Corona Virus by Dr Anurag Yadav

COVID 19 (CORONA VIRUS)
DR ANMOL MANASWINI
DR ANURAG YADAV
1
By Dr Anmol Manaswini @SRRITCD

Things to be dealt!!!
Introduction
Pathogenesis
Clinical Features
Diagnosis
Management
Prevention
2

Introduction
• Corona viruses are important human and
animal pathogens.
• At the end of 2019, a novel coronavirus was
identified as the cause of a cluster of
pneumonia cases in Wuhan, a city in the
Hubei Province of China.
• It rapidly spread, resulting in an epidemic
throughout China, followed by a global
pandemic.
3

• In February 2020, the World Health
Organization designated the disease COVID-19
• The virus that causes COVID-19 is designated
severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2); previously, it was
referred to as 2019-nCoV.
• Understanding of COVID-19 is evolving
everyday
4

Corona Virus
Single Stranded RNA
Non segmented
Protein Envelope (Capsid)
Crown Shaped Virions
<100nm
Largest among RNA Viruses
CORONA VIRUS (CoV)
6

7

CORONA VIRUS (CoV)
8
(79%)
(51%)

EPIDEMIOLOGY
• Globally, over 50 million confirmed cases of
COVID-19 have been reported.
• Cases have been reported in all continents,
except for Antarctica.
• The reported case counts underestimate the
overall burden of COVID-19, as only a fraction of
acute infections are diagnosed and reported
• The rate of prior exposure to SARS-CoV-2, as
reflected by seropositivity, exceeds the incidence
of reported cases by approximately 10-fold or
more
9

Next generation Sequencing (NGS) revealed that bats are the
primary source of the CORONA virus as there was 98% homology
between bats and Human viruses 10

CORONA VIRUSES ARE ZOONOTIC
Dromedary Camels
Civet Cats
Bats
Pangolins
11

Pathogenesis of SARS
12

Transmission
Person to person
Direct transmission
(via droplet)
Indirect
transmission
(via fomites)
Vertical
transmission
Breast feeding
13

14

15

Person to person transmission
•Respiratory droplets > 5-10 microns
•Droplet nuclei <5 microns
16

Procedures that generate aerosols
17

Period of Infectivity- Highest is 2 days prior to onset of symptoms
and until 7 days after development of symptoms
18

Transmission cycle
19

Disease progression and Host response
20

Immunity following infection
Humoral immunity
• Detectable neutralizing antibodies depending on
severity
• These antibodies decline over a period of few
months
Cell mediated immunity
• Studies have also identified SARS-CoV-2-specific
CD4 and CD8 T cell responses
21

High risk factors for severe disease
• Age > 60yrs
• Cardiovascular disease
• Diabetes mellitus
• Hypertension
• Chronic lung disease
• Chronic kidney disease
• Cancer
22

Symptoms
• Fever
• Dry cough
• Dyspnea
• Myalgia/fatigue
• Sputum production
• Sore throat
• Headache
• Diarrhoea
23

Other Symptoms
• Conjunctival congestion
• Anosmia
• Dysguesia
• Hemoptysis
• Nausea
24

Clinical features
Uncomplicated
Mild pneumonia
Severe
Penumonia
ARDS
Sepsis
&
Septic
Shock
25

26
• Fever
• Cough
• Sore throat
• Nasal congestion
• Malaise
• Headache
Uncomplicated
• Signs of Pneumonia
• But No signs of Severe Pneumonia
Mild Pneumonia
• Fever with suspected respiratory
infection plus one of the following
• RR>30/min
• Respiratory distress
• SpO2 <90% on Room air
Severe
Pneumonia
No signs of Dehydration Sepsis
or SOB

Acute Respiratory Distress Syndrome
(ARDS)
27
Definition
• Onset: new or worsening respiratory symptoms within one week of known clinical
insult.
• Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully
explained by effusions, lobar or lung collapse, or nodules.
• Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid
overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic
cause of oedema if no risk factor present
Oxygenation
(adults)
• Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP
≥5 cm H2O, or non-ventilated)
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5
cm H2O, or non-ventilated)
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cm H2O, or non-
ventilated)
• When PaO2 is not available,SpO2/FiO2 ≤315 suggests ARDS (including
in non-ventilated patients)

Sepsis
• life-threatening organ dysfunction
caused by a dysregulated host
response to suspected or proven
infection, with organ dysfunction
• altered mental status
• difficult or fast breathing
• low oxygen saturation
• reduced urine output
• fast heart rate
• weak pulse
• cold extremities or low blood
pressure
• skin mottling
• laboratory evidence of
Coagulopathy, thrombocytopenia,
acidosis, high lactate or
hyperbilirubinemia
Septic shock
• persisting hypotension
despite volume
resuscitation
• requiring vasopressors to
maintain MAP ≥65
mmHg
• serum lactate level
< 2 mmol/Ls
28

Complications
Short term
• ARDS
• Cardiac
• Acute liver injuery
• AKI
• DIC
• Pancreatic injury
• Septic shock
• Secondary infection
• Neurological
complication
Long term
• End stage pulmonary
fibrosis
• Rhabdomyolysis
29

Differential diagnosis
Infectitious
Viral
Adenovirus
Influenza/parainfluenza
Respiratory syncytial
virus
Rhinovirus
Other
Atypical
pneumonia(Mycoplasma,
Chlamydia,Legionella)
Acute HIV syndrome
Dengue/Malaria
Non
infectitious
Acute Pulmonary
embolism
Acute coronary
syndrome
Acute chest
syndrome(SCA)
Acute exacerbertion of
COPD
Pulmonary edema
30

Laboratory
investigation
Radiological
Imaging
Microbiological
tests
Diagnosis
31

Laboratory abnormalities
• Lymphopenia
• Thrombocytopenia
• Elevated liver
enzymes/Bilirubin
• Elevates blood urea
nitrogen / creatinine
• Cardiac biomarkers
– Elevated lactate
dehydrogenase (LDH)
– Elevated troponin
– Elevated creatine
phosphokinase (CPK)
•Elevated inflammatory
markers
•C-reative protein
[CRP]
• ferritin
•ESR
•Inflammatory cytokines
•interleukin 6 [IL-6]
•tumor necrosis factor
[TNF]-alpha
•Coagulation abnormlities
•Elevated D-dimer (>1
mcg/mL)
•Elevated prothrombin
time (PT)
•FDP’s 32

Laboratory features associated with
severe COVID-19
Abnormality Possible threshold
Elevations in:
•D-dimer >1000 ng/mL (normal range: <500 ng/mL)
•CRP >100 mg/L (normal range: <8.0 mg/L)
•LDH
>245 units/L (normal range: 110 to 210
units/L)
•Troponin
>2× the upper limit of normal (normal
range for troponin T high sensitivity:
females 0 to 9 ng/L; males 0 to 14 ng/L)
•Ferritin
>500 mcg/L (normal range: females 10 to
200 mcg/L; males 30 to 300 mcg/L)
•CPK
>2× the upper limit of normal (normal
range: 40 to 150 units/L)
Decrease in:
•Absolute lymphocyte count <800/microL 33

IMAGING FINDINGS
• Chest radiographs
– normal in early or mild disease
– 20 percent did not have any
abnormalities on chest radiograph at
any point during the illness
–consolidation and ground-glass
opacities, with bilateral, peripheral,
and lower lung zone distributions
– peak in severity at 10 to 12 days after
symptom onset 34

• Chest CT
• Typical appearance—
– Peripheral, bilateral, GGO with or without
consolidation or visible intralobular lines ("crazy-
paving")
– Multifocal GGO of rounded morphology with or
without consolidation or visible intralobular lines
("crazy-paving")
– Reverse halo sign or other findings of organizing
pneumonia (seen later in the disease)
35

Indeterminate appearance
• Absence of typical features AND
• Presence of:
– Multifocal, diffuse, perihilar, or unilateral GGO
with or without consolidation lacking a specific
distribution and are non-rounded or non-
peripheral.
– Few very small GGO with a non-rounded and non-
peripheral distribution.
36

• Atypical appearance
Absence of typical or indeterminate features AND
• Presence of:
– Isolated lobar or segmental consolidation without
GGO
– Discrete small nodules (centrilobular, "tree-in-bud")
– Lung cavitation
– Smooth interlobular septal thickening with pleural
effusion
37

38

39

Microbiological
diagnosis
Molecular
diagnosis
Serological
diagnosis
40

Samples for RT PCR
Lower respiratory tract Upper respiratory tract
41

Sampling Technique
42

Serologic Testing
• Currently approved tests
to detect antibodies to
the spike and
nucleocapsid proteins
• Rapid lateral flow assays
detect IgM and IgG
produced during infection
• Seroconversion in 7 days
in 50% patients
43

Management
• Supportive measures
• Immunomodulator drugs
• Non Invasive or invasive ventilator support
• Convalescent plasma therapy
44

Supportive measures
• Maintain adequate Hydration
• Analgesics
• Antipyretics
• Thromboembolic prophylaxis
• Awake proning
• Breathing exercises
45

46

47

48

50

51

Monoclonal antibody treatment
• Bamlanivimab is a neutralizing monoclonal antibody
that is derived from human convalescent plasma and
targets the SARS-CoV-2 spike protein
52

• In November 2020 bamlanivimab received
emergency use authorization (EUA) from the
US Food and Drug Administration (FDA) for
the treatment of adult non-
hospitalized COVID-19 patients with mild to
moderate illness
– not requiring supplemental oxygen
OR
– if on chronic supplemental oxygen, without an
increased oxygen requirement
53

Ventilator support
54

Extracorporeal membrane oxygenator
55

Convalescent plasma
• Obtained from individuals who have
recovered from COVID-19 is a potential option
for therapy of SARS-CoV-2 infection in
hospitalized patients
• Neutralizing antibodies are thought to be the
main active component(Passive immunity)
56

• Although convalescent plasma improved the rate
of nasopharyngeal viral RNA clearance at 72
hours compared with standard treatment alone,
there were no statistically significant differences
in the overall rates of clinical improvement by 28
days.
• It is possible that convalescent plasma provides
clinical benefit when
– it contains high neutralizing antibody titers
– is given early in the course of disease (ie, in patients
who do not require mechanical intubation)
– may be of particular interest for individuals with
deficits in antibody production (eg, those receiving
anti-CD20 therapies)
57

Follow up
• For most patients, outpatient based visits are
scheduled on days 4, 7, and 10 (following the
onset of clinical illness)
• Increased frequency of follow up in :
– Patients aged ≥65 years
– Any patient with moderate dyspnea at the time of
initial evaluation
– Patients who we feel may not reliably report a
deterioration in symptoms
58

Recovery
• According to the WHO
Severity of disease Recovery time
Mild 2 weeks
Severe 3-6 weeks
59

Reinfection
• CDC suggests that the possibility of reinfection
be investigated in patients who:
– Have a repeat positive NAAT ≥90 days after the
initial infection, regardless of symptoms
or
– Have a repeat positive NAAT 45 to 89 days after
the initial infection AND have symptoms
consistent with COVID-19 (with no alternative
explanation or in the setting of recent exposure)
60

Vaccination
61
• The Covid-19 vaccine AZD1222 developed by
Swedish-British pharma major AstraZeneca and the
University of Oxford could come as better news than
that of the vaccines developed by Pfizer-
BioNTech and Moderna, despite both of them having
earlier reported much higher protection
• The 70% overall efficacy of up to 95 per cent.

62

63

Prevention
• Maintain 6 feet or 2 meters distance
• Wear masks
• Hand washing or using 60% alcohol sanitizer
• Respiratory hygeine
• Avoid touching
– Eyes
– Nose
– Mouth
• Ensure adequate ventilation indoor spaces
• Avoid social gatherings
64

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Corona Virus by Dr Anurag Yadav

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