Specialist ENT CORONA VIRUS DISEASE 2019

CORONA VIRUS DISEASE 2019

Introduction:

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Corona virus causes respiratory tract infections that can be mild such as common cold or can be life threatening, such as SARS (Severe acute respiratory syndrome), MERS (Middle East respiratory syndrome), and COVID-19 ( Corona virus disease 2019). 

History:

The disease was first identified in December 2019 in Wuhan, the capital of China’s Hubei province and it then spread globally, resulting in a 2019–20 coronavirus pandemic.

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Disease transmission: The virus is most contagious when people are symptomatic. However, spread may be possible before symptoms appear. The incubation period for COVID-19 is typically five to six days but may range from two to 14 days. The virus survives for hours to days on surfaces.

Modes of Spread:

  1. Primarily spread during close contact (within 1–3 m) and by small droplets produced when people cough, sneeze, or talk.
  2. Bioaerosol transmission may be possible. Some medical procedures such as intubation, tracheostomy and cardiopulmonary resuscitation (CPR) may cause respiratory secretions to be aerosolized and thus result in airborne spread.
  3. It may also spread when one touches a contaminated surface (fomite transmission) and  then via eyes, nose, or mouth. It may spread by feces.

Pathophysiology:

  1. The lungs are the organs most affected by COVID-19 because the virus accesses host cells via the enzyme ACE2, which is most abundant in the type II alveolar cells of the lungs. The virus uses a special surface glycoprotein called a “spike” (peplomer) to connect to ACE2 and enter the host cells. The density of ACE2 in each tissue correlates with the severity of the disease in that tissue.
  2. The virus also affects gastrointestinal organs as ACE2 is abundantly present in the glandular cells of gastricduodenal and rectal epithelium as well as endothelial cells and enterocytes of the small intestine.
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Clinical features:

  1. Some patients may be totally asymptomatic.
  2. Flu like symptoms like fever, cough, fatigue, and shortness of breath.
  3. Upper respiratory symptoms, such as sneezingrunny nose or sore throat may be seen.
  4. Gastro intestinal symptoms like nauseavomiting and diarrhea.
  5. Emergency symptoms include difficulty in breathing, persistent chest pain or pressure, confusion, difficulty waking up and bluish face or lips. Immediate medical attention is advised if these symptoms are present.
  6. In some cases the disease may progress to pneumoniamulti-organ failure, and death.
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Diagnosis:

  1. The standard method of testing is real-time Reverse transcription polymerase chain reaction (rRT-PCR).

    Preferred sample: Throat and nasal swab stored in viral transport media (VTM) and transported on ice.

    Alternate: Nasopharyngeal swab, BAL (Broncho alveolar lavage) or endotracheal aspirate which has to be mixed with the viral transport medium and transported on ice. Results are generally available within a few hours to two days.
  2. X ray of chest is of little value in early stages.
  3. HRCT scan chest shows bilateral multilobar ground-glass opacities with a peripheral, asymmetric and posterior distribution. Consolidation develops as the disease progresses.
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Specialist ENT Screenshot 2020 11 29 book near final miscellaneous12

Prevention:

  1. Social distancing-
    • To prevent the transmission of the virus, infected individuals are instructed to stay home except to get medical care.
    • Avoid any physical contact in greetings.
    • Wearing a face mask is recommended when outdoors or where the infection is suspected to exist.
    • Social distancing means maintaining six feet apart distance.
    • Avoid sharing personal household items.
  2. Respiratory hygiene-
    • Covering up the mouth and nose with a tissue during any cough or sneeze.
    • Proper hand hygiene after blowing one’s nose.
    • Spitting in public places should be avoided.
  3. Hand washing
    • Wash hands periodically with soap and warm water for at least 20 seconds, especially when hands are visibly dirty.
    • Avoid touching the nose, mouth or even eyes with unwashed hands.
    • Washing the hands after any cough and sneeze.
    • In the cases where soap and water are not available to wash the hands, then wash hand using an alcohol-based hand sanitizer with at least 60% alcohol.
  4. In package shipping-
    • Recommends washing the hands with soap and water during 20 seconds after handling.
  5. Mask use-
    • According to the World Health Organization, the use of masks is recommended if a person is coughing or sneezing, and when one is taking care of someone with an infection or suspected infection.
    • It helps to avoid touching the own face.
    • Common masks and face coverings should be washed frequently, or dumped after use.
    • N-95 masks are strongly recommended.
  6. Experienced prevention-
    • Coronaviruses die after being heated at 56 °C during 30 minutes.
    • Vitamins C and D and zinc rich food or supplements to boost immunity.
  7. When infected-
    • Stay home except to get medical care.
    • Wear a face mask before entering the healthcare provider’s office.
    • When in any room or vehicle with another person, cover coughs and sneezes with a tissue.
    • Regularly wash hands with soap and water. 
    • Staying away a certain distance from the rest of residents in the house. (home quarantine)
    • Using different bedroom and bathroom and avoid sharing personal household items.
Virology and drug target:
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Management:
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i. At this time there are no medical therapies that have been definitively shown to improve outcomes in patients with COVID-19.

ii. The reported clinical benefits of the combination of hydroxychloroquine and azithromycin for patients with COVID-19 come either from media reports or nonrandomized trials with small numbers of participants (<100 patients).

iii. Given the important role the immune response plays in the complications of COVID-19, active clinical trials are evaluating immunomodulatory drugs (such as IL-6 receptor antagonists) in this disease. In patients with “cytokine storm,” characterized by marked elevation in inflammatory markers, use of IL-6 receptor antagonists can be considered. The role of corticosteroids remains controversial and current guidelines from the World Health Organization do not recommend their use unless another concomitant indication exists such as chronic obstructive pulmonary disease exacerbation or pressor-refractory shock.

iv. Patients who are stable as an outpatient or have no evidence of oxygen requirement or pneumonia by imaging can generally be managed with supportive care alone. Patients who have evidence of hypoxia or pneumonia, especially those with risk factors for disease progression such as age older than 65 years, cardiac or pulmonary comorbidities, and immunosuppression can be considered for specific COVID-19 therapy after discussing the risks and benefits with the patient and in accordance with local hospital treatment guidance.

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