Categories
CORONAVIRUS/COVID-19

The Great Invader: How COVID Attacks Every Organ

April 23, 2020 — We have underestimated and misunderstood COVID-19 since it first appeared. And as we learn more, it’s clear that COVID-19 can be more than just a respiratory disease. It’s joined the ranks of other “great imitators” — diseases that can look like almost any condition.


It can be a gastrointestinal disease causing only diarrhea and abdominal pain. It can cause symptoms that may be confused with a cold or the flu. It can cause pinkeye, a runny nose, loss of taste and smell, muscle aches, fatigue, diarrhea, loss of appetite, nausea and vomiting, whole-body rashes, and areas of swelling and redness in just a few spots.

In a more severe disease, doctors have also reported people having heart rhythm problems, heart failure, kidney damage, confusion, headaches, seizures, Guillain-Barre syndrome, and fainting spells, along with new sugar control problems.

It’s not just a fever and coughing, leading to shortness of breath, like everyone thought at first.

This makes it incredibly difficult to diagnose and even harder to treat.

“This is a disease progression we have never seen for any infection that I can think of, and I’ve been doing this for a couple of decades,” says Joseph Vinetz, MD, an infectious disease specialist at Yale School of Medicine.

How It Invades

When viral particles land in our eyes, nose, or mouth, “spike proteins” on the virus connect with a specific receptor, known as ACE2, on the surface of our cells, allowing entry. ACE2 receptors make a great target because they are found in organs throughout our bodies. Once the virus enters, it turns the cell into a factory, making millions and millions of copies of itself — which can then be breathed or coughed out to infect others.

In order to evade early detection, the coronavirus uses multiple tools to prevent the infected cells from calling out for help. The virus snips off distress signal proteins that cells make when they are under attack. It also destroys antiviral commands inside the infected cell. This gives the virus much more time to make copies of itself and infect surrounding areas before it is identified as an invader. This is part of the reason why the virus spreads before immune responses, like fever, begin.

Direct Attack

Many with mild or no symptoms are able to fend off the virus before it gets worse. These people may have symptoms only in the upper airway, at the site where they were first infected. But when someone’s body can’t destroy the virus at its entry point, viral particles march deeper into the body. The virus seems to take a few paths from there, either setting up camp in the lungs, fighting its way into the digestive tract, or doing some combination of both.

“There’s clearly a respiratory syndrome, and that’s why people end up in the hospital. Some people get a gastrointestinal illness with diarrhea, maybe some abdominal pain, which may or may not be associated with a respiratory illness,” says Vinetz.

Once the virus is deeply embedded in the body, it begins to cause more severe disease. This is where direct attack on other organs that have ACE2 receptors can occur, including heart muscle, kidneys, blood vessels, the liver, and potentially the central nervous system. This may be one reason for the vast array of symptoms COVID-19 can cause.

“It’s highly unlikely that any other organs can be affected through direct invasion without severe disease,” Vinetz adds.

The brain and nerves may also fall prey to direct attack. Kenneth Tyler, MD, chair of the Department of Neurology at the University of Colorado School of Medicine, cautions that direct central nervous system (CNS) attack is still being worked out at this time. There are many routes a virus could take to invade the CNS. One somewhat disputed view is that the loss of smell could indicate that the nerve responsible for smell is infected and can carry the virus into the CNS, including the brain. “This can be shown to occur in experimental models with non-human coronaviruses and is a potential route of invasion for some other viruses. However, there is no evidence to date establishing that this actually occurs with SARS-CoV-2,” the official name of the virus that causes COVID-19.

Early findings, including those from autopsy and biopsy reports, show that viral particles can be found not only in the nasal passages and throat, but also in tears, stool, the kidneys, liver, pancreas, and heart. One case report found evidence of viral particles in the fluid around the brain in a patient with meningitis.

Collateral Damage That Kills

Severe damage to the lungs may be one trigger that activates and overstimulates the immune system through a barrage of signaling chemicals, known as cytokines.

The flood of these chemicals can set off what is referred to as a “cytokine storm.” This is a complex interplay of chemicals that can cause blood pressure to drop, attract more killer immune and inflammatory cells, and lead to even more injury within the lungs, heart, kidneys, and brain. Some researchers say cytokine storms may be the cause of sudden decompensation, leading to critical illness in COVID-19 patients.

A new finding suggests there may be another deadly culprit. Many doctors are discovering that abnormal clotting, known as thrombosis, may also play a major role in lethal COVID-19. Doctors are seeing clots everywhere: large-vessel clots, including deep vein thrombosis (DVT) in the legs and pulmonary emboli (PE) in the lungs; clots in arteries, causing strokes; and small clots in tiny blood vessels in organs throughout the body. Early autopsy results are also showing widely scattered clots in multiple organs.

Adam Cuker, MD, a hematologist at the Hospital of the University of Pennsylvania who specializes in clotting disorders, says these clots are happening at high rates even when patients are on blood thinners for clot prevention. In one study from the Netherlands, 31% of patients hospitalized with COVID-19 got clots while on blood thinners.

Cuker says that “new studies validate what we have all been seeing with our eyes, which is that ‘boy, it seems that these patients are clotting a lot.’ … And it could be that the rate of thrombotic events are even higher than we truly recognize.” Though the reason for the clotting is still not clear, it seems to be playing a much larger role in death than previously understood.

Beyond the collateral damage from cytokine storms and clotting, other things like low blood pressure that comes from a severe illness, low oxygen levels, ventilator use, and drug treatments themselves can all harm organs throughout the body, including the heart, kidneys, liver, brain, and other organs.

Double-Edged Sword

Even though researchers are learning more each day about the virus and how and where it attacks the body, treatment geared toward these targets also pose significant problems. Many drugs come with a risk of destroying the delicate balance that allows the body to help fight the disease or to manage inflammation.

The ACE2 receptor that the virus uses to enter cells is a key player in lowering inflammation and reducing blood pressure. Targeting or blocking this receptor as a treatment strategy to prevent viral entry into cells may actually worsen blood pressure, increase the risk of heart failure and kidney injury, and increase inflammation that may worsen lung injury.

Drugs that target the immune response to lower the risk of a cytokine storm may also tamp down the immune response, making it hard to kill off the virus over the long run.

Using medicines to prevent clotting may end up causing severe bleeding. Cuker points out that “we don’t have a good read on bleeding … we have limited evidence about the clotting risk … we have zero evidence on bleeding risk in these patients, and it’s a real priority to understand this risk, especially because one of our strategies to treat the clotting is stepping up intensity the of anti-coagulation.”

Timing is likely to be key in treatment strategies. For example, patients may need a drug to boost the immune system early on in the disease, and then one to tamp it down if the disease progresses and cytokine markers begin to rise.

Just the Tip of the Iceberg

Cuker says that  what we know about clotting and almost everything else when it comes to COVID-19 “is just the tip of the iceberg.”

Sanober Amin, MD, PhD, a dermatologist in Texas, agrees. She’s been tracking the wide variety of skin findings that dermatologists across the world have been noting on social media.

She recently posted images on social media that show the wide variety of skin findings she has been seeing and hearing about. Her post received a massive response. Amin says that “dermatologists from around the world, from Turkey to France to Canada to the U.S., are sharing information about rashes that they’ve observed in people with COVID-19.”

 Some rashes seem to be consistent with what’s called a viral exanthema, which is a term for a general rash that can happen with almost any virus. But, Amin says, “some skin findings are more consistent with superficial clotting in blood vessels close to the skin.”This is what some have started to call “ COVID toes,” also called pernio. Dermatologists are seeing more cases of these small clots in toes and fingers, especially in children.It’s hard to know which skin conditions are related to COVID-19 because a lot of people without “typical” symptoms are not being tested, Amin says. Researchers will still need to work out which symptoms may be caused by the virus and which may just be unrelated early findings.

Unanswered Questions

For now, much of the information we have about the symptoms of COVID-19 come from hospitalized patients who are very sick by the time they seek care and may not be able to share information about the early signs and symptoms they may have had.

Because of the lag in  testing in the U.S., we still don’t know the full extent of what mild and moderate versions of the disease look like, or what effects the disease has on people who have many symptoms but aren’t quite sick enough to be hospitalized.

One open question is what the long-term effects may be for survivors. What does life look like after being on a ventilator or suddenly needing dialysis? Will we see decreases in heart, lung, and kidney function that is long-lasting and permanent, or will patients eventually recover?

We also don’t know how people will clear infections. If the new coronavirus ends up being an acute infection, like other coronaviruses, most recovered people should develop at least a short-term immunity. It’s also possible that the virus may persist as a latent infection, like chickenpox, lying dormant in the body, only to re-emerge periodically as shingles does, or become a chronic infection, like hepatitis B, living within the body for a sustained period of time, causing long-term damage.

“It’s definitely going to be an acute infection … there’s no way it’s going to be latent or chronic, no way … I think so … we’ll see,” Vinetz says.

Source: The Great Invader: How COVID Attacks Every Organ






Categories
CORONAVIRUS/COVID-19

Restaurant And Bar Service Under CC Virus Rules

Governor Michael DeWine of Ohio recently floated the idea of requiring those who drink alcohol to also order food.


TA-FC ClipBoard: When the bars and restaurants reopened after the viral shutdown, I was surprised that the regulars still came in and spent the same amount of time as before the viral shutdown – most of them are single. That made it difficult for other patrons to get served given the distance rule.

Although the regulars often take food home with them, they sit and drink for about four hours. Some have to be driven home by staff or other kindly patrons. They’re so drunk they can hardly walk much less talk or eat.

  • So if you require DRINK AND DINE, then be clear about take out. People will reheat the food when they get home; they don’t care how long it sets on the bar waiting.

The bartenders tolerate it for tips. It seems to me though that four hours isn’t going to result in a bigger tip than two hours. But what do I know except my observations.

When someone is so drunk they poop on the seat and floor where they sit, and the employees have to clean it up, something is very wrong with the workings of that establishment.

It seems that where police officers or FBI or CIA or other government employees hang, those establishments aren’t held to the same standards as other establishments. They need to be.

I agree that if the state is trying to keep open bars and restaurants, by discouraging the people who drink for hours at a time, or the younger crowd who most often stand as they’re looking for hook ups, it’s probably a good idea to DRINK AND DINE ONLY.

DRINK AND DINE OR NO SERVICE. Most customers who eat and drink, do it and leave, they don’t hang around.

However, people will find a way around the rule by ordering a bag of chips or a side of fries to keep in front of four people pretending to snack on them.

It seems during this viral outbreak that a lot of people strategize on how they can legally, so to speak, break the rules. It seems almost instinctual the way they do it. We don’t see all the people who stay home, but it’s surely a whole lot more than go out.

The problem arises when a few go out and return to their homes and jobs to infect everybody with the virus that they got from hanging out.

Remember that drinkers are impaired, so when making rules that apply to them, one must consider their impairment and willingness to break rules that are harmful to themselves and others.

What rules will they obey? From my observations I’d say none.

You’d have to pay them and they’d still find a way to break them. Maybe one day of compliance and that’s all they can think or talk about. Not even a full day. Then it’s a little compliance. Wear the mask over your chin or on top of your head, or pull it down when you talk.

There are no rules they won’t break. However, if the management or owner thinks the rules are ridiculous, they set the tone.

Restaurants and bars are unique in that once you’re in, the mask comes off to eat and drink, and pretty much stays off till you leave.

The problem I encountered was people approaching to talk without the mask and getting way too close for comfort. Add to that the racial tensions in an environment of distancing and people’s actions get misunderstood, mostly because they’re in an environment with impaired people.

There was a rule about menus. They had to be paper, disposable. Well I saw some, but they clearly weren’t disposable, and still other establishments flagrantly ignored it. In the beginning the plastic menus would be swiped with cleaner, but it didn’t take long before no one did it. The appearance was there – the bottles and cloths.

As an afterthought and in the spirit of levity, I’d say hire all the people who find ways to skirt the rules while staying inside the boundaries whereby if they ever ended up in court they’d win. They must share some quality that some employers may find useful. Put them to work and shut the bars and restaurants a little longer.

The ones who stayed closed when others opened were the smartest. Look at what they’re doing and how they’re getting along.

The people doing the best jobs are the grocery stores. Lots of new hires don’t want to obey the rules, but when it’s mandatory, it gives the owners more power over noncompliance.

I think that’s the key, if it’s law they’ll do it.

People are CC Virused out. A spike doesn’t mean anything at this late stage of circulating misinformation for political purposes. Everything is either proTrump or anti Trump.

There’s too much variation among states regarding rules of the virus, compliance and non-compliance. Doing what’s best for your state doesn’t seem to be working to the benefit of the people in those states. Sure it’s the people’s fault, but there is simply too much conflicting information out there.

Attacking people for wearing a mask? Being called a racist for social distancing? Why are some groups more compliant?

The governor of New York sent virus-recovering people into nursing homes. If they were not contagious, then they should have been sent home. Seniors are at the greatest risk, yet they’re turning senior residences into public housing, which takes all ages, which puts seniors at risk – a high risk. It’s the younger ones who aren’t wearing the masks.

Make the masks mandatory statewide. Employers need to supply the masks; they’re not doing it. Only some.

Close restaurants and bars for six weeks. Reassess. What did they do wrong? How will they improve when they reopen this time?

This isn’t a game.

Selling drugs out of restaurants and bars needs to stop. Find another place, where people don’t gather. They take over the place. It puts everybody on edge and they push people out who have a right to be there.

Bartenders and waiters set the tone for the customers. They want tips, so they bend the rules.