CORONAVIRUS (COVID-19) LEADS TO CYTOKINE STORM SYNDROME

EARLIER INTERVENTION IS BETTER THAN CRISIS MANAGEMENT

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Personal Hygiene targets the outside of the body.

 

​Oxygen Therapy including Normobaric and Hyperbaric Oxygen target the internal cellular metabolism (cytokine storm syndrome).

 

  • Oxygen Therapies are effective in treating both the primary infection but also the cascading secondary challenges associated with the coronavirus immune response.

  • With any infection, the body’s immune system responds by attacking the foreign virus or bacteria. While this immune response can rid the body of the infection, it can also sometimes cause collateral damage in the body termed a “cytokine storm". The immune cells produce cytokines to fight infection, but if too many are released, it can cause chronic autoimmune problems in the body.

 

 * People most vulnerable to COVID-19 are individuals with pre-existing health challenges associated with chronic cytokine storm syndrome.

 

Spanish Flu​

Cytokine Sepsis Syndrome

  • Cytokine Gene Expression Testing is at the forefront of medical advances and immunotherapy interventions however not entirely new. The first member of the cytokine storm family to be recognized by physicians was sepsis. The appreciation that the consequences of sepsis are a result not of the pathogen, but rather the immune response to the pathogen, dates back to observations made by William Osler in 1904 in his book, The Evolution of Modern Medicine

  • Cytokine Storm Syndrome - also termed a "sepsis syndrome" is a diverse set of (autoimmune) conditions unified by a clinical phenotype of systemic inflammation, multi‐organ failure, hyperferritinemia and if untreated, often death.  This "clinical constellation" (cytokine storm) is caused by the elaboration of extreme amounts of pro-inflammatory cytokine mediators resulting from unchecked feedforward immune activation and amplification. The initiating factors leading to the end state of cytokine storm are heterogeneous and derive from rheumatologic, oncologic, and infectious origins.  Cytokine Storm Syndrome : Looking Toward the Precision Medicine Era

Med Hypotheses. 2000 Sep;55(3):232-8.

HIV: reactive oxygen species, enveloped viruses and hyperbaric oxygen

Baugh MA.

Author information

  • BaroAntiviral, San Diego, California 92103, USA.

Abstract

This paper demonstrates that there are many examples in the literature of contradictory data concerning reactive oxygen intermediates (ROIs), responsible for producing cellular oxidative stress (OS), and their enhancement or diminution of viral replication. Nevertheless, ROIs repeatedly have been shown to be virucidal against enveloped-viruses, like the human immunodeficiency virus (HIV). 

 

 

NEWS UPDATE

https://www.washingtonpost.com/health/2020/03/07/how-doctors-treat-sickest-coronavirus-patients/

  • There are no targeted therapeutics or vaccines for the new virus — and so doctors and nurses in the ICUs are left to administer drugs and oxygen to keep patients alive long enough for their bodies to fight the infection and repair lungs ravaged by pneumonia.

  • As the virus attacks the lungs, it becomes harder and harder for patients to get enough oxygen into their bloodstream to support their kidneys, liver, heart, brain and nervous system.

https://www.nytimes.com/article/coronavirus-body-symptoms.html

As cases of coronavirus infection proliferate around the world and governments take extraordinary measures to limit the spread, there is still a lot of confusion about what exactly the virus does to people’s bodies.

 

  • The symptoms — fever, cough, shortness of breath — can signal any number of illnesses, from flu to strep to the common cold. Here is what medical experts and researchers have learned so far about the progression of the infection caused by this new coronavirus — and what they still don’t know.

How does this coronavirus cause infection?

The virus is spread through droplets transmitted into the air from coughing or sneezing, which people nearby can take in through their nose, mouth or eyes. The viral particles in these droplets travel quickly to the back of your nasal passages and to the mucous membranes in the back of your throat, attaching to a particular receptor in cells, beginning there.

  • Coronavirus particles have spiked proteins sticking out from their surfaces, and these spikes hook onto cell membranes, allowing the virus’s genetic material to enter the human cell. That genetic material proceeds to 'hijack the metabolism of the cell and say, in effect, ‘Don’t do your usual job. Your job now is to help me multiply and make the virus,’ said Dr. William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center in Nashville.

 

How Coronavirus Hijacks Your Cells

As copies of the virus multiply, they burst out and infect neighboring cells. The symptoms often start in the back of the throat with a sore throat and a dry cough. The virus then “crawls progressively down the bronchial tubes,” Dr. Schaffner said. When the virus reaches the lungs, their mucous membranes become inflamed. That can damage the alveoli or lung sacs and they have to work harder to carry out their function of supplying oxygen to the blood that circulates throughout our body and removing carbon dioxide from the blood so that it can be exhaled.

  • “If you get swelling there, it makes it that much more difficult for oxygen to swim across the mucous membrane,” said Dr. Amy Compton-Phillips, the chief clinical officer for the Providence Health System, which included the hospital in Everett, Wash., that had the first reported case of coronavirus in the United States, in January.

https://www.healthline.com/health-news/heres-what-happens-to-the-body-after-contracting-the-coronavirus#Immune-system

  • There’s still a lot we don’t know about the novel coronavirus that’s already sickened more than 75,000 people worldwide, with more than 2,500 deaths reported

  • But one thing that’s clear is that in serious cases, the virus can have a devastating effect on the body — and not just on the lungs.

  • Coronaviruses cause respiratory illnesses, so the lungs are usually affected first. Early symptoms include fever, cough, and shortness of breath. These appear as soon as 2 days, or as long as 14 days, after exposure to the virus.

  • But damage can also occur in other parts of the body, especially during serious illness. Those at risk of serious health challenges include individuals with pre-existing autoimmune disorders and blood glycoprotein variations.

COVID-19 initially affects the lungs

  • As with other coronavirus illnesses — including SARS, MERS, and the common cold — COVID-19 is a respiratory disease, so the lungs are usually affected first.

  • Early symptoms include fever, cough, and shortness of breath. These appear as soon as 2 days, or as long as 14 days, after exposure to the virus.

  • The severity of COVID-19 varies from mild or no symptoms to severe or sometimes fatal illness. Data on more than 17,000 reported cases in China found that almost 81 percent of cases were mild. The rest were severe or critical.

  • Older people and those with chronic medical conditions appear to have a higher risk for developing severe illness.

  • This variability also shows up in how COVID-19 affects the lungs.

  • Some people may only have minor respiratory symptoms, while others develop non-life-threatening pneumonia. But there’s a subset of people who develop severe lung damage.

  • “What we’re frequently seeing in patients who are severely ill with [COVID-19] is a condition that we call acute respiratory distress syndrome, or ARDS,” said Dr. Laura E. Evans, a member of the Society of Critical Care Medicine Leadership Council and an associate professor of pulmonary, critical care, and sleep medicine at the University of Washington Medical Center in Seattle.

  • ARDS doesn’t happen just with COVID-19. A number of events can trigger it, including infection, trauma, and sepsis.

  • These cause damage to the lungs, which leads to fluid leaking from small blood vessels in the lungs. The fluid collects in the lungs’ air sacs, or alveoli. This makes it difficult for the lungs to transfer oxygen from the air to the blood - induced hypoxia.

  • While there’s a shortage of information on the type of damage that occurs in the lungs during COVID-19, a recent report suggests it’s similar to the damage caused by SARS and MERS.

  • One recent study of 138 people hospitalized for COVID-19 found that on average, people started having difficulty breathing 5 days after showing symptoms. ARDS developed on average 8 days after symptoms.

  • Treatment for ARDS involves supplemental (normobaric and hyperbaric) oxygen and mechanical ventilation, with the goal of getting more oxygen into the blood.

Cytokine Storm Syndrome

Other organs affected by COVID-19

  • The lungs are the main organs affected by COVID-19. But in serious cases, the rest of the body can also be affected.

  • “In patients who become severely ill, a good proportion of those patients also develop dysfunction in other organ systems,” Evans said.

  • This damage to the organs isn’t always directly caused by the infection, but can result from the body’s response to infection - Cytokine Storm.

Stomach and intestines

  • Some people with COVID-19 have reported gastrointestinal symptoms, such as nausea or diarrhea, although these symptoms are much less common than problems with the lungs.

  • While coronaviruses seem to have an easier time entering the body through the lungs, the intestines aren’t out of reach for these viruses.

  • Earlier reports identified the viruses that cause SARS and MERS in intestinal tissue biopsies and stool samples.

  • Two recent studies — one in the New England Journal of Medicine and a preprint on medRxiv — report that stool samples of some people with COVID-19 tested positive for the virus.

  • However, researchers don’t know yet whether fecal transmission of this virus can occur.

 

Heart and blood vessels

  • Evans says COVID-19 can also affect the heart and blood vessels. This may show up as irregular heart rhythms, not enough blood getting to the tissues, or blood pressure low enough that it requires medications.

  • So far, though, there’s no indication that the virus directly damages the heart.

 

Liver and kidneys

  • When liver cells are inflamed or damaged, they can leak higher than normal amounts of enzymes into the bloodstream.

  • Elevated liver enzymes aren’t always a sign of a serious problem, but this laboratory finding was seen in people with SARS or MERS.

  • One recent report found signs of liver damage in a person with COVID-19. Doctors says it’s not clear, though, if the virus or the drugs being used to treat the person caused the damage.

  • Some people hospitalized with COVID-19 have also had acute kidney damage, sometimes requiring a kidney transplant. This also occurred with SARS and MERS.

  • During the SARS outbreak, scientists even found the virus that causes this illness in the tubules of the kidneys.

  • There’s “little evidence,” though, to show that the virus directly caused the kidney injury, according to a World Health Organization report.

  • Dr. James Cherry, a research professor of pediatrics in the David Geffen School of Medicine at UCLA, says the kidney damage may be due to other changes that happen during coronavirus infection.

  • “When you have pneumonia, you have less oxygen circulating,” he said, “and that can damage the kidneys.”

 

Immune system

  • With any infection, the body’s immune system responds by attacking the foreign virus or bacteria. While this immune response can rid the body of the infection, it can also sometimes cause collateral damage in the body.

  • This can come in the form of an intense inflammatory response, sometimes called a “cytokine storm.” The immune cells produce cytokines to fight infection, but if too many are released, it can cause problems in the body.

  • “A lot of [the damage in the body during COVID-19] is due to what we would call a sepsis syndrome, which is due to complex immune reactions,” Evans said. “The infection itself can generate an intense inflammatory response in the body that can affect the function of multiple organ systems.”

  • Another thing about the immune system is that, so far, there are almost no cases of COVID-19 in children under 9 years old. Scientists aren’t sure whether young children aren’t getting infected or their symptoms are so mild that no one notices it.

  • Cherry says children also have a less severe illness than adults during other kinds of infections, including measles and pneumococcal infections.

  • He says this may be because children have a “straightforward immune response,” whereas older people can sometimes have an “over-response.” It’s this excess immune response that causes some of the damage during infections.

  • “There was evidence of this happening during SARS,” Cherry said, “and I suspect it could also be playing out here [with COVID-19].”

Clin Infect Dis. 2020 Mar 16. pii: ciaa272. doi: 10.1093/cid/ciaa272. [Epub ahead of print]

Clinical Features of 69 Cases with Coronavirus Disease 2019 in Wuhan, China.

Wang Z1, Yang B2, Li Q1, Wen L1, Zhang R1.

Author information

Abstract

BACKGROUND:

From December 2019 to February 2020, 2019 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a serious outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China. Related clinical features are needed.

METHODS:

We reviewed 69 patients who were hospitalized in Union hospital in Wuhan between January 16 to January 29, 2020. All patients were confirmed to be infected with SARS-CoV-2 and the final date of follow-up was February 4, 2020.

RESULTS:

The median age of 69 enrolled patients was 42.0 years (IQR 35.0-62.0), and 32 patients (46%) were men. The most common symptoms were fever (60[87%]), cough (38[55%]), and fatigue (29[42%]). Most patients received antiviral therapy (66 [98.5%] of 67 patients) and antibiotic therapy (66 [98.5%] of 67 patients). As of February 4, 2020, 18 (26.9%) of 67 patients had been discharged, and five patients had died, with a mortality rate of 7.5%.

According to the lowest SpO2 during admission, cases were divided into the SpO2≥90% group (n=55) and the SpO2<90% group (n=14).

* All 5 deaths occurred in the SpO2<90% group. Compared with SpO2≥90% group, patients of the SpO2<90% group were older, and showed more comorbidities and higher plasma levels of IL6, IL10, lactate dehydrogenase, and c reactive protein. Arbidol treatment showed tendency to improve the discharging rate and decrease the mortality rate.

CONCLUSIONS:

COVID-19 appears to show frequent fever, dry cough, and increase of inflammatory cytokines, and induced a mortality rate of 7.5%. Older patients or those with underlying comorbidities are at higher risk of death.

J Korean Med Sci. 2016 Nov;31(11):1717-1725. doi: 10.3346/jkms.2016.31.11.1717.

Clinical Progression and Cytokine Profiles of Middle East Respiratory Syndrome Coronavirus Infection.

Kim ES1, Choe PG1, Park WB1, Oh HS1, Kim EJNam EY1, Na SH1, Kim M1, Song KH1, Bang JH1, Park SW1, Kim HB1, Kim NJ1, Oh MD2.

Author information

Abstract

Clinical progression over time and cytokine profiles have not been well defined in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection. We included 17 patients with laboratory-confirmed MERS-CoV during the 2015 outbreak in Korea. Clinical and laboratory parameters were collected prospectively. Serum cytokine and chemokine levels in serial serum samples were measured using enzyme-linked immunosorbent assay. All patients presented with fever. The median time to defervescence was 18 days. Nine patients required oxygen supplementation and classified into severe group. In the severe group, chest infiltrates suddenly began to worsen around day 7 of illness, and dyspnea developed at the end of the first week and became apparent in the second week. Median time from symptom onset to oxygen supplementation was 8 days.

The severe group had higher neutrophil counts during week 1 than the mild group (4,500 vs. 2,200/μL, P = 0.026).

In the second week of illness, the severe group had higher serum levels of IL-6 (54 vs. 4 pg/mL, P = 0.006) and CXCL-10 (2,642 vs. 382 pg/mL, P < 0.001). IFN-α response was not observed in mild cases.

 * Our data shows that clinical condition may suddenly deteriorate around 7 days of illness and the serum levels of IL-6 and CXCL-10 was significantly elevated in MERS-CoV patients who developed severe diseases.

Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2015 Oct;27(10):841-4.

[The therapeutic effect of high flow nasal cannula oxygen therapy for the first imported case of Middle East respiratory syndrome to China].

[Article in Chinese]

Luo YOu RLing YQin T.

Abstract

OBJECTIVE:

To investigate the value of high flow nasal cannula (HFNC) in treating a patient with Middle East respiratory syndrome (MERS).

METHODS:

The effect of HFNC applied in the first imported MERS patient with complication of acute respiratory distress syndrome (ARDS) to China was observed. The patient was admitted to Department of Critical Care Medicine of Huizhou Municipal Central Hospital on May 28th, 2015, and the changes in various clinical parameters and their significance were analyzed.

RESULTS:

A 43-year old male was admitted to negative pressure isolation intensive care unit with the complaint of back ache for 7 days and fever for 2 days. Vital signs and saturation of pulse oximetry (SpO2) were monitored continuously. After admission, ribavirin was given orally for 12 days and α-interferon was administered once on the first day. However, after 2-week anti-virus therapy, the virus test was positive. Ceftriaxone was given on the 4th day, and it was changed to meropenem on the 3rd day for 2 weeks. Immune globulin was given on the 4th day and continued for 1 week. Thymosin-α1 was given on the 8th day and continued for 2 weeks. According to his past history, methimazole had been given continuously for hyperthyroidism and other symptomatic treatment. Oxygen inhalation (6 L/min) was given immediately after admission, but the condition of patient worsened with the following symptoms: frequent cough and obvious shortness of breath. Moreover pleural effusion gradually increased as shown by X-ray. SPO2 was maintained only at about 0.91. Oxygenation index (PaO2/FiO2) decreased to 144 mmHg (1 mmHg = 0.133 kPa). So oxygen inhalation via nasal cannula was changed to HFNC after 2 days. The parameters were set as follows: temperature 34 degrees C, flow rate 20 L/min, fraction of inspired oxygen (FiO2) 0.50. The flow was raised 5 L/min every 10 minutes, and was continued till the target value reached 60 L/min. FiO2 was modified according to SpO2 and PaO2/FiO2. FiO2 was set to 0.80 on the 5th day of admission. Shortness of breath of the patient was improved on the 7th day of admission after the application of HFNC. FiO2 was then decreased to 0.58 as PaO2/FiO2 rose. Then the flow was gradually decreased to 30 L/min. HFNC was reduced with continuous improvement in PaO2/FiO2. HFNC was changed to low flow oxygen inhalation nasal cannula (2-3 L/min) on the 20th day. Oxygen treatment was stopped on the 23rd day, and SpO2 was maintained at 0.98-1.00. Activities on bed were gradually increased. The patient was cured and discharged from hospital on June 26th. The patient showed good tolerance and high compliance during the treatment with HFNC. No nosocomial spread occurred during the treatment.

CONCLUSIONS:

HFNC could improve respiratory function of the patient with MERS obviously, and complication ARDS was prevented. HFNC might reduce nosocomial spread.

Med Hypotheses. 2000 Sep;55(3):232-8.

HIV: reactive oxygen species, enveloped viruses and hyperbaric oxygen

Baugh MA.

Author information

  • BaroAntiviral, San Diego, California 92103, USA.

Abstract

This paper demonstrates that there are many examples in the literature of contradictory data concerning reactive oxygen intermediates (ROIs), responsible for producing cellular oxidative stress (OS), and their enhancement or diminution of viral replication. Nevertheless, ROIs repeatedly have been shown to be virucidal against enveloped-viruses, like the human immunodeficiency virus (HIV). 

 * Hyperbaric oxygen therapy (HBOT) increases the production of ROIs throughout the body, leaving no safe harbor for the virus to hide outside the genome.

 

This technique already has been tried on acquired immune deficiency syndrome (AIDS) patients, with exciting results. Historically, the biggest setback to demonstrating HBO's antiviral effects has been the investigator's folly of studying non-enveloped viruses or failing to initiate ROI production. ROIs specifically attack areas of unsaturation occurring in the polyunsaturated fatty acids of cell membranes and viral envelopes. Moreover, it consistently has been shown that a peroxidized viral envelope breaches, and a breached viral envelope causes viral disintegration.

 

J Assoc Nurses AIDS Care. 1999 Sep-Oct;10(5):42-9.

A review of fatigue in people with HIV infection

Barroso J.

Author information

  • University of North Carolina at Chapel Hill, School of Nursing, USA.

Abstract

Fatigue is often cited by clinicians as a debilitating symptom suffered by the many who are infected with HIV. This article provides a review of HIV-related fatigue, including research on possible physiological causes such as anemia, CD4 count, impaired liver function, impaired thyroid function, and cortisol abnormalities. Psychological causes of fatigue, particularly depression, are reviewed as well. Measurement issues, such as the use of inappropriate tools, the problem of measuring the presence or absence of fatigue, and the use of tools developed for other groups of patients, are reviewed. The need for a comprehensive fatigue tool that is appropriate for people with HIV is discussed. Current treatment research, including thyroid replacement, hyperbaric oxygen, and dextroamphetamine, is presented. Finally, the implications for further research, including the need for qualitative studies to learn more about the phenomenon, develop an instrument to measure fatigue, and examine variables together to get a complete picture of this complex concept, are reviewed.

 

J Assoc Nurses AIDS Care. 1996 Jan-Feb;7(1):43-5.

HIV antiviral effects of hyperbaric oxygen therapy

Reillo MR1, Altieri RJ.

Author information

  • 1Lifeforce Hyperbaric Medical Clinic, Baltimore, MD, USA.

Abstract

Researchers have speculated that hyperbaric oxygen (HBO) therapy has an antiviral effect in HIV infection. To determine HBO's antiviral effect, the authors performed ex vivo and in vivo quantitative assays on HIV-infected plasma and peripheral blood mononuclear cells (PBMCs) at baseline and after treatment. The authors also HBO-treated uninfected PBMCs and then exposed them to HIV at ambient pressure. HIV viral load was decreased in the infected cells, and few viruses entered uninfected PBMCs exposed to HBO. The results of this study support the theory that HBO has an antiviral effect.

J Assoc Nurses AIDS Care. 1993 Jul-Sep;4(3):33-8.

Hyperbaric oxygen therapy for the treatment of debilitating fatigue associated with HIV/AIDS

Reillo MR.

Author information

  • Maryland Medical Center, Bethesda.

Abstract

Twenty-five HIV-infected patients underwent hyperbaric oxygen therapy to determine the treatment's effectiveness in relieving the debilitating fatigue associated with HIV/AIDS and its effect on immunologic function. Patients were treated with 100% oxygen at two atmospheres of absolute pressure three times per week for two months, then two times per week on an ongoing basis. Laboratory markers were assessed monthly.

  • All patients experienced relief of debilitating fatigue within one month of hyperbaric oxygen therapy. It was concluded that hyperbaric oxygen therapy is an effective adjunctive treatment in the medical management of HIV/AIDS. Laboratory markers, clinical significance, nursing implications, and cost-effectiveness of hyperbaric oxygen therapy are discussed.

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