Atypical Manifestations: ‘COVID Patients Are Coming In With Neuro, Cardiac & Gastro Symptoms’
Mumbai: The number of COVID-19 cases continues to rise across India. Mumbai has had over 85,000 cases, and nearly 5,000 deaths--the highest among all Indian cities.
How has our understanding of this disease changed over the last three months? What is the state of preparedness of the public health and the medical system? We speak with Tanu Singhal, consultant, paediatrics and infectious diseases at the Kokilaben Dhirubhai Ambani Hospital, and Harish Chafle, consultant, intensivist and chest physician at the Global Hospital in Mumbai.
Dr Singhal, what are the changes and new trends that you have seen in COVID-19, particularly in the last one month?
TS: We are seeing atypical manifestations now; we are recognising them more. For example, we are seeing adults coming in with strokes--basically, paralytic attacks. They do not have any risk factors for strokes, and [there are] young people getting fatal strokes. We are seeing more gastrointestinal manifestations--patients coming in with diarrhoea, vomiting and turning out to be COVID-positive. We are seeing neurological complications also--patients coming in with a confusional state, for which no other explanation is found.
Children continue to be less affected. Even now, we are hardly seeing children with severe disease. We had earlier spoken about this Kawasaki-like disease in children, which was being seen in other countries like France, Italy, the UK and the US. We have seen a couple of cases in Mumbai now as well--of children coming in with high fever, rash, and low blood pressure and then deteriorating very fast.
You talked about neurological conditions. Is this triggered by COVID?
TS: We do have patients with pre-existing neurological problems who are coming with COVID as well. But we have people coming in with neurological manifestations for which there is no other explanation apart from COVID. For example, we had a young woman coming in with seizures--status epilepticus--and we could not find any other cause except COVID.
We are seeing people who have previous neurological problems but have come with changes in their mentation [mental activity], for which there is no other cause. We are seeing a lot of patients coming in with a loss of sense of taste and smell. Earlier, we would not see it commonly but now we have people coming in saying they have lost taste and smell, and that is how you recognise that they had COVID earlier.
We are also seeing a lot of body ache and myalgia. Even patients who have had mild COVID and have recovered and gone home say that for two weeks, they are not able to get back to work because they have severe body aches.
Dr Chafle, you mentioned that the average length of stay of patients in hospital has come down. Could you take us through how and why this is happening?
HC: I think because of our more stringent discharge policies, and better understanding of the disease, the patients are presenting to us earlier, so that we can treat them [better]. Also, with the use of antiviral drugs like remdesivir and the interleukin-6 blocker tocilizumab that are now available, we are able to better control the disease, and I think that is how the length of stay has come down to around seven days--in Global Hospital, and I think it is the same at the other ICUs and the other hospitals.
The patients are not becoming that [severely] unwell, because we are able to hold the interleukin storm and other things [in the] initial viremic phase and then the immunity response of the patient. So, when we use these drugs judiciously at the proper time in the disease process, patients are not becoming more sick and are going home earlier.
Earlier, we were mostly focusing on pulmonological symptoms and trying to understand the connection with the respiratory tract. How has that changed?
HC: Initially, the predominant symptoms were upper respiratory illness like fever, sore throat, cough. But as the disease has progressed, I think the virus is changing its antigenicity, the virulence power of the virus is changing. So, [there is] involvement in other systems, which is a milder form. If someone has a loss of taste or smell, myalgia, or loose motions as the presenting symptom, they are not that sick.
Dr Singhal, are you also seeing similar trends?
TS: The [revised] discharge policy, [where] if the person has clinically recovered, you can send them [home] 10 days from the onset of symptoms, and you do not need to do a negative test, has really helped in saving resources and shortening hospital stay.
I agree with Dr Chafle when he is saying that we have more options now, and we know better when to use them. While we had these drugs like steroids and tocilizumab even two to three months earlier, we were not so adept at using them. Now, we are used to using these drugs and I feel remdesivir has made some difference. We have started using it in our practice for the past couple of weeks and we are having fewer ventilated patients as compared to earlier.
However, we have seen people who have had atypical manifestations who have also progressed very rapidly. We have had people with neurological complaints, and cardiac problems--sudden onset myocarditis--who have worsened. And there have been a couple of patients who have come with gastrointestinal manifestations, who have later gone on to develop respiratory symptoms.
Another thing we are seeing now is, because of this policy of uniform swabbing of all patients admitted to a hospital at the time of admission, many people who have come with other illnesses test COVID positive, we cannot connect COVID to their other illness. They may have had a fracture or a road traffic accident and they are COVID positive. That just tells us that the asymptomatic infection in the population has also gone up tremendously.
Dr Chafle, how are you seeing the pressure today in terms of allocation of beds?
HC: Initially, when the pandemic started in India, we were taking patients directly. Now, the norms have changed. The patients are being taken to the hospital through a war-room--the patient has to call [the war-room] and tell the symptoms, and that is how it [hospital admission] is getting streamlined.
Initially, all the private hospitals were admitting patients on their own, but now as the government has decided the 80:20 policy, 80% of the patients are coming from the government hospitals and the war rooms directly, and 20% are the direct intake. And the triage of patients [at an early stage] in the accident or emergency department is also helping us know which patient should go where, and that is how the admission process is getting streamlined.
You have said that the average length of stay has come down to seven days. Has that made a difference in overall availability of beds?
HC: Bed availability has become easier these days. The length of the stay [has] become less, there is more turnover of the patients; the patients get discharged, [and] we can take newer patients. And as Dr Singhal rightly said, the government has helped us all by removing the clause that retesting is required for a certain group of individuals.
Dr Singhal, among the cases where you have seen mortality, what are the broad findings and understanding?
TS: I would say that--in our hospital at least--if you have patients with severe COVID, the mortality is between 25-30%. One of the reasons for this high mortality is that many relatives give a “do not escalate care” [order], because many people who are afflicted with severe COVID are elderly; they have other comorbidities. So many times, the relatives take this decision of not escalating care further, [and] that also contributes to mortality.
But generally, we have seen mortality in patients who are elderly, who have other problems. Kidney disease has emerged as a very big risk factor: Dialysis patients are at a higher risk of getting COVID. And if they get COVID, they have a bad time. You cannot give them drugs like remdesivir and many of them die.
So, elderly people, those who are on dialysis, especially post-transplant patients--we have lost three or four proposed renal and liver transplant patients. We had a patient with thalassemia major who passed away.
So, all in all, I would say the chance of a person who is less than 50 years of age, who is otherwise healthy and not overweight, dying from COVID is very low. We may have just had a couple of deaths in this segment.
You said relatives are not escalating care. Do you mean keeping that patient in the ICU for a longer period?
TS: No, the patient cannot leave the intensive care unit because he is COVID positive, but they say, “If this patient deteriorates, do not intubate. Do not use a lot of drugs like tocilizumab or remdesivir etc. Just give them supportive care.”
The other thing we are seeing now is a cohort of patients who are long-stay patients in the ICU. Earlier, you would have dead patients or they would recover. Now, you have these patients who have remained in the ICU for three to four weeks and they have a completely different set of problems. They have infections, they have fibrosis in the lungs, they are difficult to take off the ventilator.
And we are now seeing re-admissions--patients discharged with COVID who are now coming back because of other problems. We must understand that COVID does not leave your body pristine; once you get COVID, even if you recover, your lungs are damaged, they get fibrosed. So many patients come back after a couple of weeks with either new infections or worsening saturation.
Are you talking about serious patients, where the disease has progressed beyond a point?
TS: Yes, mostly it is seriously ill patients, but there are some patients who are moderately sick also who are coming with re-admission, maybe for a urinary tract infection or bacterial pneumonia. Or they have lung findings that were not picked up in the first admission and now have fibrosis.
Dr Chafle, apart from the broader suggestions about sanitising, masks and distancing, what else would you tell people at this point of time, to be careful of and to stay on guard?
HC: This disease has given a lot of bad memories to everyone. In addition to following the basic norms of hand hygiene, maintaining social distancing, I would advise everyone to have a high-protein properly cooked diet, proper hydration, and [to] remain positive, because I have seen a lot of patients going into depression very soon in this illness. If a single member in the family or in the vicinity gets affected, there is chaos all around.
So, do not push the panic button. As we all know, this disease is not severe in everyone who is infected. Only a set group of patients who are above 60 and have comorbidities and other illnesses additionally present, they become sick. Otherwise, other patients, even if they get infected, they will become alright on their own. So, keeping a moral boost, a positive attitude and a good immunity would definitely help all of us fight this battle.
Dr Singhal, what is your advice, having seen what you have seen in the last few months, to people and those who might feel that they might be coming in contact, or might test positive?
TS: First of all is, do not travel unnecessarily. Even if the lockdown is open, go out only if you need to. And second, do not be afraid to get tested. There is a lot of stigma about testing, because people think that if they are sick, they are febrile, and if they get tested and turn positive, their houses will be sealed, their family members will be quarantined.
But that, I think, is not the right approach. Especially if the person is elderly and sick, they should get tested because the chances of the test coming positive in the early part of the illness are higher, and then if you know you are positive, appropriate measures can be taken. There is nothing to be afraid of, but please do not be afraid of testing.
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