COVID-19: Diagnosis and Treatment

by Sean Elliott, MD

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    00:01 COVID-19 Diagnosis, Differential Diagnosis, and Treatment.

    00:06 Diagnosis of COVID-19, largely has been accomplished, by nucleic acid amplification testing or "NAAT," typically, by reverse transcriptase polymerase chain reaction, an (RT-PCR) assay.

    00:19 Antigen testing can be performed, it is certainly rapid, it can be performed as a point of care test, so, at the site of a clinic or emergency department, but it is less sensitive than NAAT.

    00:31 Serology or antibody detection of course will be adequate for diagnosing prior infection or infection at least three to four weeks prior to the time of testing, however, there is variable sensitivity and specificity, keeping in mind that the antibody, assay, must be specific to a component of the SARS-Coronavirus II and not creating a false positive result in reaction to something else.

    00:56 Also important, in the diagnosis of COVID-19, is, to exclude as best as one is able other etiologies or even coexisting processes such as other respiratory infections, congestive heart failure, multi-organ failures, exacerbations of underlying reactive airway disease or asthma or even COPD, and anxiety.

    01:18 There is, as you would imagine an extensive overlap, between the presentation and symptoms of COVID-19 and many other respiratory illnesses, such as, influenza, rhinovirus or even other coronaviruses, as the cause of the common cold, pertussis, causing whooping cough and even atypical pneumonia, caused by such bacteria as mycoplasma or even tuberculosis.

    01:43 With that extensive overlap, you can imagine an initial presentation, is completely non-specific, patients with COVID-19 and other respiratory illnesses, will start off with a flu-like illness, they will likely have lymphopenia, especially, if one is having an initial robust presentation, with elevated white blood cells and a neutrophil predominance, so-called left shift, if that response also includes, bands or metamyelocytes.

    02:14 However, lymphopenia, can be quite prominent several days even several weeks into COVID-19 and maybe a suggestion that the patient has COVID-19, versus other respiratory illnesses.

    02:27 Certainly, development of pneumonia can be seen in all respiratory illnesses, that's part of the name and including COVID-19 and all these can progress to severe disease, also can have critical complications, especially, if an initial, viral respiratory disease other than SARS-Coronavirus II, develops a secondary bacterial pneumonia as a complication.

    02:50 So, whereas the initial presentation is nonspecific, One, can use a specific testing which will help distinguish COVID-19, from other respiratory illnesses.

    03:01 So, in that patient with a non-specific presentation and in whom one suspects COVID-19, one, can perform RT-PCR testing or a quick antigen test, followed by PCR confirmation for SARS-Coronavirus II.

    03:17 If the patient is sick enough to require hospitalization and potentially other interventions, then a chest computed tomography or a CT scan, may demonstrate bilateral ground glass opacities and diffused pneumonia or even unilateral patchy processes, in patients with COVID-19, versus other findings and other types of respiratory illnesses.

    03:40 In kidneys, one can develop or one can see elevated BUN and creatinine or evidence of acute kidney injury, again, this doesn't distinguish COVID-19, from other infections or respiratory illnesses, but it is more commonly seen in patients earlier on in their COVID-19, than you might anticipate in other illnesses.

    04:02 Similarly, cardiac abnormalities, keeping in mind that the virus does have tropism for among other organs, the heart, one can see elevated troponin, so, evidence, of myocardial damage or injury as well as an abnormal EKG, so, showing a dysrhythmia or even sometimes access deviation on the EKG.

    04:23 Liver function abnormalities, so elevated liver enzymes such as, AST, ALT, GGT, lactite dehydrogenase, the alpha-HBDH, all these can be seen early on in acute COVID-19, which is, on the way to becoming severe, but again, keep in mind there is still an overlap with other respiratory illnesses.

    04:46 What about treatment, so, in patients who are outpatients, so, mild disease, or mild about to become severe if they have comorbidities, there are several monoclonal antibody cocktail therapies, typically, two monoclonal antibodies in combination, which target, as two separate antigens, expressed by SARS-Coronavirus II, typically, these are two components of the spike protein, created or expressed by SARS-Coronavirus II.

    05:17 In the United States as well as elsewhere in the world, these monoclonal cocktails, antibody cocktails, have been approved for patients with mild to moderate disease and risk factors for progression and continuing studies demonstrate their efficacy, the challenge of course is in parts of the world, which now, is everywhere in which a variance, mutant variants have emerged, not all of the monoclonal antibodies remain efficacious, against the newest variants and especially against the delta variant.

    05:48 Other therapies of course are being evaluated, as prophylactic interventions but none has been proven to be helpful, in patients who have mild disease only.

    05:59 What about those patients who have severe disease and are hospitalized.

    06:03 Again, there is emerging evidence in this this field and the ideal management continues to evolve, however, absolutely oxygen therapy is a necessary, because patients principally present with hypoxia and decreased peripheral oxygenation, there are several series now which have demonstrated benefit for those patients with moderate to severe disease with tocilizumab, which is, a monoclonal antibody, targeting the interleukin-6 receptor.

    06:32 Prophylactic anticoagulation, some benefit has been shown there as well, keeping in mind that a complication of COVID-19 is, thrombosis due in part to the immune reaction to the virus itself.

    06:45 Those patients who are moderate to severe, progressing to severe critical disease, also qualify for use of dexamethasone therapy, while, other steroids have been tried and also found to be efficacious and then the antiviral drug remdesivir, however, if these patients rapidly proceed to mechanical ventilation, it is unclear that either of these interventions, has any ability to prevent that, once they've actually presented and presented with respiratory failure.

    07:15 Those severest of the severe patients, may require intubation, mechanical ventilation and even sometimes, “ECMO,” “Extracorporeal membrane oxygenation.” So, this is of course I guess the scary part of the pandemic, knowing that while 80% of patients have mild disease, there is still a 15% severe and a 5% critical component, who can develop very, very, concerning complications, so, it is good to have ways to diagnose them early and hopefully provide some sort of intervention to prevent progression to, that point were, they require ventilation, intubation and potentially ECMO.

    About the Lecture

    The lecture COVID-19: Diagnosis and Treatment by Sean Elliott, MD is from the course Coronavirus.

    Included Quiz Questions

    1. Nucleic acid amplification test (NAAT)
    2. Western blot
    3. Serology testing for antibodies
    4. Rapid antigen test
    5. SARS-CoV-2 viral culture
    1. Patients with mild-to-moderate symptoms
    2. Patients with severe symptoms
    3. Patients in intensive care
    4. Patients requiring mechanical ventilation
    5. Asymptomatic patients who have not yet gotten severely ill
    1. Elevated BUN, creatinine, and liver function tests
    2. D-dimer
    3. Neutrophil count
    4. Hemoglobin and hematocrit
    5. Erythrocyte sedimentation rate (ESR) and CRP
    1. Monoclonal antibody
    2. Antiviral
    3. Antibiotic
    4. Anticoagulant
    5. Steroid

    Author of lecture COVID-19: Diagnosis and Treatment

     Sean Elliott, MD

    Sean Elliott, MD

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