COVID-19 Pandemic – Clinical Syndrome and Empirical Therapy

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Salient Points

This article focuses on the COVID pandemic sweeping across the world, the role of testing, the sensitivity of PCR based tests, alternative tests apart from PCR for the population that cannot afford testing.

The article includes the following criteria to define the clinical syndrome and guide testing.

  • Mandatory criterion: fever ≥ days, with no other localising symptoms
  • Epidemiological Setting: travel from abroad or to a large city in the country/ crowded place
  • Major Criteria: dry cough/ anosmia of recent onset/ chest crackles/ peripheral infiltrates on CXR
  • Minor Criteria: Diarrhoea/ severe headache/ Myalgia/ lymphopenia with normal/low normal WBC count

A presumptive diagnosis of the clinical syndrome is made as follows:

  • In epidemiological setting: 2 major or 1 major and 1 minor criteria
  • Without epidemiological setting: 2 major+ 2 minor, or 1 major + 3 minor criteria

Detailed Summary

In the face of a pandemic, the presence of a typical epidemiological setting is very important for defining the clinical syndrome. When a disease has a very high strike such as in a pandemic, a clinical diagnosis may actually pick up more true cases than a lab test. Relying purely on lab tests may underestimate the true disease prevalence and incidence.

It is important to assume that every individual with the clinical syndrome diagnosed by criteria has COVID 19 and to act accordingly.

  • This approach ensures the patients best interest and reduces health care costs.
  • It also gives a better estimate of disease prevalence and incidence.

Criteria used to define the clinical syndrome

  • Mandatory criterion
    1. Fever for 3 or more days
    2. Without other localising symptoms such as dysuria, skin or soft tissue infections
  • Epidemiological setting
    1. Travel within the past 4 weeks to or from any other country or a big crowded city in the country.
    2. Visit within the last 4 weeks to a crowded place (bus stand , railway station, movie theatre, airport, place of worship etc)
  • Major criteria
    1. Dry cough
    2. Sudden recent onset of Anosmia or loss of taste sensation
    3. PE findings of crepitations on chest auscultation
    4. CXR showing peripheral patchy infiltrate
  • Minor criteria
    1. Diarrhoea
    2. Severe headache
    3. Body aches
    4. Normal or low normal total WBC count and Lymphopenia

Clinical Syndrome can be presumed to be present on the basis of

  1. Presence of 1 epidemiological setting along with 2 major criteria or 1 major criteria and 1 minor criteria.
  2. Even in the absence of epidemiological setting, the presence of 2 major criteria and 2 minor criteria or 1 major criteria and 3 minor criteria is sufficient.

Due to the limited availability of Laboratory testing, a positive lab test and a negative lab test must be established.

Therefore we can consider 2 groups of patients

  1. Those having COVID 19 Clinical syndrome – Large number
  2. Those with confirmed COVID 19 cases – Smaller number

Procedures to follow by suspected cases.

  1. Isolate affected subjects at home for 2-3weeks.
  2. Younger members of family aged less than 40 must be primary caregivers.
  3. Must follow a detailed isolation procedure at home – to prevent family spread.
  4. Other family members are assumed to be infected unless proven otherwise, therefore they must remain home quarantined for the next 4 weeks – to prevent community spread.
  5. Fever and cough are very common symptoms – it is essential for every household to possess simple medications such as paracetamol for fever and an antihistamine which will minimise sneezing and nasal discharge.
  6. HCQ and Chloroquine have shown some efficacy in-vitro experiments. Shown to reduce viral load and hasten viral clearance.

Presumptive treatment

  1. Hydroxychloroquine – 200mg – 2 tab Q12 hours on day 1, followed by 200mg – 1 tab Q 12 hours for 4 more days.

Note –

  1. Youngsters must monitor clinical illness daily and avoid HCQ
  2. Avoid HCQ in those with Chronic Renal or Liver Disease.
  3. DM patients must reduce doses of anti-diabetic drugs by 25-30% when on HCQ + Monitor Blood glucose levels and resume original doses after the course is over.
  4. Those with Cardiac disease must look out for potential DDIs – receive ECG on alternate days till end of course, with monitoring of serum electrolytes and magnesium.

Preventive treatment regime for household

  • HCQ 200mg 2 tabs, twice daily for day 1 followed by 200mg 2 tabs once a week for next 3 weeks

Preventive treatment for contacts should be initiated as soon as the presumptive case is diagnosed. If not it may be started up to day 14 of presumptive diagnosis in a member of a household or group.

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