covid elogs
) Covid 19 with co morbidity (Pulmonology/Rheumatology)
Questions:
1) How does the pre-existing ILD determine the prognosis of this patient?
The pre-existing ILD significantly worsens the prognosis of this covid patient.
Interstitial lung disease is characterized by dyspnea, decreased pulmonary diffusing capacity, decreased FVC and TL
Radiology (HRCT) usually shows the development of new pulmonary opacities and fibrosis.
.
Prognosis: Poor
2) Why was she prescribed clexane (enoxaparin)?
The main pathogenesis of systemic inflammation caused by Covid-19 is by inducing a cytokine storm that causes epithelial cell necrosis, increased vascular permeability, dysfunctional humoral and CMI which all collectively lead to acute lung injury and ARDS
Of these cytokines, IL-6 is one that is the most important in determining the prognosis. IL-6 levels are highly elevated in patients with severe disease
CASE 9-2: COVID-19 SEVERE
QUESTIONS:
1) Since patient didn't show any previous characteristic diabetes signs, did the Covid-19 infection aggravate any underlying condition and cause the indolent diabetes to express itself? If so what could be the biochemical pathways that make it plausibl
The patient had slight hyperglycemia, high HbA1c levels (7.1%), which may have aggravated due to COVID-19.
2) Did the patient's diabetic condition influence the progression of her pneumonia?
Yes, with DM or hypergycemia in patients leads to an increase in COVID-19 severity.
3) What is the role of D Dimer in the monitoring of covid? Does it change management or would be considered overtesting?
D- Dimer levels indicate the severity of COVID-19, pertaining to possible thrombotic compliicatons- as D Dimer is formed post- fibrinolysis.
D- Dimer does change the management, as D-Dimer levels above 2000ng/dl were found to have a direct link with increasing severity of COVID-19
CASE 9-3 (COVID-19 SEVERE)
QUESTIONS:
1. Why was this patient given noradrenaline?
Following kidney failure, the patient had sudden and persistent hypotension.
2. What is the reason behind testing for LDH levels in this patient?
LDH (Lactate Dehydrogenase) catalyzes the conversion of lactate to pyruvate and back.
In this patient it may be due to inflammation and its high level indicates severity.
3. What is the reason for switching from BiPAP to mechanical ventilation with intubation in this patient? What advantages did it provide?
Although BiPaP is a positive pressure system, unlike tracheal intubation, it does not send the air to the trachea and depends on the patient's ability to respire.
In this patient, as SpO2 levels were dropping to 30% so switched to mechanical ventilation
CASE 9-4 (COVID-19 MILD)
QUESTIONS:
1. Is the elevated esr due to covid related inflammation?
Yes, as ESR is an important indicator of immunological loss and immunological dysfunction.
2. What was the reason for this patient's admission with mild covid? What are the challenges in home isolation and harms of hospitalization?
Hospitalisation was due to Grade 3 Shortness of Breath (SOB), and long duration of COVID-19 infection.
Challenges of home isolation-
Physical emotional and social challenges
Harms of hospitalisation-infection,cost and overtesting
In case of home isolation patient cannot physically meet their .family .
Socially people maynot support because of the self safety .
CASE 9-5 (COVID-19 SEVERE)
QUESTIONS:
1) What was the reason for coma in this patient?
Severe hypoxia and low spo2 leading to coma
2) What were the competency gaps in hospital 1 Team to manage this intubated comatose patient that he had to be sent to hospital 2? Why and how did hospital 2 make a diagnosis of hypokalemic periodic paralysis? Was the coma related?
The main competency gap was in the lack of testing for serum electrolytes, as the hypokalemia had caused weakness and fatigue in this patient.
Hospital 2 make a diagnosis of hypokalemic periodic paralysis based on the fact that the patient had generalised weakness before becoming comatose, along with tingling and symptoms of paralysis. On testing serum electrolytes, his potassium levels were found to be 2.3 mEq/L (normal-3.5-5)
3) How may covid 19 cause coma?
Yes, as the brain is extremely sensitive to oxygen, oxygen deprivation due to COVID-19 can lead to a comatose state.
Spo2 levels (20%), which may have caused the coma.
CASE 9-6 (COVID-19 WITH ALTERED SENSORIUM)
https://vijaykumarkasturi.blogspot.com/2021/05/65-years-old-male-with-viral-pneumonia.html
QUESTIONS:
1. What was the cause of his altered sensorium?
Probable causes include
Hypoxia and increased urea levels leading to uraemic encephalopathy
2. what is the cause of death in this patient?
The cause of death in this patients was due to complications of COVID-19, most probably Acute Kidney Failure (AKI) due to increased urea and creatinine levels.
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7) A 67 year old lady in the ICU with COVID induced Viral Pneumonia .
https://drsaranyaroshni.blogspot.com/2021/05/a-67-year-old-lady-in-icu-with-covid.html
Q1. What is the grade of pneumonia in her?
A. Moderate based her ct severity score.
Q2. What is the ideal day to start steroids in a patient with mild elevated serum markers for COVID ?
A. It isbest to start dexamethasone before cytokine storm onset.
Q3. What all could be the factors that led to psychosis in her ?
A. The following can lead to ICU psychosis
Sleep deprivation
Stress
Continuous monitoring
Lack of orientation
Dehydration
Q4. In what ways shall the two drugs prescribed to her for psychosis help ?
A. Pirecetam improves memory and causes cognitive enhancement
Resperidone acts by decreasing the dopaminergic pathways in the brain
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Q5. What all are the other means to manage such a case of psychosis?
A. The icu psychosis can be managed by sleep deprivation correction
Haloperidol drug is used for managing icu psychosis.
Anti-psychotics.
Q6. What all should the patient and their attendants be careful about ( w.r.t. COVID )after the patient is discharged ?
A. The patient is supposed to self isolate after they are discharged for next 7 days
Look for danger signs like breathlessnes and bluish discolouration
Continue o2 monitoring.
Q7. What are the chances that this patient may go into long covid given that her "D Dimer" didn't come down during discharge?
Elevated levels of D Dimer and CRP and persistence of cough,fever and breathlessnes
8) 35YR/M WITH VIRAL PNEUMONIA SECONDARY TO COVID 19 INFECTION
Q1. Can psoriasis be a risk factor for severe form of COVID?
A. There is no evidence that patients with moderate-to-severe psoriasis receiving systemic treatments, including biologics, have higher risk of SARS-CoV-2 infection hospitalization and mortality
Q2. Can the increased use of immunomodulatory therapies cause further complications in the survivors?
A. Immunomodulators help COVID 19 patients by reducing the cytokine storm but they also have thepotential to increase the risk of infection (like mucormycosis),
Q3. Is mechanical ventilation a risk factor for worsened fibroproliferative response in COVID survivors?
A. Mechanical ventilation, which is necessary for life support in patients with acute respiratory distress syndrome as seen in COVID 19 can cause lung fibrosis.
It can also cause lung injury and fibroproliferative response in COVID Patients leads to fibrosis and finally death.
9) 45 year old female with viral pneumonia secondary to Covid-19
Q1. What is the type of DM the patient has developed ?(is it the incidental finding of type 2 DM or virus induced type 1DM)?
A. Incidental type 2 DM can be differentiated from de novo covid induced type 1 DM with the help of the HbAc1 levels.
As HbAc1 levels are indicators of long term blood ssugar levels they are likely to be raised in pre existing DM that was incidentally discovered. But in case ofthe diabetes being de novo in nature then the HbAc1 levels are unlikely to be raised.
So we cannot determine.
Q2. Could it be steroid induced Diabetes in this patient?
A. Yes,As the patient was given dexamethasone as a part of her treatment regimen it is possible that her elevated glucose levels are a result of steroid induced hyperglycemia.
10) A little difference that altered the entire covid recovery game: a report of two patients with focus on imaging findings.
Q1. What are the known factors driving early recovery in covid?
A. The following factors can lay a role:
Younger age group
No diabetes
PaO2/FiO2 levels
No comorbidities
Mild symptoms
No fever for long duration
11) Viral pneumonia secondary to COVID of a denovo Diabetes Mellitus
1. How is the diabetes related to the prognosis of COVID patients? What are the factors precipitating diabetes in a patient developing both covid as well as Diabetes for the first time?
A. People suffering from diabetes are likely to experience more severe symptoms and has poor prognosis
Possible causes for de nov diabetes in COVID19 include:
1.Cytokine storm damages beta cells
2.Pancreatic cell damage by large viral load
·
Q2. Why couldn't the treating team start her on oral hypoglycemics earlier?
A. To bring down her sugar levels and early recovery we opt faster acting drugs like insulin over oral hypoglycemics.
12) Moderate to severe covid with prolonged hospital stay:
Questions:-
1) What are the potential bio clinical markers in this patient that may have predicted the prolonged course of her illness?
Serum LDH: 571U/L (Normal range=140-280U/L
ALP : 342 U/L (Normal range=44-147U/L)
SpO2: 82% at RA (Normal range= >96%)
HR: 124bpm (Normal range=60-100bpm)
Classically, the bio clinical markers that are predictive of a Covid-19 patient's outcome are
C reactive protein [>57.9mg/dL]
D-Dimer [>1mcg/ml associated with poorer prognosis]
Serum LDH [>248U/L]
IL-6 [2.9 times higher in severe disease compared to mild disease]
SGPT [Isolated rise in SGPT >3 times the normal value]
ESR [high sustained level after recovery from infection]
Albumin
Platelet count
Neutrophil count
NLR: [>5.5]
Urea
Creatinine
High sensitivity Troponin
The patient in question has elevated levels of serum LDH and ALP. Her CRP and D-Dimer levels are not high enough to be considered as a bad prognostic factor.
Sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219356/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194951/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896696/
13) Severe covid with first diabetes
Link to Case report log :
https://vignatha45.blogspot.com/2021/05/58-years-female-patient-with-viral.html
1) What are the consequences of uncontrolled hyperglycemia in covid patients?
Hyperglycemia can lead to anomalous glycosylation of tissue receptors throughout the body. One of these receptors happens to be ACE2, the same receptor SARS-CoV2 uses to gain entry into the host cell. In fact, glycosylation of ACE2 is necessary for the virus to establish an infection.
Uncontrolled hyperglycemia freely facilitates this glycosylation, making these patients more susceptible to Covid-19 infections and increasing the severity of the infection by helping increase the viral load (by increasing the concentration of glycosylated ACE2)
Control of blood sugar can also decrease the chances of a cytokine storm during the second phase of the infection.
Uncontrolled hyperglycemia hence, suggests a poor prognosis in Covid-19 patients.
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188620/#:~:text=Therefore%2C%20high%20and%20aberrantly%20glycosylated,and%20a%20higher%20disease%20severity.
2) Does the significant rise in LDH suggests multiple organ failure?
Lactate dehydrogenase has 5 isoenzymes that are present in various tissues such as the heart, RBCs, lungs, liver, kidney, brain, and skeletal muscle.
Since covid-19 primarily causes lung damage, LDH3 is released into the blood giving an elevated titer.
Multi-organ damage that involves the heart (myocarditis) or kidneys (renal failure) can lead to an elevation in respected isoenzymes found in these tissues.
Hence, a significant rise in LDH indicates a poor prognosis and points towards multi-organ damage.
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251362/
3) What is the cause of death in this case?
This patient was diagnosed with uncontrolled hyperglycemia with severe covid pneumonia.
LFT shows elevated AST, ALT, and ALP with a gross increase in bilirubin titer.
The D-Dimer is elevated (560ng/ml) and the LDH is 835U/L both of which are indicators of a poor prognosis.
The most likely cause of death in this patient seems to be ARDS.
The immediate cause of death: Most probably cardio-pulmonary arrest
Antecedent cause: Severe covid-19 pneumonia
14) Long covid with sleep deprivation and ICU psychosis
Questions:
1)Which subtype of ICU psychosis did the patient land into according to his symptoms?
Hyperactive delirium: Manifests as agitation, restlessness, refusal to cooperate with caregivers, unprovoked mood changes, hallucinations
2)What are the risk factors in the patient that has driven this case more towards ICU psychosis?
Hypertension
History of cerebrovascular accident (makes him more prone to a new one)
Steroid use
Sedative use (Gabapentin)
COPD
3)The patient is sleep-deprived during his hospital stay. Which do you think might be the most probable condition?
A) Sleep deprivation causing ICU psychosis
B) ICU psychosis causing sleep deprivation
B) ICU psychosis causing sleep deprivation is more likely in this patient
4) What are the drivers toward current persistent hypoxia and long covid in this patient?
Elevated bio clinical markers like D-Dimer, LDH, Neutrophils, WBCs(absolute), IL-6, and CRP all contribute to persistent hypoxia and worsen the prognosis. In addition to this, ICU psychosis adds to the prolonged hospital stay.
15) Moderate Covid with comorbidity (Truncal obesity and recent hyperglycemia
Question
1. As the patient is a non-diabetic, can the use of steroids cause a transient rise in blood glucose?
Cortisol stimulates gluconeogenesis in the liver and inhibits glycogen synthesis, increasing blood glucose. Continuous treatment with corticosteroids can lead to elevated blood glucose titers even in non-diabetics.
2. If yes, can this transient rise lead to long-term complications of New-onset diabetes mellitus?
It is still unclear if the alterations brought about by covid-19 in the glucose metabolism are permanent and persist or remit after the resolution of infection. There are ongoing studies that aim to answer these questions.
Steroid diabetes is a term coined to describe diabetes mellitus arising as a result of glucocorticoid use for more than 50 years
3. How can this adversely affect the prognosis of the patient?
Hyperglycemia in general is indicative of a poorer prognosis in a patient compared to covid patients with normal blood glucose levels.
4. How can this transient hyperglycemia be treated to avoid complications and a bad prognosis?
Oral hypoglycemics (such as sulfonylureas) are efficient at controlling blood glucose levels in non-diabetics who develop steroid-induced hyperglycemia.
5. What is thrombophlebitis fever?
Fever in response to thrombophlebitis that is caused due to release of inflammatory mediators
6. Should the infusion be stopped in order to control the infusion thrombophlebitis? What are the alternatives?
No.
Thrombophlebitis can be treated by local compressive dressings, NSAIDs (topical and/or systemic)
16) Mild to moderate covid with hyperglycemia
Questions:
1. What could be the possible factors implicated in elevated glycated HB ( HBA1c ) levels in a previously Non-Diabetic covid patient?
The possible factors that could have led to precipitation of diabetes in a covid-19 patient are:
Genetic susceptibility to diabetes
Pre diabetic state
Viral insult to the beta cells of the pancreas
High dose steroid usage
17) Covid 19 with hypertension comorbidity
1)Does hypertension have any effect to do with the severity of the covid infection.If it is, Then how?
Yes, hypertensive patients are at a higher risk of COVID 19 severity.
They have high risk of developing cardiovascular and endorgan failure
2)what is the cause for pleural effusion to occur??
Pneumonia caused due to COVID-19 infection lead to increase permeability of microvascular circulation which lead to pleural effusion(exudative type)
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18) Covid 19 with mild hypoalbuminemia
QUESTIONS:
1. What is the reason for hypoalbuminemia in the patient?
The reason for hypoalbuminemia in COVID_9 patient is due to increased catabolism of albumin to make amino acids as well as simulataneous decrease in albumin synthesis
2. What could be the reason for exanthem on arms? Could it be due to covid-19 infection ?
Exanthem is an eruptive skin rash seen in viral infections. Yes, this could be due to COVID-19 infection. The exanthem in COVID-19 resembles that of varicella.
2. What is the reason for Cardiomegaly?
High blood pressure might be the underlying cause for cardiomegaly in this patient.
Uncontrolled high blood pressure leads to increase in work load of heart leading to cardiomegaly.
3. What other differential diagnoses could be drawn if the patient tested negative for covid infection?
· Chicken pox
· Shingles
· Pytriasis
4. Why is there elevated D-Dimer in covid infection? What other conditions show D-dimer elevation?
D-dimer is increased in a COVID-19 patient. It may be related to the viral life cycle. The apoptotic processes target the endothelial cells of the vasculature resulting in triggered coagulopathy and ultimately result in increased d-dimer levels.
20) Covid 19 with first time diabetes
Questions:
1)Can usage of steroids in diabetic Covid patients increases death rate because of the adverse effects of steroids???
COVID-19 infection causes systemic inflammation and cytokine leadth to inceased death rate.
In diabetic patient due to disruption of carbohydrates metabolism and leading to hyperglycemia can be the outcome of steroids.
2)Why many COVID patients are dying because of stroke though blood thinners are given prophylactically?
In COVID-19 infection due to cytokine storm and inflammation leading to damage of blood vessels. Due to high cholesterol levels it is causing stroke.
3)Does chronic alcoholism have effect on the out come of Covid infection?If yes,how?
Yes, chronic alcoholism does worsen the prognosis of COVID-19 patient.
Chronic alcoholism leads to impaired immune response
21) Severe Covid with Diabetes
Questions-
1. What can be the causes of early progression and aggressive disease(Covid) among diabetics when compared to non diabetics?
it is observed that there is a early as well as aggressive progression of COVID 19 in diabetics.
Hyperglycemia and low immunity
2. In a patient with diabetes and steroid use what treatment regimen would improve the chances of recovery?
methylprednisolone from 40 mg/day to 160 mg/day for 6 days according to the weight and status of the patients.
Continous monitoring of blood sugar levels.
3. What effect does a history of CVA have on COVID prognosis?
History of CVA with coagulopathy leads to poor prognosis
23) Covid 19 with multiple comorbidities:
1) What do you think are the factors in this patient that are contributing to his increased severity of symptoms and infection?
· Old age
· Diabetes mellitus type 2
· Chronic kidney disease
· Bronchial asthama
2) Can you explain why the D dimer levels are increasing in this patient?
Increase in D dimer levels are due to coagulopathy and increased viral load.
3) What were the treatment options taken up with falling oxygen saturation?
· Head elevation
· O2 supplementation
4) Can you think of an appropriate explanation as to why the patient has developed CKD, 2 years ago? (Note: Despite being on anti diabetic medication, there was no regular monitoring of blood sugar levels and hence no way to know for sure if it was being controlled or not)
During the early stage diabetes, glomeruli ability to filter blood decreases which leadsto accumulation of waste material and scarring of glomeruli eventually CKD
Medical Education
Elog making helping me alot in learning new cases and questions and discussions are very much helpful. Through e blogging i learnt a lot of things which was very new my best experience where we can correlate with very first symptom her progression and final investigation treatment modality of the patient .Thank you so much sir for making patient centered learning as a best platform for acquiring great clinical knowledge.
Thanks to all the interns and pgs for the guidance.
May 19th 2021
I was alloted a case for eblog making.
May 20 2021
I published the case with possible questions.
Thanks to Dr.Rakesh Biswas sir for this making this e learning interesting with case discussions and blogging
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