects: QT prolongation
Dose (Adult) : 400mg PO Q12h x 1 day, 200mg PO
Q12h x 4 days
Pediatric: 6.5mg/kg/DOSE PO q12h x 1 day, then
3.25mg/kg/DOSE PO q12h x 4 days (up to adult
maximum dose

49. TOCILIZUMAB (optional)
IL-6 inhibitor
 reduce the cytokine storm in COVID-19
Reports of tocilizumab use in COVID-19 infections have
been mostly anecdotal from Italy or case series data
from China.
Adverse effects: elevation of liver enzymes, Increased
risk of re-activation of other Respiratory infections.
Dose: 4-8 mg/kg (max 400mg) IV x 1

50. ASCORBIC ACID
Ascorbic acid did appear to improve mortality in the
multi-center CITRIS-ALI trial.
Extremely limited evidence suggests that ascorbic acid
could be beneficial in animal models of corona virus
(Atherton 1978).
Administration of a moderate dose of IV vitamin C
could be considered (e.g. 1.5 grams IV q6 ascorbic
acid plus 200 mg thiamine IV q12). This dose seems
to be safe. However, there is no high-quality evidence to
support ascorbic acid in viral pneumonia.

51. Complications
I. Acute respiratory distress syndrome (ARDS) ;
17% to 29%
II. Acute cardiac injury ; 7% to 12%
III. Arrhythmias ; 16%
IV. Secondary infection ; 10%
V. Acute respiratory failure ; 8%
VI. Acute kidney injury ; 3% to 7%
VII.Septic shock ; 4% to 8%
VIII.DIC ; 71% of non-survivors

52. References
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study. Chin Med J (Engl). 2020 Jan 30 .
2. WHO. Pneumonia of unknown cause – China. January 2020 .
3. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an
outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi. 2020 Feb
17;41(2):145-151 .
4. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): symptoms. February 2020 .
5. Yu P, Zhu J, Zhang Z, et al. A familial cluster of infection associated with the 2019 novel coronavirus indicating potential
person-to-person transmission during the incubation period. J Infect Dis. 2020 Feb 18 .
6. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N
Engl J Med. 2020 Jan 29 .
7. Lu R, Zhao X, Li J, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus
origins and receptor binding. Lancet. 2020 Jan 30 .
8. Chen Y, Guo Y, Pan Y, et al. Structure analysis of the receptor binding of 2019-nCoV. Biochem Biophys Res Commun.
2020 Feb 17. pii: S0006-291X(20)30339-9 .
9. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med.
2020 Feb 19.
10. National Institutes of Health. NIH officials discuss novel coronavirus that recently emerged in China. January 2020 .
11. Clinicaltrials.gov. Safety and immunogenicity study of 2019-nCov vaccine (mRNA-1273) to treat novel coronavirus.
ClinicalTrials.gov identifier NCT04283461. February 2020 .
12. WHO. Coronavirus disease (COVID-19) advice for the public. 2020 .
13. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): prevention and treatment.
February 2020 .
14. WHO. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected.
January 2020 .
15. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus
pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Jan 30
16. H. Lu, Drug treatment options for the 2019-new coronavirus (2019-nCoV), Biosci. Trends (2020),
https://doi.org/10.5582/bst.2020.01020.