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New Delhi, August 19, 2020 :
Dr KK Aggarwal
It’s been now seven months since COVID-19 was first detected last year in December in Wuhan, China. We have come a long way since then and the knowledge and experience gained over this time has certainly helped to better manage the patients.
Timely diagnosis and treatment give the patient the best chance to recover from COVID-19. It is important to carefully elicit medical history. Otherwise, important health cues can be missed and the disease may be misdiagnosed, which may prove to be costly for the patient. It is crucial to know what should be done and what should not be done in the given clinical situation. Here are a few dos and don’ts with regard to the diagnosis and management of COVID-19.
Ignoring atypical minor symptoms
The symptoms of COVID-19 are no longer limited to the respiratory system (dry cough, fever, and difficulty in breathing). Many extra-pulmonary symptoms of COVID-19 have now been reported. These may differ even in different members of the same family.
Several atypical symptoms of COVID-19 have been reported. These include nausea/vomiting, diarrhea, headache, increased frequency of urination, right abdominal pain, sudden loss of taste and/or smell (bitter and sour tastes are retained), skin lesions (rash, vesicles), conjunctivitis, COVID-toes (presenting as gout-like symptoms), hiccups, calf pain, tiredness, malaise, dizziness, etc.
Such unusual symptoms of COVID-19 are likely to be missed. Do think of COVID-19 in these times and get the patient tested.
COVID-19 can present with isolated diarrhea
Diarrhea may sometimes be the only symptom of COVID-19. Later on fever, the cough may or may not develop. Acute diarrhea in COVID-19 is always small intestinal diarrhea. It is painless, there is no blood or mucous in stool. The virus may remain in the stool for up to 3 months. A patient who has diarrhea may be a superspreader, i.e., he can spread the infection to other members of the family.
If a patient presents with new-onset, intermittent diarrhea for 48 hours duration, do have a high index of suspicion for COVID-19.
Do not ignore fever after exertion
Fever of COVID-19 is typically low grade (<100.40F) and occurs after exertion. The fever is inflammatory and not due to the viral infection. It does not respond to paracetamol, instead, the fever responds to anti-inflammatory drugs like mefenamic acid, naproxen, nimesulide, and indomethacin.
Do not miss the first time detected, low-grade fever after exertion. This may often be the first symptom of COVID-19.
Missing Day 1 of the illness
A person can test positive for COVID-19 even when there is a single symptom. This can be a single loose motion, headache, loss of smell, calf pain, isolated skin rash, and any other non-specific symptom as discussed above. Other symptoms may appear after 48-72 hours.
If you have been exposed to COVID-19, the first symptom is most important. Do not ignore any symptoms, which cannot be explained. This is Day 1 of the illness; the test may or may not be positive.
Day 1 is important as pneumonia usually will develop around Day 3 of the infection.
Ignoring Days 3-6 of the illness
Critical days are Day 3-6 after the first symptom or positive test, whichever is earlier.
The patient may develop pneumonia around the third day of the illness, although not every patient develops pneumonia. Look for fall in SpO2 on 6MWT by 4 (hypoxia; this may be a sign of micro-or macrovascular emboli) or development of exertional tachycardia or difficulty in talking or cough; these are suggestive of pneumonia. If undetected and untreated, complications may set in after Day 5.
If the patient is given steroid (dexamethasone)/LMWH/antiviral at the onset of pneumonia (Day 3), mortality should be an exception and not a rule.
Not recognizing red flags
Not taking due precautions for any comorbid condition, fall in SpO2 or development of shortness of breath or cough on 6MWT, CRP >26, absent eosinophils, and absolute lymphocyte count <1000 on CBC are red flag signs of COVID-19.
Do baseline CBC, ESR, CRP, CRT, ferritin, and/or D-dimer. Repeat ESR, CBC, and CRP daily.
Do not ignore isolated lymphopenia and eosinopenia on Day 1 of the illness. These may sometimes predate inflammation and may be a sign of oncoming inflammation.
Treating the report, not the patient
The RT PCR test using throat/nasal swab is the gold standard test for the diagnosis of COVID-19. But it has a sensitivity of around 67%. This means that about 33% of the results may be a false negative. If the patient has classical symptoms of COVID-19 and the report is negative, repeat the test. A CT scan or chest X-ray can be done on Day 1 itself.
If you suspect that the patient has COVID-19, don’t wait for the confirmation. You may miss Day 3 of the illness, so then you will miss pneumonia, happy hypoxia. Isolate the patient and start treatment.
Rapid antigen tests may also give false-negative results.
Therefore, always interpret the test results with the clinical presentation of the patient.
Mistaking COVID-19 as typhoid because typhoid test is positive
Typhoid antigen tests can give a false-positive result in COVID-19. Patients with COVID-19 can have a fever and diarrhea. If you miss COVID-19, thinking it to be a case of typhoid fever, this can be dangerous for the patient. If you miss COVID-19, you will miss pneumonia on Day 3-6 and complications can develop, which may be irretrievable at times.
If you suspect that the patient has typhoid, do not do a Typhidot or Widal test. Instead, send a blood culture. Unless the blood culture is positive, do not treat these patients for typhoid.
Gargling may reduce the viral load in the throat
Evidence has shown that the virus is present in high quantities in the throat, making it a major reservoir of the virus, not only for the symptomatic patients but also for the asymptomatic ones. Although gargling will not eliminate the virus, it may reduce the viral load in the throat thereby reducing the risk of transmission.
Gargling with an oral antiseptic such as povidone-iodine along with the use of face mask and handwashing may be advised as a preventive measure against the virus.
Author : Dr. KK Aggarwal, President CMAAO, HCFI, and Past National President IMA
