Coronavirus Disease 2019 (COVID-19, SARS-CoV-2)

Epidemiology

China 2019-2020 Pandemic (NEJM, 2020) [MEDLINE]

  • Case Series of 1,099 COVID-19 Laboratory-Confirmed Hospitalized Cases
    • 552 Hospitals in 30 Provinces
    • Cases Reported Through January 29, 2020
  • Age
    • Median Age: 47 y/o
  • Sex
    • 58.1% of Cases were Male
  • Smoking History
    • Only 14.5% of Cases were Former/Current Smokers
  • Coexisting Disorders: one of the following was present in only 23.7% of cases
  • Contact with Wildlife
    • Only 1.9% of Cases Had Contact with Wildlife
  • Geography
    • 43.9% of Cases Lived in Wuhan
    • Among Non-Residents of Wuhan, 72.3% of Cases Had Contact with Residents of Wuhan (Including 31.3% Who Had Visited the City)
  • Incubation Period: 4 days (interquartile range: 2-7 Days)

Washington State 2019-2020 Pandemic (NEJM, 2020) [MEDLINE]

  • Case Series of 24 Critically Ill Patients Requiring ICU Admission
    • Community Transmission was First Detected in Washington State in February, 2020
  • Age
    • Mean Age: 64 ± 18 y/o
  • Sex
    • 63% of Patients were Male
  • xxxx
    • XXXX

Microbiology

  • COVID019 is a 30 kb Single-Stranded RNA Virus
    • XXXX

Diagnosis

Chest X-Ray (CXR) (see Chest X-Ray, [[Chest X-Ray]])

  • xxx

Chest CT (see Chest Computed Tomography, [[Chest Computed Tomography]])

  • xxxx

COVID-19 Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR)

  • xxxx

Clinical Manifestations

General Comments

  • xxx

Gastrointestinal Manifestations

  • Diarrhea (see Diarrhea, [[Diarrhea]])
    • Epidemiology
      • Diarrhea Occurred in 3.8% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
  • Elevated Liver Function Tests (LFT’s)
    • Epidemiology
      • Transaminitis Occurred in Approximately 21-22% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
      • Hyperbilirubinemia Occurred in 10.5% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
  • Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])
    • Epidemiology
      • Nausea/Vomiting Occurred in Only 5% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]

Hematologic Manifestations

  • Hyperferritinemia (see Hyperferritinemia, [[Hyperferritinemia]])
  • Increased D-Dimer (see Increased D-Dimer, [[Increased D-Dimer]])
    • Epidemiology
      • D-Dimer ≥0.5 mg/L was Observed in 46.4% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
  • Leukopenia/Lymphocytopenia (see Leukopenia, [[Leukopenia]])
    • Epidemiology
      • Lymphocytopenia was Present in 83.2% of Patients at Time of Admission (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
  • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]])
    • Epidemiology
      • Thrombocytopenia (<150k) Occurred in 36.2% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]

Neurologic Manifestations

  • Headache (see Headache, [[Headache]])
    • Epidemiology
      • Headache Occurred in 13.6% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]

Pulmonary Manifestations

Upper Respiratory Infection (URI) Symptoms

  • Clinical
    • Nasal Congestion Occurred in 4.8% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
    • Pharyngitis Congestion Occurred in 13.9% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
    • Pharyngitis Occurred in 8% of Cases (Seattle 2020 Pandemic: Case Series of 24 Critically Ill Patients Requiring ICU Admission) (NEJM, 2020) [MEDLINE]

Pneumonia/Acute Respiratory Distress Syndrome (ARDS) (see Pneumonia and Acute Respiratory Distress Syndrome)

  • Epidemiology
    • Physician-Diagnosed Pneumonia Occurred in 91.1% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
    • ARDS Occurred in Only 3.4% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
    • XXX
  • Diagnosis
    • Chest X-Ray (CXR) (see Chest X-Ray, [[Chest X-Ray]])
    • Chest CT (see Chest Computed Tomography, [[Chest Computed Tomography]])
      • Ground Glass Infiltrates were the Most Common Radiologic Finding: Present in 56.4% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
      • No Radiographic Abnormality was Found in 17.9% of Non-Severe Disease Cases and 2.9% of Severe Disease Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
      • In a Series of 51 Patients with Chest CT and RT-PCR Assay Performed within the First 3 Days, Sensitivity of CT for COVID-19 Infection was 98%, as Compared to RT-PCR Sensitivity of 71% (p<0.001) (Radiology, 2020) [MEDLINE]
    • COVID-19 Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR) (see xxxx, [[xxxx]])
      • In a Series of 51 Patients with Chest CT and RT-PCR Assay Performed within the First 3 Days, Sensitivity of CT for COVID-19 Infection was 98%, as Compared to RT-PCR Sensitivity of 71% (p<0.001) (Radiology, 2020) [MEDLINE]
  • Clinical
    • Onset of Symptoms
      • In Seattle Case Series of 24 Critically Ill Patients Requiring ICU Admission, Symptom Onset Occurred 7 ± 4 Days Prior to Hospital Admission (NEJM, 2020) [MEDLINE]
    • Cough (see Cough)
      • Cough Occurred in 67.8% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
      • Cough Occurred in 88% of Cases (Seattle 2020 Pandemic: Case Series of 24 Critically Ill Patients Requiring ICU Admission) (NEJM, 2020) [MEDLINE]
    • Sputum
      • Sputum Production Occurred in 33.7% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
      • Sputum Occurred in 42% of Cases (Seattle 2020 Pandemic: Case Series of 24 Critically Ill Patients Requiring ICU Admission) (NEJM, 2020) [MEDLINE]
    • Dyspnea (see Dyspnea)
      • Sputum Occurred in 18.7% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
      • Dyspnea Occurred in 88% of Cases (Seattle 2020 Pandemic: Case Series of 24 Critically Ill Patients Requiring ICU Admission) (NEJM, 2020) [MEDLINE]
    • Hemoptysis (see Hemoptysis)
      • Hemoptysis Occurred in Only 0.9% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
  • Treatment
    • Mechanical Ventilation
      • Invasive Mechanical Ventilation was Required in 2.3% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]

Renal Manifestations

  • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])
    • Epidemiology
      • AKI Occurred in Only 0.5% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]

Rheumatologic Manifestations

  • Arthralgias/Myalgias
    • Epidemiology
      • Arthralgias/Myalgias Occurred in 14.9% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
  • Elevated Creatine Kinase (CK) (see xxxx)
    • Epidemiology
      • Elevated Creatine Kinase (≥200 U/L) Occurred in 13.7% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]

Other Manifestations

  • Fatigue (see Fatigue)
    • Epidemiology
      • Fatigue Occurred in 38.1% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]
  • Fever (see Fever, [[Fever]])
    • Epidemiology
      • Fever Occurred in 43.8% of Cases at Time Of Admission (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) [MEDLINE]
        • Only 21.7% of Fevers were ≥38.1 Degrees C
      • Fever Occurred in 88.7% of Cases During Hospitalization (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) [MEDLINE]
        • 57.2% of Fevers were ≥38.1 Degrees C
      • Fever Occurred in XXXX% of Cases (Seattle 2020 Pandemic: Case Series of 24 Critically Ill Patients Requiring ICU Admission) (NEJM, 2020) [MEDLINE]
  • Chills (see xxxx)
    • Epidemiology
      • Chills Occurred in 11.5 % of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) [MEDLINE]
  • Elevated Procalcitonin (see xxxx)
    • Epidemiology
      • Elevated Procalcitonin (≥0.5 ng/mL) Occurred in 5.5 % of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) [MEDLINE]
  • Increased C-Reactive Protein (CRP) (see Increased C-Reactive Protein, [[Increased C-Reactive Protein]])
  • Increased IL-6 (see xxxx, [[xxxx]])
  • Increased Serum Lactate Dehydrogenase (LDH) (see xxxx, [[xxxx]])
  • Septic Shock (see Septic Shock, [[Septic Shock]])
    • Epidemiology
      • Septic Shock Occurred in Only 1.1% of Cases (Chinese 2019-2020 Pandemic: Case Series of 1,099 Hospitalized Patients) (NEJM, 2020) [MEDLINE]

Treatment

Respiratory Support

  • xxxx

Post-Exposure Prophylaxis

  • Clinical Efficacy
    • XXXX

Pharmacologic Therapy

Remdesivir (XXX) (see Remdesivir, [[Remdesivir]])

  • Manufactured by Gilead Pharmaceuticals
    • Currently in Trials
  • Administration
    • Day 1 Dose: 200 mg IV
    • Day 2-10 Dose: 100 mg qday
  • Clinical Efficacy
    • XXXX

Lopinavir–Ritonavir (Kaletra) (see Lopinavir–Ritonavir, [[Lopinavir–Ritonavir]])

  • History
  • Pharmacology
    • SARS-CoV-2 Protease Inhibition
  • Administration
    • XXX
  • Clinical Efficacy
    • Randomized Controlled Trial of Lopinavir–Ritonavir in SARS-COV-2 (COVID-19) (NEJM, 2020) [MEDLINE]
      • No Clinical Benefit

Chloroquine Phosphate (see Chloroquine, [[Chloroquine]])

  • Administration
    • XXXX
  • Contraindications
    • Prolonged Q-T Syndrome (see Torsade, [[Torsade]])
  • Adverse Effects
    • Hepatotoxicity
  • Clinical Efficacy
    • Systematic Review of Chloroquine for COVID-19 (J Crit Care, 2020) [MEDLINE]
      • Chloroquine seems to be effective in limiting the replication of SARS-CoV-2 (virus causing COVID-19) in vitro
    • In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Clin Infect Dis, 2020) [MEDLINE]
      • Hydroxychloroquine was found to be more potent than chloroquine to inhibit SARS-CoV-2 in vitro

Hydroxychloroquine (Plaquenil) (see Hydroxychloroquine, [[Hydroxychloroquine]])

  • Administration
    • XXXX
  • Contraindications
  • Adverse Effects
    • Cardiotoxicity
  • Clinical Efficacy
    • In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Clin Infect Dis, 2020) [MEDLINE]
      • Hydroxychloroquine was found to be more potent than chloroquine to inhibit SARS-CoV-2 in vitro

Teicoplanin (XXX) (see Teicoplanin, [[Teicoplanin]])

  • Clinical Efficacy
    • XXXX

Tocilizumab (Actemra) (see Tocilizumab, [[Tocilizumab]])

  • Pharmacology
    • XXXX
  • Administration
    • XXX
  • Clinical Efficacy
    • XXX

Favipiravir (Avigan) (see Favipiravir, [[Favipiravir]])

  • Pharmacology
    • Inhibition of Viral RNA-Dependent RNA Polymerase
  • Administration
    • XXX
  • Clinical Efficacy
    • XXX

Sarilumab (Kevzara) (see Sarilumab, [[Sarilumab]])

  • Pharmacology
    • XXXX
  • Administration
    • XXX
  • Clinical Efficacy
    • XXX

Corticosteroids (see Corticosteroids, [[Corticosteroids]])

  • No Efficacy

Intravenous Immunoglobulin (IVIG) (see Intravenous Immunoglobulin, [[Intravenous Immunoglobulin]])

  • Unclear Efficacy

Avoidance of Nonsteroidal Anti-Inflammatory Drugs (NSAID’s) (see Nonsteroidal Anti-Inflammatory Drugs, [[Nonsteroidal Anti-Inflammatory Drugs]])

  • xxxx

Avoidance of Angiotensin Converting Enzyme Inhibitors (ACE-I) (see Angiotensin Converting Enzyme Inhibitors, [[Angiotensin Converting Enzyme Inhibitors]])

  • xxxx

Anticoagulation

  • xxx

Prognosis

  • Clinical Features in the 2019-2020 Chinese Pandemic (NEJM, 2020) [MEDLINE]
    • Primary Composite Endpoint of Admission to the Intensive Care Unit, Use of Mechanical Ventilation, or Death Occurred in 6.1% of Cases
      • Required ICU Admission: 5% of cases
      • Required Invasive Mechanical: 2.3% of cases
      • Mortality Rate: 1.4%
    • Median Hospital Length of Stay: 12 days (Interquartile Range: 10-14 days)

References

Epidemiology

  • Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths. J Microbiol Immunol Infect. 2020 Mar 4. pii: S1684-1182(20)30040-2. doi: 10.1016/j.jmii.2020.02.012 [MEDLINE]
  • The COVID-19 epidemic. Trop Med Int Health. 2020 Mar;25(3):278-280. doi: 10.1111/tmi.13383 [MEDLINE]
  • Understanding of COVID-19 based on current evidence. J Med Virol. 2020 Feb 25. doi: 10.1002/jmv.25722 [MEDLINE]
  • Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Mar 26;382(13):1199-1207. doi: 10.1056/NEJMoa2001316 [MEDLINE]

Diagnosis

  • Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. Radiology. 2020 Feb 19:200432. doi: 10.1148/radiol.2020200432 [MEDLINE]

Clinical

  • Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032 [MEDLINE]
  • Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648 [MEDLINE]
  • Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020 Feb 21. doi: 10.1001/jama.2020.2565 [MEDLINE]
  • Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020 Feb 18. pii: S2213-2600(20)30076-X. doi: 10.1016/S2213-2600(20)30076-X [MEDLINE]
  • Covid-19 in Critically Ill Patients in the Seattle Region – Case Series. N Engl J Med. 2020 Mar 30. doi: 10.1056/NEJMoa2004500 [MEDLINE]
  • Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020 Mar 19. doi: 10.1001/jama.2020.4326 [MEDLINE]
  • Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020 Mar 13. doi: 10.1001/jamainternmed.2020.0994 [MEDLINE]
  • Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020 Mar 3. doi: 10.1001/jama.2020.3204 [MEDLINE]
  • Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507-513. doi: 10.1016/S0140-6736(20)30211-7 [MEDLINE]
  • Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-1062. doi: 10.1016/S0140-6736(20)30566-3 [MEDLINE]
  • WHO COVID-19 Report [LINK]

Treatment

  • A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med. 2020 Mar 18. doi: 10.1056/NEJMoa2001282 [MEDLINE]
  • Teicoplanin: an alternative drug for the treatment of coronavirus COVID-19? Int J Antimicrob Agents. 2020 Mar 13:105944. doi: 10.1016/j.ijantimicag.2020.105944 [MEDLINE]
  • A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care. 2020 Mar 10. pii: S0883-9441(20)30390-7. doi: 10.1016/j.jcrc.2020.03.005 [MEDLINE]
  • New insights on the antiviral effects of chloroquine against coronavirus: what to expect for COVID-19? Int J Antimicrob Agents. 2020 Mar 11:105938. doi: 10.1016/j.ijantimicag.2020.105938 [MEDLINE]
  • In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Clin Infect Dis. 2020 Mar 9. pii: ciaa237. doi: 10.1093/cid/ciaa237 [MEDLINE]
  • Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-271. doi: 10.1038/s41422-020-0282-0 [MEDLINE]
  • Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. [MEDLINE]
  • Of chloroquine and COVID-19. Antiviral Res. 2020 Mar 5;177:104762. doi: 10.1016/j.antiviral.2020.104762 [MEDLINE]
  • COVID-19: combining antiviral and anti-inflammatory treatments. Lancet Infect Dis. 2020 Feb 27. pii: S1473-3099(20)30132-8. doi: 10.1016/S1473-3099(20)30132-8 [MEDLINE]

Prognosis

  • Coronavirus covid-19 has killed more people than SARS and MERS combined, despite lower case fatality rate. BMJ. 2020 Feb 18;368:m641. doi: 10.1136/bmj.m641 [MEDLINE]