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COVID 19 (SARS-CoV-2) Updates, Speculation and Information

Review the most up to date literature published and speculations/anecdotes and cited articles from around the globe.

Speculations:

  • Pulmonary edema and infiltrates are being caused by coronavirus binding of pulmonary ACE, causing capillary leak and upregulation of ACE-2.
  • Based on the sequence similarities of the RBM between SARS-CoV-2 and SARS-CoV, several independent research groups investigated if SARS-CoV-2 also utilizes ACE-2 as a cellular entry receptor.
  • anti-ACE-2 antibodies or could be used to block SARS-CoV-2 binding to the receptor. Additionally, TMPRSS2 inhibitors could be used to prevent SARS-CoV-2 entry into host cells. Camostat has been used to treat chronic pancreatitis in Japan and is currently undergoing Phase 1/2 trial testing in the United States.26 If deemed safe, camostat could be a potential treatment option of CoV infections.27 It is also possible that antibodies developed during SARS-CoV infection could help prevent or treat COVID-19. Hoffmann et al. showed that sera from recovering SARS patients reduced SARS-CoV-2 S protein-driven entry into Vero-E6 cells.21 However, future studies are needed to determine whether any of these options are effective in disrupting the interaction between virus and receptor in vivo.

https://www.rndsystems.com/resources/articles/ace-2-sars-receptor-identified

Clinical presentations and concerns

  • Acute respiratory distress syndrome (ARDS) is a major complication in patients with severe disease. In the study of 138 patients ARDS developed in 20 percent after a median of eight days, and mechanical ventilation was implemented in 12.3 percent https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19/abstract/39 ]. In another study of 201 hospitalized patients with COVID-19 in Wuhan, 41 percent developed ARDS; age greater than 65 years, diabetes mellitus, and hypertension were each associated with ARDS https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19/abstract/57
  • Some information from Europe is that there appears to be severe myocarditis and/or severely depressed LVEF <10% occurring in some patients with rapid decline around the 7-9 day mark after symptomatic infection.
  • in the setting of severe cardiogenic shock, may suffer VT/VT or PEA and ultimately pass once this state is reached. In europe this presentation was more rare, however improved in some patients with IVIG and glucocorticoids.

https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa190/5807656

Investigational treatments

  • no controlled data supporting the use of any of these agents, and their efficacy for COVID-19 is unknown (22).
  • Remdesivir – Remdesivir is a novel nucleotide analogue that has activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro and related coronaviruses (including SARS and MERS-CoV) both in vitro and in animal studies (22).
  • Chloroquine/hydroxychloroquine – Both chloroquine and hydroxychloroquine inhibit SARS-CoV-2 in vitro (22) .
  • Lopinavir-ritonavir – protease inhibitor, for HIV infection, has in vitro activity against the SARS-CoV [30]
  • Tocilizumab – Treatment guidelines from China’s National Health Commission include the IL-6 inhibitor tocilizumab for patients with severe COVID-19 and elevated IL-6 levels (31).
  • Others include IVIG, steroids, oseltamivir, interferon beta and convalescent serum. No published data as of yet.

Other data:

  • March, 2020, the WHO declared the COVID-19 officially a Pandemic.
  • Per ACOG ” The approach to prevention, evaluation, diagnosis, and treatment of pregnant women with suspected COVID-19 should be similar to that in nonpregnant individuals”
  • (ACOG) specifies that infants born to mothers with confirmed COVID-19 should be considered a patient under investigation and appropriately isolated and evaluated (32).

EMRAP link to LIVE and ongoing COVID updates
https://covid.emrap.org/

Centers for Disease Control and Prevention (CDC)

Real time link to the Coronavirus map and current Published global cases:

https://coronavirus.jhu.edu/map.html

References:

  1. Fehr, A.R. and S. Perlman (2015) Methods Mol. Biol. 1282:1.
  2. Centers for Disease Control and Prevention (n.d.) Common Human Coronaviruseshttps://www.cdc.gov/coronavirus/general-information.html.
  3. Yang, Y. et al. (2020) J. Autoimmun. [Epub ahead of print].
  4. Gu, J. and C. Korteweg (2007) Am. J. Pathol. 170:1136.
  5. Zhou, P. et al. (2020) Nature [Epub ahead of print].
  6. Schoeman, D. and B.C. Fielding (2019) Virol. J. 16:69.
  7. de Wit, E. et al. (2016) Nat. Rev. Microbiol. 14:523.
  8. WHO (2003) Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003.
  9. WHO (2020) Coronavirus Disease 2019 (COVID-10) Situation Report – 50.
  10. Lu, R. et al. (2020) Lancet. 395:565.
  11. Li, F. (2016) Annu. Rev. Virol. 3:237.
  12. Wan, Y. et al. (2020) J. Virol. [Epub ahead of print].
  13. Li, W. et al. (2003) Nature 426:450.
  14. Riordan, J.F. (2003) Genome Bio. 4:225.
  15. Kuba, K. et al. (2010) Pharmacol. Ther. 128:119.
  16. Jinag, F. et al. (2014) Nat. Rev. Cardiol. 11:413.
  17. Ksiazek, T.G. et al. (2003) N. Engl. J. Med. 348:1953.
  18. Harmer, D. et al. (2002) FEBS Lett. 532:107.
  19. Leung, W.K. et al. (2003) Gastroenterology 125:1011.
  20. Tikellis, C. and M.C. Thomas (2012) Int. J. Pept. 2012:256294.
  21. Hoffmann, M. et al. (2020) Cell [Epub ahead of print].
  22. Belouzard, S. et al. (2009) Proc. Natl. Acad. Sci. U.S.A. 106:5871.
  23. Matsuyama, S. et al. (2010) J. Virol. 84:12658.
  24. Iwata-Yoshikawa, N. et al. (2019) J. Virol. 93:e01815.
  25. Huang, L. et al. (2003) J. Biol. Chem. 278:15532.
  26. Ramsey, M.L. et al. (2019) Trials 20:501.
  27. Zhou, Y. et al. (2015) Antiviral Res. 116:76.
  28. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19
  29. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China JAMA 2020
  30. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19/abstract/77
  31. Reuters. China approves use of Roche drug in battle against coronavirus complications. https://www.reuters.com/article/us-health-coronavirus-china-roche-hldg/china-approves-use-of-roche-arthritis-drug-for-coronavirus-patients-idUSKBN20R0LF (Accessed on March 11, 2020).
  32. American College of Obstetricians and Gynecologists. Practive Advisory: Novel Coronavirus 2019 (COVID-2019). https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Novel-Coronavirus2019 (Accessed on February 26, 2020).
  33. Seattle: COVID-19 patients compromised by comorbidities https://www.auntminnie.com/index.aspx?sec=sup&sub=xra&pag=dis&ItemID=128508

Stefan Meyering DO, FAAEM, FACEP

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

Article Peer Reviewed By:
Anant Patel DO FACEP @AnantPatels

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