Everywhere in the world, people are on the alert for symptoms of the new coronavirus disease. From normal 'flu-like symptoms' to 'feeling like a truck hit you' the symptoms seem to varied, according to accounts reported.
In countries where community spread has been registered it is even more scary for residents, and people have taken to social media to share their angst about getting sick. Shortness of breath, fever, cough are the typical signs of infection with the new coronavirus, which are signs far too similar to a really bad cold or a regular flu for comfort.
Strange symptoms, neurological complications
Although flu-like symptoms are the most common ones seen in COVID-19 positive patients, there have been reports of rare and strange signs too. One of these is a diminished sense of smell and taste. Some patients exhibit altered mental status, or encephalopathy, a catchall term for brain disease or dysfunction that can have many underlying causes, as well as other serious conditions.
In early March, a 74-year-old man came to the emergency room in Boca Raton, Florida, with a cough and a fever, but an X-ray ruled out pneumonia and he was sent home. The next day, when his fever spiked, family members brought him back. He was short of breath, and could not tell doctors his name or explain what was wrong - he had lost the ability to speak.
Doctors suspected the patient, who had chronic lung disease and Parkinson's, had COVID-19, and were eventually proven right when he was finally tested.
On Tuesday, doctors in Detroit reported another disturbing case involving a female airline worker in her late 50s with COVID-19. She was confused, and complained of a headache; she could tell the physicians her name but little else, and became less responsive over time. Brain scans showed abnormal swelling and inflammation in several regions, with smaller areas where some cells had died.
Physicians diagnosed a dangerous condition called acute necrotizing encephalopathy, a rare complication of influenza and other viral infections.
There's no ventilator for the brain. If the lungs are broken we can put the patient on a ventilator and hope for recovery. We don't have that luxury with the brain
"The pattern of involvement, and the way that it rapidly progressed over days, is consistent with viral inflammation of the brain," Dr. Elissa Fory, a neurologist with Henry Ford Health System, said through an email. "This may indicate the virus can invade the brain directly in rare circumstances." The patient is in critical condition.
These reports from the US follow similar observations by doctors in Italy and other parts of the world, of COVID-19 patients having neurological issues which led to strokes, encephalitis-like symptoms and blood clots, as well as tingling or numbness in the extremities, called acroparesthesia.
In some cases, patients were delirious even before developing fever or respiratory illness, according to Dr. Alessandro Padovani, whose hospital at University of Brescia in Italy opened a separate NeuroCovid unit to care for patients with neurological conditions.
"We absolutely need to have an information finding mission, otherwise we're flying blind," said Dr. Sherry H-Y. Chou, a neurologist at the University of Pittsburgh School of Medicine said.
"There's no ventilator for the brain. If the lungs are broken we can put the patient on a ventilator and hope for recovery. We don't have that luxury with the brain."
Experts have emphasized that most COVID-19 patients appear to be normal neurologically. "Most people are showing up awake and alert, and neurologically appear to be normal," said Dr. Robert Stevens, a neurologist at the Johns Hopkins School of Medicine in Baltimore who is tracking neurological observations.
Stevens emphasized that all mechanistic explanations at this point are hypotheses because so little is known: "It could be as simple as low levels of oxygen in the bloodstream," resulting from respiratory failure, along with an increase in carbon dioxide, which "can have significant impact on the function of the brain, and lead to states of confusion and lethargy," he said.
"We are still in the early days of this, and we don't really know for sure."
What happens inside the body when it gets bad?
Dr Daniel Brenner has had a busy week in the emergency department of Johns Hopkins Hospital in Baltimore, Maryland, seeing dozens of presumed COVID-19 patients. The most significant complication for coronavirus patients is Acute Respiratory Distress Syndrome (ARDS) in which the lungs stiffen and become inflamed and the body is starved of oxygen.
With hundreds of cases now coming in, Brenner said it becomes "very tricky to tease out who needs to be in the hospital, the people who are at high risk for developing severe symptoms and needing supplemental oxygen" versus those who can recover from home.
We're all trying to learn it on the fly.
The most significant complication for coronavirus patients is Acute Respiratory Distress Syndrome (ARDS) in which the lungs stiffen and become inflamed and the body is starved of oxygen.
Doctors have found placing patients on the stomach in the "prone" position helps prevents fluid from building up in the relatively more healthy area in the back of the lung, said Brenner. The technique is commonly used on preterm babies requiring ventilators, but for adults it is labor intensive and requires constant monitoring to make sure the breathing tube isn't displaced.
COVID patients also seem to require higher levels of air pressure on their ventilators than people who have developed ARDS by other means, added Brenner.
From start to end
BBC reported on the method the new virus infects a person. It first infects the cells lining your throat, airways and lungs and turns them into "coronavirus factories" that spew out huge numbers of new viruses that go on to infect yet more cells.
At this early stage, the report says, you will not be sick and some people may never develop symptoms. The incubation period, the time between infection and first symptoms appearing, varies widely, but is five days on average.
If the disease progresses it will be due to the immune system overreacting to the virus. "The virus is triggering an imbalance in the immune response, there's too much inflammation, how it is doing this we don't know," Dr Nathalie MacDermott, from King's College London, explained as reported by BBC.
WHO figures show that 13.8 per cent of infected patients have severe disease (dyspnea, high respiratory frequency ≥30/minute, low blood oxygen saturation, and/or increased lung infiltrates - an infiltrate is the filling of airspaces with fluid).
This stage is where oxygen moves into the blood and carbon dioxide moves out, but in pneumonia the tiny sacs start to fill with water and can eventually cause shortness of breath and difficulty breathing.
Some people will need a ventilator to help them breathe.
6.1 per cent of cases are critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). By this point, according to experts, there is a real chance of death. The immune system is now spiralling out of control and causing damage throughout the body.
The Lancet Journal published a study of patients and the severe case breakup looks like this: "Many patients presented with organ function damage, including 17 (17%) with ARDS, eight (8%) with acute respiratory injury, three (3%) with acute renal injury, four (4%) with septic shock, and one (1%) with ventilator-associated pneumonia."
At this point, treatment gets more invasive and last-ditch. An example is ECMO or extra-corporeal membrane oxygenation where an artificial lung takes blood out of the body through tubes, oxygenates it and pumps it back in.
The risk factor for such severe cases is higher with age and/or other underlying conditions such as diabetes, hypertension, and immuno-compromised people who have weakened immunity due to previous illness, cancer or other conditions.
Prof John Wilson, president-elect of the Royal Australasian College of Physicians and a respiratory physician explained the details, the Guardian reported. When people with COVID-19 develop a cough and fever, Wilson said, this is a result of the infection reaching the respiratory tree – the air passages that conduct air between the lungs and the outside.
He explained: “The lining of the respiratory tree becomes injured, causing inflammation. This in turn irritates the nerves in the lining of the airway. Just a speck of dust can stimulate a cough.
“But if this gets worse, it goes past just the lining of the airway and goes to the gas exchange units, which are at the end of the air passages.
“If they become infected they respond by pouring out inflammatory material into the air sacs that are at the bottom of our lungs.”
If the air sacs then become inflamed, Wilson said this causes an “outpouring of inflammatory material [fluid and inflammatory cells] into the lungs and we end up with pneumonia.”
He said lungs that become filled with inflammatory material are unable to get enough oxygen to the bloodstream, reducing the body’s ability to take on oxygen and get rid of carbon dioxide.
“That’s the usual cause of death with severe pneumonia,” he added.
The basic treatment for the coronavirus is fairly straightforward. Some need fluids, oxygen and a fever addressed, while the more severe cases may need to be sedated, ventilated and fed through a tube.
Dr. Peter Chen, head of pulmonary and critical care medicine at Cedars-Sinai, said his team has been conducting drills to accomplish those tasks as efficiently as possible and be able to handle more patients. But, he added, for "the majority of people, it's not rocket science."
"They have a single organ failure - their lungs," he said. "We manage the lungs until the lungs hopefully calm down. That's it. It's pretty much supportive."
The challenge comes in getting the supplies needed to treat patients with the highly infectious virus. Like hospitals across the country, Cedars-Sinai and MLK are scouring for masks, gowns and ventilators.
Who is dying?
Bloomberg reported about a study of the deaths in Italy: "Almost half of the victims suffered from at least three prior illnesses, and about a fourth had either one or two previous conditions. More than 75 per cent had high blood pressure, about 35 per cent had diabetes and a third suffered from heart disease."
Berkeley economist Edward Miguel explained, "The median age in a lot of countries is 20 or 18, much younger than in Europe, and it appears that young people who are infected are often asymptomatic or just get a cold." The median age in the United States is 38.
- Inputs from AFP, AP, NYT, BBC, The Lancet Journal, WHO and Guardian