By Mary O’Brien, M.D.
We knew this was coming, or at least we should have known. Several subsets of patients with complex reactions to COVID-19 (the disease from the coronavirus infection) are being recognized. The very young, the very old, and the very sick may be predisposed to rare and intense immune responses to infection with this coronavirus. Here is what we know so far:
- “Cytokine Storm” can be a dire consequence of COVID-19 especially in older patients with several underlying illnesses. Cytokines are polypeptides or proteins secreted by immune cells coming into contact with bacterial or viral antigens and/or endotoxins. Cytokines can also be synthesized by adipose cells (one of the reasons overweight patients are at serious risk). Cytokines include chemokines, interleukins, interferons, and tumor necrosis factors among others. Simply put, cytokines influence the magnitude of an inflammatory immune response. Multiple genetic factors seem to play a role. Clinically, an older, chronically-ill patient with COVID-19 (or other infections, such as influenza) can deteriorate dramatically over 6-12 hours. Vital signs become unstable, O2 saturation drops, respiratory distress intensifies, and inflammatory markers like C-reactive protein rise. Cardiac function is seriously compromised and liver, kidney, and neurologic function decline rapidly. Severe clotting disorders may develop.
The outcome is poor, but aggressive efforts to suppress the massive autoimmune inflammatory response may help if initiated at the earliest stages.
- Toxic Shock Syndrome: This is an acute, serious, systemic illness triggered by a response to exotoxins produced by staph or strep bacteria. It was first noted in young women in the early 1980s and was linked to tampons, diaphragms, or contraceptive sponges left in the vagina. It can occur after childbirth, abortion, or surgery. Symptoms include a high fever, diffuse red rash resembling scalded or burned skin, hypotension and multi-organ system failure leading to shock. Prompt and aggressive treatment involves removal of foreign bodies, debridement of incisions or wounds, IV fluids, and IV antibiotics (clindamycin and vancomycin). IV immunoglobulin can be used.
Several patients in the New York area, who tested positive for COVID-19, have presented with symptoms similar to Toxic Shock Syndrome.
- Kawasaki Disease: This is a childhood illness with a dramatic presentation and complications related to vasculitis, probably of an autoimmune nature. Each year in the U.S. there are between 3,000 to 5,000 cases, mostly in children under the age of five years. Rare cases occur in young infants, teens, or young adults. Occasional community clusters occur, especially in late winter and spring, without clear evidence of person-to-person transmission. Diagnosis requires the presence of four out of five clinical findings after fever lasting five or more days.
- Bilateral conjunctivitis — injection or intense redness without exudate, drainage, or crusting.
- Mucocutaneous injection of the lips, tongue, and oral mucosa. Lips are red, raw, dry, cracked, and fissured. The tongue is enlarged, red, and possibly tender. The classic description is “strawberry tongue.”
- Skin changes involving the hands and feet. There is pronounced edema and erythema especially on the palms, soles, and nail beds. Full-thickness desquamation or sloughing off of skin on the fingers, palms, soles, and toes leaves the underlying denuded skin red, raw, and tender. These changes typically begin around Day 10.
- Polymorphous rash over the trunk may resemble measles, scarlet fever, hives, or erythema multiform. The perineal area is often involved.
- Cervical lymphadenopathy with at least one lymph node in the neck ≥ 1.5 cm in diameter.
The cardiac complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, pericarditis, and valvular disease. EKG and echocardiogram are indicated at the time of diagnosis and in regular follow-up visits for at least a year. Treatment involves high-dose aspirin and IV immune globulin. Approximately 85 children in the New York area who are COVID-19 positive are being evaluated for this condition, now called “Pediatric Multisystem Inflammatory Syndrome.”
Cytokine storm, Toxic Shock Syndrome, and Kawasaki Disease are rare in their original forms or as complications of COVID-19. The overwhelming majority (over 82 percent) of patients testing positive for COVID-19 remain asymptomatic or mildly ill. The survival rate in the U.S. (rarely mentioned) is over 99.5%.
Those of us in health care must always be aware of unusual or rare complications of any illness. But perspective is crucial, a concept lost on many in the realms of media and politics. After all, the best way to control people is to keep them afraid.
Knowledge, perspective, and prudence: not fun, but essential.