What is it really like to have COVID-19 in China?
Dr. Bernard explains using three real-life examples from colleagues at Wuhan hospitals who described and translated these cases to Dr. Bernard.
Note this video was recorded on Feb. 23, 2020. For up-to-date information, follow MedPage Today's COVID-19 coverage.
Watch the video above or read the transcript below:
ZT is a 61-year-old man, presenting to the emergency room with fever, cough, and weakness on Dec. 20, 2019.
Several years ago, he was diagnosed with liver disease. Over the next 7 days, ZT was monitored in the respiratory unit at the Wuhan hospital, and he started to develop trouble breathing.
A throat swab tested positive for the coronavirus, SARS-CoV-2 infection, meaning he has COVID-19, the disease caused by the virus.
A CT scan of his chest confirmed viral pneumonia. On the eighth day of hospitalization, December 28th, ZT was transferred to the intensive care unit. A tube was placed down his throat so that a machine could help him breathe.
Three days later, on New Year's Eve, ZT was transferred to the infectious disease hospital in Wuhan City so he could be more closely monitored.
On New Year's Day, ZT fell unconscious. His blood pressure started to drop. The next day, he entered respiratory failure. He was hooked up to life support.
A second infection was found in ZT. This time, bacteria. Other germs were starting to grow inside him.
Acids were found in his blood, as his organs started shutting down. At 8:47 p.m., on Jan. 9, 2020, 8 days after he was moved to the infectious disease hospital, ZT's heart suddenly stopped beating. A code was announced in the hospital, and doctors rushed to resuscitate him, but at 11:13 p.m., 2.5 hours later, the code was called. ZT could not be resuscitated.
Pneumonia, fever, life support, acids in blood.
These are all things that are dealt with in hospitals every day. Nothing new here.
Problems with the lungs can cause critical illness quickly -- but can be even quicker when the heart gets involved.
BM is a 69-year-old man, presenting to the emergency room with fever, cough, and breathing trouble on Jan. 3, 2020. At the Wuhan Red Cross Hospital on the day of presentation, BM was intubated because he was actually in respiratory failure and had hypoxemia.
"Hypo" meaning low.
"Ox" refers to oxygen.
And "emia" meaning presence in blood. Low oxygen presence in blood because of respiratory failure. But this wasn't his only problem.
Parts of his heart muscles were floating around in his blood. This is something you find when someone has a heart attack.
But BM didn't have a heart attack.
A throat swab confirmed SARS2 infection and COVID-19 disease. The next day, Jan. 4, 2020, BM was transferred to the infectious disease hospital in Wuhan City, when he became unconscious.
A CT scan found pneumonia.
BM was moved into the intensive care unit. He was turned over on to his stomach, to help get more oxygen in his lungs during machine ventilation. And this brings us to why this is happening in BM, and why is he being treated this way.
The COVID-19's main feature is pneumonia. But how does the virus cause this?
The spikes on the virus surface, are protein. The viral genome dictates how every protein is made. We have the genome fully sequenced, so we know these spikes are similar to the ones on the first SARS virus that had an outbreak in 2003.
These spikes interact with something called angiotensin-converting enzyme 2 or ACE2 in humans. It looks like this is how it enters cells of the lower lung. When it enters, it injects its RNA and hijacks the lung cell to create viral materials instead of letting the cell live its normal life. It kills the cell while creating more virus.
But the lungs aren't the only place where humans have ACE2. The stomach and the intestines have it. Specific parts of the male anatomy have it. It's on the kidneys. And, it's in the heart, which could explain BM's damaged heart.
Problems in the stomach probably won't kill someone immediately. Problems in male anatomy probably won't kill someone immediately. But a problem of the heart or lungs can kill someone in minutes, which brings us back to pneumonia.
When the body's immune system detects viral damage in the lungs, it reacts. It expands the blood vessels, so more immune cells can enter, but this also means fluid fills BM's lungs. This makes breathing harder, because now the lungs can't exchange oxygen and carbon dioxide with the blood.
The machine ventilator was used to push pressure into BM's lungs.
But high pressure in lowers the movement of air out. What's the air going out? Carbon dioxide.
So, carbon dioxide levels increase in the blood when the pressure is high. This is uncomfortable and patients will instinctively try to breathe against the ventilator. That might knock things off sync, so medicines were given to temporarily paralyze BM's respiratory muscles, so he can't fight the machine. Medicines were given to sedate him so that he wouldn't be fully conscious while paralyzed.
All of these things, low tidal volume ventilation, muscle paralysis and sedation, and early prone position, that's turning him on to his stomach, have been shown to decrease mortality in patients with acute respiratory distress syndrome, just like BM.
Dialysis was started because his kidneys were starting to fail. A viral infection in the lung can cause other germs to start growing, and in BM, bacteria was starting to grow.
Why this happens is not really clear. It could be that a viral infection reduces the body's available resources to fight a bacterial co-infection. But it also could be that viruses directly sabotage the immune system's ability to fight off a co-infection.
Whatever the case is, BM was started on multiple antibiotics to cover many kinds of bacteria. He was treated for his symptoms in intensive care. But it wasn't enough.
Five days later on Jan. 9, 2020, the bacteria that was in his lungs was floating around in his blood. His blood pressure started to drop because his immune system was reacting to that bacteria by dilating all the blood vessels. Tiny clots were forming in his bloodstream that were lodging into the blood vessels of his organs, blocking blood flow and causing them to shut down. At midnight on Jan. 15, 2020, BM's heart stopped beating. A code was announced in the hospital, as doctors rushed in to try to resuscitate him. By 12:45 a.m., the code was called. BM could not be resuscitated.
These two critically ill cases of COVID-19 are cases of severe pneumonia. That is how the virus affects humans.
If these were isolated cases that happened months apart from each other in different parts of the country, maybe no one would have thought twice about it.
But if multiple cases come through in a short time, in the same place, with an illness this serious, then it's cause for concern. In America, in 1981, there was an outbreak of 11 cases of rare fungal pneumonia. This ended up being the first description of AIDS.
Because that fungus that caused their pneumonia is everywhere in the air. You might be breathing it right now, but your immune system handles it, no problem. An AIDS patient, though, has a weak immune system.
When these 11 cases were identified back then, no one knew what AIDS was, meaning these patients were in end-stage disease. The fungus was growing all over their lungs, causing that rare pneumonia. So, "rare pneumonia" coming up often, can trigger an alarm of an outbreak of communicable disease, but you have to be careful. You don't want to cry wolf, but you also don't want to not tell anyone something bad could be spreading.
So here's what we know. Fever and pneumonia are present in almost all cases of COVID-19. Other problems like with the heart and kidneys and stomach, it depends.
There could be people who are infected and don't have symptoms. It looks like those people can spread the virus through respiratory droplets from their lungs.
Surface contamination? The data are not conclusive, so wash your hands. Asymptomatic spread is the scarier scenario because those people may not get isolated or quarantined immediately, and infect others unknowingly, so that's why it would be best if we could do a serology or a testing method to find antibodies in someone to the SARS2 virus.
But on the flip side, if someone is held in isolation, with maybe some of the potentially more subjective symptoms, are they really short of breath, or do they think they're short of breath now that they know they're being held in isolation? What happens when they don't have symptoms, but insist they do and demand treatment that they don't need? Nobody wants that tube down their throat, trust me.
But if the illness keeps getting worse: pneumonia, fever. Secondary infection. Bacteria breaks off and starts floating around in the blood. Organs start to shut down because blood pressure is too low from the immune system trying to attack the bacteria in blood. Metabolic waste and acid build up in the blood, causing the heart to stop beating.
But the good news is that ZT and BM aren't the majority of patients. Unfortunately, they died. The official number says mortality for COVID-19 is somewhere between 2%-5%. OK, assume we take that with a grain of salt. The cases that are confirmed here in the United States show the same pneumonia and respiratory issues described by doctors in China.
So ZT and BM were older patients who had prior medical histories. Severe pneumonia is going to hit that demographic pretty hard.
What does it look like when a younger, healthy person is infected?
ZW is a 35-year-old man presenting to the emergency room at Wuhan General Hospital with a 3-day fever.
Dec. 5, 2019.
He had no past medical history and was not taking any medications.
A chest CT found viral pneumonia. Keep in mind this is before there were global announcements of an outbreak. Over the next 4 days, ZW's kidney and lung function slowly worsened.
On day 5, ZW started on supplemental oxygen and was given symptomatic treatment. ZW's condition worsened over the next 5 days, but started to stabilize by day 11, when he tested positive for SARS2 virus. Several weeks later on January 20th, ZW was placed for surveillance and eventually discharged.
ZW's case is similar to the one that happened in Washington State, which was published in the New England Journal of Medicine on Jan. 31, 2020.
This was the first case confirmed in the U.S.
This patient, also 35 years old -- also no past medical history.
He presented to urgent care with a 4-day history of cough and fever. Which isn't out of the ordinary for mid-January cold and flu.
He had a confirmed COVID-19 infection done by a throat swab. How was he treated for fever? Tylenol and ibuprofen. How did he get treated for his cough? Cough syrup. As the days went by, blood tests started showing some abnormalities related to his liver, but it didn't seem like anything too bad was really happening at that point.
But on hospital day 5, his chest CT showed an atypical pneumonia. They already knew at that point he had the SARS2 infection, so this probably wasn't too surprising to them, but on that day, the patient started having trouble breathing. He wasn't getting enough oxygen from the air, so he was given supplemental oxygen.
Since he had been at the hospital so long by this point, was this decline in breathing from SARS2 virus? Or was it from hospital bacteria? Antiviral medicine won't work on bacteria. Antibiotics won't work on a virus. If he's not treated with the right medicine for the right pathogen, he's going to get sicker, so the medical team started him on antibiotics.
The next day, pneumonia was still found in both lungs and the medical team was able to get a medicine that's in research, remdesivir. This medicine confuses the virus.
By looking like one of the genetic backbones of the viral genome, the virus uses it to reproduce. But because it's not actually the right backbone, the virus can't reproduce properly. This could be one way to treat COVID-19, because it appeared to work for this patient as his condition improved over the next few days.
The medicine appears to be in China now for use in a trial, along with many others.
So, focus on what's going on where you are at the moment. In America, not even 50 cases, it's actually 35 at the time of me recording this. If you feel fever and chills, shortness of breath, and fatigue over the last few days, get that checked out. It's more likely to be flu than SARS2 if you're in the USA, but if it is SARS2, you're going to get good care for it here.
Wash your hands when you come home from a public place, or if you touch something in your house that came from the outside. If you're young and healthy, non-smoker, no past medical history, and you feel ill, don't panic cause you have every advantage on your side in the U.S. If you're older with past medical history, don't take any chances with any fever, in general. #alertnotanxious
Because I can't create a new video every time something new develops, I've created a playlist with other medical YouTubers on there. In the context of medicine and medical treatments, these are all great resources to learn more about the SARS2 virus and resulting COVID-19 disease. Again, #alertnotanxious and I hope these videos help you find the resources that you need. Take care of yourself. And be well.
Dr. Bernard would like to thank the following from Wuhan Union Medical College Hospital and Wuhan Jinyintan Hospital for description and translation of the cases above:
David Lai, MD; Che Sed, PhD; Zheng Chuansheng, PhD; Fan Yanqing MD; Han Xiaoyu MD; and She Heshui, MD.
"Dr. Bernard" is a licensed physician and clinical adjunct professor at the University of Illinois. See more of his videos on his "Chubbyemu" YouTube channel.