Just Go Away

The SARS-COV-2 virus, better known as COVID-19 continues to reveal itself as a deadly and debilitating virus.  Doctors are discovering that it is a systemic, multi-organ disease that often affects the heart, brain and kidneys.  It has also affected the endocrine and hematopoietic systems, particularly with respect to creating a hypercoagulable state.  The sickest patients are often noted to have elevated D-dimer levels along with hypoxemia.  Physicians are beginning to speculate that hypoxemia in COVID-19 patients could be secondary to small pulmonary thrombi and resultant shunting of blood.  The importance of coagulopathies and D-dimer levels was also revealed by a review of 172 COVID-19 patients treated and “cured” at the Shenzhen Third People’s Hospital in Shenzhen, China.  The patients were treated in the period between January 23, 2020, and February 21, 2020 and their discharge criteria included two negative blood tests for the virus at least 24 hours apart.  The discharge criteria also included a normalization of the inflammatory markers IL-6 and CRP but NOT the D-dimer level.  What they found was that even though the patients were “clinically cured” at the time of their discharge, 25 of the 172 patients tested positive for the virus once again.  Of the 25 “reinfected” patients 17 were women and 6 were children less than 12 years of age.  The average time from discharge to “reinfection” was 7 days with a range of 4-12 days.  The reinfection lasted for a much shorter period than the initial infection.  After carefully examining the records of patients who did suffer a relapse or reinfection they found that the lymphocyte concentrations and D-dimer levels of the 25 affected were slightly higher than those who remained virus free.   The D-dimer levels also inversely correlated with the duration of treatment.  Recommendations from the study were to include other immunologic parameters such as the absolute lymphocyte count and the D-dimer before discharging a patient or assuming the patient has been “cured.”  Treatment regimens for the SARS-COV-2 virus are still being determined and adjusted on a case by case basis.  The standard of care, particularly for those with elevated D-dimer levels, may soon include anticoagulants such as heparin or even thrombolytic agents such as tissue plasminogen activator (tPA).  Coagulopathies can be particularly dangerous to pregnant patients.

The sickest patients treated for the SARS-COV-2 virus in China were often noted to have an elevation in their level of troponin I.  They were also found to have elevations in several inflammatory markers and coagulation factors.  It was hoped that once the infection had cleared these abnormalities would return to normal.  In some patients the virus has had a more lasting impact on a number of systems.  Liver functions remained abnormal even after patients had been discharged.  Cardiologists discovered that 10-15% of COVID-19 patients had evidence of heart failure even when they suffered less than significant respiratory involvement.  The SARS-COV-2 virus has a high affinity for the lungs and doctors fear there may be permanent lung damage after the acute effects have resolved.  In previous coronavirus infections such as with SARS and MERS there was long lasting lung damage in the form of fibrosis (in the case of MERS).  The longest survivors of this latest coronavirus have only been “cured” for three months.  As a result we don’t know if there will be any permanent damage to the lungs or other organs.  Will alterations to the lungs, heart, liver and other organs recover completely?  How long will that take?  Patients could remain compromised for months or years to come.  Another concern is whether or not the virus could remain dormant in the body only to be reactivated at some future date.  We are taking this one day at a time; everything is yet to be determined.

 

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