COVID-19: Diagnosis and Treatment

00:08 COVID-19 Diagnosis, Differential Diagnosis, and Treatment.

00:13 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.

00:25 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.

00:37 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.

01:03 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.

01:25 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.

01:50 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.

02:20 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.

02:33 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.

02:57 So, whereas the initial presentation is nonspecific, One, can use a specific testing which will help distinguish COVID-19, from other respiratory illnesses.

03:08 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.

03:23 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.

03:47 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.

04:08 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.

04:30 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.

04:52 Well, for symptomatic patients with mild to moderate COVID 19 and do not have any comorbid conditions can generally be treated as lower risk.

05:00 This allows for telephone or telemedicine evaluation of dyspnea, oxygen saturation if available.

05:06 An overall clinical picture of the patient based on the patient's responses, they can be directed to the emergency department or scheduled for an in-person clinic visit if their symptoms warrant further evaluation.

05:18 Usually the things that get them sent to the emergency department are severe dyspnea, low oxygen saturation or more severe symptoms like chest pain, stroke, or hypoxia.

05:30 For outpatients with mild to moderate COVID symptoms and are at risk of progression to severe disease.

05:35 Early COVID specific antiviral treatment is recommended within five days of onset.

05:40 One of the most commonly prescribed treatments is paxlovid, but monoclonal antibodies can still be used in regions where the infection is likely to be a susceptible variant.

05:50 Plasma and remdesivir can also be used in some circumstances, and if there is a situation where none of these treatments are available, Molnupiravir can be used.

06:01 Of course, the ideal management is evolving as the pandemic continues and local protocols may differ depending on the region.

06:08 One generality to remember is that specific anti-virus therapy will have more effective given early in the course of infection while immune modulating agents have more efficacy at later disease stages.

06:21 In the hospital setting, supplemental oxygen continues to play a very important role in the most severe cases.

06:27 Other treatments, such as dexamethasone, broad spectrum antivirals, anticoagulants and antipyretics are also frequently used in treatment algorithms based on the patient's global clinical picture.

06:39 In most cases, the recommendation is to continue a patient on their chronic medications such as ACE or ARB antihypertensives.

06:48 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.