Covid 19 Presentation and diagnosis

1. COVID -19 (SARS-CoV 2)
PRESENTATION AND DIAGNOSIS
BY DR JAMAL UMAR
RESIDENT PULMONOLOGY
KHYBER TEACHING HOSPITAL

2. BACKGROUND

3. TRANSMISSION
 via respiratory droplets produced when a person
sneezes or coughs.
 virus has been detected in blood, and faecal
transmission may also be possible.
 also been detected in saliva
 INCUBATION PERIOD : 2 to 14 days

4. PATHOGENESIS
 binds to the angiotensin-converting enzyme-2
(ACE2) receptor in humans
 a spike glycoprotein receptor binding domain of
SARS-CoV-2
 higher binding affinity for ACE2 on host cells
compared to SARS-CoV.
 Furin like cleavage site has been identified in the
spike protein of the virus; this does not exist in
other SARS-like coronaviruses.
 High viral loads have been detected in nasal and
throat swabs soon after symptom onset.
 asymptomatic patient have a similar viral load
compared with symptomatic patients.

5. HISTORY TAKING
 mild illness 81%
 severe illness 14%
 critical illness 5%
 Fever 43-98%(high grade sustained
for 10 days, may be intermittent)
 ABSENCE OF FEVER DOESNOT
RULE OUT THE DIAGNOSIS

6. SYMPTOMS
 Cough 68-82%
 Sputum 4-56%
 Breathlessness 3-64% (Onset on day
6)
 SILENT OR HAPPY HYPOXEMIA
 Seen in elderly
 No increased work of breathing but
severe hypoxia

7. SYMPTOMS
 Less common: GI disturbance (diarrhoea, nausea, vomitting may precede fever)
upto 10%
 Rhinorrhea 4-24%
 Sore throat 14%
 Myalgias 11-15%
 Headache 6-34%
 Anosmia Upto 2/3rd of patients with covid (67%)

8. RISK FACTORS FOR SEVERE DISEASE
EPIDEMIOLOGICAL
SEVERE
PNEUMONIA
or
ARDS
 Increasing Age >60 yrs
 Obesity
 Diabetes mellitus
 Hypertension
 Immunocompromised states
 Malignancy
 Kidney disease
 Liver Disease
 Chronic respiratory illnesses
 Heart disease

9. RISK FACTORS OF SEVERE DISEASE
CLINICAL
 RR > 35 breaths/ min
 SaO2 < 93 % RA
 HR < 125 bpm

10. RISK FACTORS OF SEVERE DISEASE
LABORATORY CRITERIA
 D dimers >1000 ng/ml
 S LDH > 245
 S ferritin > 300
 Elevated cardiac troponins
 Lymphopenia < 0.8 x 10 9

11. DISEASE PROGRESSION
Cough/Fever
Day 1
SOB
Day 6
Admission day
Day 8
ITU
Day 10
ARDS
Day 12
AKI/ACI
Day 15
Death
Day 19

12.  Key feature: Acute Respiratory Distress Syndrome with a cytokine storm
• Expect admission 7-10 days
• Patients can seem relatively ok, then rapidly deteriorate
 Severe hypoxia
 May be minimal work of breathing
 Normal CO2
• Fulminant cardiomyopathy can be a late feature as patients recover from ARDS
 BE VIGILANT OF PATIENTS WITH INCREASING O2
REQUIREMENT

13. CYTOKINE RELEASE SYNDROME
 Ferritin >1000 mcg/L or increasing in last 24 hours. Or
 Ferritin >2000 mcg/L in patients requiring oxygen therapy or ventilatory support.
Or
 Lymphopenia <800 cells/ml or < 20% or N:L > 5 plus 2 or more of the following
 Ferritin > 700 mcg/L and increasing in last 24 hrs
 LDH > 245 IU and increasing in last 24 hrs
 D dimers > 1000 ng/ml or increasing in last 24 hrs
 CRP > 70 mg/L or rising in last 24 hrs

14. INITIAL INVESTIGATIONS
 Pulse oximetry (Low SaO2)
 ABG (as indicated to detect hypoxemia and hypercarbia)
 FBC
 Comprehensive metabolic panel
 Coagulation screen
 Inflammatory markers (serum procalcitonin and C-reactive protein)
 Serum troponin
 Serum lactate dehydrogenase
 Serum creatine kinase
 Blood and sputum cultures

15. INVESTIGATIONS
Test Result Comments
WCC Normal N:L ratio > 3 poor prognosis
Lymphocytes Low Low in 80% of cases
Neutrophils Normal / High
Platelets Mildly low < 100 poor prognosis
CRP High > 125 poor prognosis. If normal
consider alternate diagnosis eg
heart failure

16. INVESTIGATIONS
Test Result Comments
Lactate Mildly High
Troponin High Poor prognosis. Not MI -
ECG
Urea /Creat Mildly High AKI usually mild
Albumin Low
CK High Rhabdomyolysis may
contribute to renal failure
late in disease
AST/ALT High 5 times normal, transient,
no fulminant hepatitis; rise
day 14
Ferritin High

17. DIAGNOSTIC TESTS
 RT-PCR assays for SARS-CoV-2 in all patients with suspected infection
(Sensitivity upto 67-80%)
Lower respiratory tract specimens
 Sputum
 endotracheal aspirate
 bronchoalveolar lavage where possible and depending upon the patient’s
condition
Upper respiratory tract specimens
 nasopharyngeal aspirate
 combined nasopharyngeal and oropharyngeal swabs may be used if lower
respiratory tract specimens cannot be collected

18. DIAGNOSTIC TESTS
 If initial testing is negative in a patient who is strongly suspected to have
COVID-19, recollect specimens from multiple respiratory tract sites (nose,
sputum, endotracheal aspirate) and retest(positive in 23% of patients)
 Blood, urine, and stool specimens may also be used to monitor for the presence
of the virus (sensitivity of diagnoses is uncertain.
 Collect nasopharyngeal swabs for testing.
 Serological testing is not available as yet, but assays are in development
 CXR /CT changes present before swab positive
 If high clinical suspicion continue isolation and PPE

19. CHEST RADIOGRAPHY
 Request information – ensure COVID-19 respiratory history, smoking history
 Typically patchy ground glass
 opacities peripheral and basal
 Unilateral in 25%, Bilateral in 75 %
 Number of lung segments involved increases with more severe disease

20. CHEST RADIOGRAPHY
 Over time, patches coalesce into dense consolidation
 May be subtle /appear normal (40%)
 effusions(5%)
 Cavitation
 mass
 lymphadenopathy

21. RADIOGRAPHIC FINDINGS
 84-year-old female
 dyspnea for two weeks, no fever, no
cough
 ill-defined consolidations in the
periphery of the mid- and lower-lung
fields
 COVID-19 was confirmed by RT-PCR

22. RADIOGRAPHIC FINDINGS
50-year-old female patient
COVID 19 detected by RT-PCR
acute respiratory distress syndrome (ARDS)
ill-defined consolidations in both lungs, with a
predominance in the lower lung fields

23. RADIOGRAPHIC FINDINGS

24. CT FINDINGS
 Consultant request Sensitivity around 80% - may be normal
in early stages
 Peripheral ground-glass opacities
 Crazy paving
 Diffuse alveolar damage
 Organising pneumonia
 Less likely
 non-peripheral, effusions, lymph nodes
 Unlikely
 lobar pneumonia, cavitation, Tree-in bud changes

25. CHEST X RAY AND CT SCAN

26. CT FINDINGS
 27 years old male
 COVID 19 detected
 BL lower lobe GGOs

27. REFERENCES
1. Kings Clinical Summary guidelines’ on Kwiki. Information from EMCRIT.com
2. Vaduganathan M, Vardeny O, Michel T, McMurray JJ, Pfeffer MA, Solomon
SD. Renin–angiotensin–aldosterone system inhibitors in patients with Covid-19.
New England Journal of Medicine. 2020 Apr 23;382(17):1653-9.
3. Simpson S, Kay FU, Abbara S et al. Radiological Society of North America
Expert Consensus Statement on Reporting Chest CT Findings Related to
COVID-19. Endorsed by the Society of Thoracic Radiology, the American
College of Radiology, and RSNA. Radiology: Cardiothoracic Imaging. 2020
Mar 25;2(2):e200152.
4. Jajodia A, Ebner L, Heidinger B, Prosch H. Imaging in corona virus disease
2019 (COVID-19)—A scoping review. European journal of radiology open.
2020 May 11:100237.
5. BMJ Best Practice topic based on the web version that was last updated: Mar 02,
2020.