Coronavirus Pandemic Update 44: Loss of Smell & Conjunctivitis in COVID-19, Is Fever Helpful?

Coronavirus Pandemic Update 44: Loss of Smell & Conjunctivitis in COVID-19, Is Fever Helpful?


welcome to another MedCram COVID-19
update we are headed to a half a million total confirmed worldwide over 20,000
deaths and 115 thousand total recovered with most of that growth outside of
China at this point if we look at the world ometer website most of the deaths
that are occurring are in Italy and Spain with the United States starting to
move up as well the number of new cases in Italy looks as though it might have
peaked will have to see more in the future in terms of its direction while
the total deaths in Italy continued to escalate over in the United States the
total number of cases continues to grow total number of deaths is over a
thousand here in the United States already New York City seems to be the
epicenter of what’s going on here in the states and they are predicting that the
peak number is still about two to three weeks away in New York and remember that
New York is ahead of just about everybody else of course if we were able
to flatten the curve then that’s gonna delay that even more but hopefully the
peak won’t be as high okay I want to talk to you about a couple of updates in
terms of signs and symptoms this is from the American Academy of Ophthalmology
which is warning us that there have been several reports that the virus may cause
conjunctivitis and possibly be transmitted by aerosol contact with the
conjunctiva and the Academy is recommending protection from the mouth
nose and eyes when caring for patients potentially infected with SARS Cove –
also there are recommendations there on how to sterilize the equipment that’s
used the other name for conjunctivitis is pinkeye it’s not uncommon to have
conjunctivitis when you have an upper respiratory viral infection so be aware
of that the other sign in symptom is related to the loss of smell as a marker
of Cova 19 infection this is a letter that was written by the president of the
ear nose and throat Association in the UK dar
Kumar and he’s talking here about post-viral anosmia that by itself is not
unusual what they’re seeing however is they’re seeing a huge rise in the number
of patients that are complaining of the inability to temporarily smell after a
viral infection they mentioned here that in South Korea where testing has been
more widespread 30% of patients testing positive have had anosmia as their major
presenting symptom in otherwise mild cases on the flip side of that they’re
also noticing that patients without any other signs or symptoms consistent with
asymptomatic kovat 19 are presenting with the only sign being anosmia and
that may be suggestive of an asymptomatic infection with covin 19 and
he’s talking about him personally having seen four patients in one week all under
the age of 40 and otherwise asymptomatic except for recent onset and nas mia and
he usually sees only about once a month so this is something to be on the
lookout for he also has some recommendations at the bottom of the
letter he says that there is potential that if any adult with anosmia but no
other symptoms was asked to self quarantine for seven days in addition to
the current symptom criteria used to trigger quarantine we might be able to
reduce the number of otherwise asymptomatic individuals who continue to
act as vectors not realizing the need to self isolate it would also be an
important trigger for healthcare personnel to employ full PPE or personal
protective equipment and help to counter the higher rates of infection found
amongst ENT surgeons compared to our other health care workers and of course
we’ll put links to these articles as well as other ones in the description
below so we’re going to talk about the immune system as promised and remember
what we talked about how a good immune system in both of these situations could
help not only the person having the good immune system but also reducing the
number of people going into our healthcare system so here is what is
represented as the population at whole and then there is a certain amount that
will catch the infection which is here infection and then about 80 percent
those people will not need to go to the hospital because they have a sufficient
immune system but the 20% here we could improve and perhaps if we had a good
immune system we might be able to not even become infected in the first place
and we talked about in our last update what they were doing by giving a BCG
vaccine even if there were given one earlier life to give another one they’re
hoping to see that their immune system will be heightened not just against
tuberculosis as it’s designed for but also an improvement in your innate
immune system so that’s your lymphocytes your leukocytes your natural killer
cells your neutrophils etc what is it that we can do to improve our own immune
system so the first thing I want to talk about is fever fever is one of those
signs that you get when you have a viral infection and it’s one of those things
that you might see also with kovat 19 although it’s not universal so here’s a
paper that was published in 2017 looking at the presence of fever in adults
versus children and one of the things in the article that’s interesting to note
is they looked at a number of different viruses and you can see here for corona
virus if we were to take this as a representative of the current kovat 19
cases only two out of seven cases presented with fever giving it about a
twenty eight percent incidence of fever in the discussion they say here we have
shown using prospectively collected data that the rate of fever in adults with
confirmed viral respiratory infections is much lower than described in children
nevertheless it is present and it would behoove us to take a look at the
mechanisms of fever both in adults and children so here’s another paper that
was published in the world Journal of Clinical Pediatrics back in 2012 titled
fever management evidence versus current practice and I found it to be a very
good source of some interesting studies regarding fever and under the heading
that says evidence that fever is beneficial they had a number of points
it talks about fever having an adverse effect on back tear
on viruses how it improves the activity of a lot of signaling like interleukin 1
also cells that are involved in the immune system that we’ve talked about
including T cells B cells and antibody production a lot of these things are
mediated at temperatures that are just above normal around 38 39 40 degrees
centigrade 38 degrees correlates to about 100 point 4 there’s also some
studies here that show that interferon which is of course in antiviral agents
has enhanced antiviral activity above 40 degrees centigrade so there are a number
of references here and I’ll include all of those papers in the description below
in those references we can see here in vitro that as we increase the
temperature here on the x axis the percent yield in this case of poliovirus
starts to drop similarly if we look at the development of poliovirus at 37
degrees centigrade in that paper it was quite prolific over a period of time
repeat the experiment here at 40 degrees centigrade there is a precipitous drop
again these aren’t in vitro studies so let’s look at some human studies so
while there have been a lot of bacterial studies I wanted to highlight a viral
study with Rhino virus which is a virus that causes a common cold as well this
paper was published back in 1990 there was 56 healthy subjects and all of them
had Rhino virus introduced into them but then there were forearms there was an
aspirin arm there was a Tylenol arm there was an ibuprofen arm and then
there was a placebo arm and in each of these arms they measured something
called a serum neutralizing antibody response so we’re looking for the
antibody response after these people that were infected with Rhino virus and
what they found is that in the aspirin and in the tylenol group these together
were statistically significantly lower in terms of that antibody response when
it was compared to placebo and that p-value was less than point zero five and what we’re finding more and more of
recently is that temperature is intricately related to the immune
function of the cell here’s a paper that was published in 2018 that shows that
temperature regulates certain cellular messaging systems that allow the immune
system to respond to infections this signaling pathway known as NF kappa-b is
a signaling mechanism that allows the cell to respond to these infections and
it was recently highlighted in an article in medical news today a
signaling pathway called nuclear factor Kappa B plays an important role in the
inflammation response in the context of infection or disease this protein helps
the expression and the production of certain immune cells these proteins
respond to the presence of viral or bacterial molecules in the system and
that is when they start switching relevant genes related to the immune
response at the cellular level they also note here that this NF kappa-b
becomes more active at higher temperatures and less active at lower
temperatures so the question is is it the fever that’s causing the NF Kappa
beta to go up or is it the NF Kappa beta that’s causing the fever well they did
some experiments and they found this protein called the a20 protein is what
tells the NF kappa-b protein to go up and so if you knock out
this a 20 then that is gonna prevent the NF kappa-b from activating and when it
doesn’t it’s no longer going to be doing the things that it needs to do to
augment the immune system so in essence fever somehow stimulates a twenty which
then stimulates NF kappa-b an NF kappa B is essential for immune system how do we
deal with fever well remember what we talked about a couple of lectures ago we
have something called arachidonic acid which is converted into prostaglandin
and specifically prostaglandin e2 that’s mediated through something called the
– enzyme and what are one of the big inhibitors of the cox-2 enzyme but
NSAIDs remember what NSAIDs are aspirin ibuprofen and indomethacin so because of
this in other studies many scientists and many practitioners especially in the
pediatric population are advocating that fevers based on known viral infections
shouldn’t be treated just based on the number itself and the fact that the
temperature is elevated that in fact the fever may actually be beneficial to the
recovery of the patients and unless the fever is excessive or the patient’s
dehydrated or there’s lethargy which means that the patient doesn’t want to
move very much then fever shouldn’t be treated couple of points here to
remember number one a fever is not hyperthermia hyperthermia is what one
might get if they were running on a very hot day and their temperature was 105
106 107 those are clearly very dangerous temperatures and they need to be treated
aggressively otherwise someone could die but in the sense where there is a viral
infection and a fever is being caused and there’s no other complication as a
result of that fever there is a question about whether or not that fever should
be treated the other point I want to make and it’s very important is that
there are a number of adults in this country that are on aspirin for very
good reasons and this is not a reason to stop it you should never stop any
medication without consulting your physician
there are people with stents people with strokes for which aspirin is life-saving
not to mention that people take ibuprofen and in the medicine for
rheumatological conditions as well I’m simply saying that perhaps an elevated
temperature in your body may be part of the solution to getting better over the
viral infection and not part of the problem I would be interested in your
comments below regarding this issue I think one of the conclusions that I draw
from this is that there is a benefit in infectious disease to having an elevated
body temperature okay we’ll see if our next update please take a moment to
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