The head of the pulmonology department of the 2nd City Clinical Hospital of Minsk, Irina Volynets, has been in healthcare for forty years and for most of that time she has been helping people with lung diseases and other serious respiratory problems. Winner of the republican competition “Doctor of the Year”, chief freelance pulmonologist of Minsk. The 40-bed department she headed received patients with covid pneumonia for three months and only on Monday began to return to its usual mode of operation. The doctor shared with the “R” correspondent her experience of how complex coronavirus patients got sick and recovered.
Pulmonologist Irina Volynets: “This is what Covid pneumonia looks like on a CT image.”
Risk from the unknown
— Irina Nikolaevna, you have treated pneumonia before.
This pathology is often complicated by the common flu, colds during the season of respiratory infections, as well as “swine flu”. What is different about pneumonia caused by COVID-19? — Indeed, viral pneumonia can be caused by a fairly wide range of microorganisms. But on a CT scan they look the same. Coronavirus pneumonia is dangerous because we have not encountered it before. For influenza
For complications, there are antiviral drugs: you prescribe, for example, oseltamivir in a timely manner in the first 48 hours - and the patient gets better. In addition, since we have high coverage of influenza vaccinations, people now suffer from influenza pneumonia less often and tolerate them more easily. But in three months of fighting covid pneumonia, we have gained experience in diagnosing and treating them, and if there is a second wave of morbidity, we will meet it fully armed.
Why do we get sick without fever?
Recently, at a doctor’s appointment, our editor Maria Milerius was asked a strange question: “Are you sick with or without a fever?”
“Was it possible to do that?” - she thought and decided to find out what it was like to be sick without a fever. The prospect of enduring flu and ARVI seasons with a cool head and steady feet is, of course, fascinating.
However, medicine has a different opinion: normally, an infection is accompanied by an increase in temperature - in this way the body tries to fight the situation.
What to do if, according to all the signs, it’s better for you to lie down, but the thermometer shows 36.6, they asked Ivan Romasov, a cardiologist and therapist at the Semeynaya clinic.
Ivan Romasov,
therapist at the Semeynaya clinic
First you need to understand what body temperature is. In fact, it is a complex indicator (or, more precisely, a biomarker) of all thermal processes in the body.
The constancy of temperature is maintained under the condition that heat generation and heat loss from the body are equal. Thermoregulation is controlled by our nervous system through thermoreceptors and the hypothalamus, and the adrenal glands and thyroid gland activated by them.
An increase in temperature above 37.0 in scientific language is called hyperthermia. The absence of hyperthermia during infection may depend on several factors.
- Immune system status
Normally, the production of antibodies (inflammatory reaction) is accompanied by an increase in body temperature. In cases of severe immunodeficiency, this may not occur.
In nature, there are hundreds of thousands of viral and bacterial pathogens with varying degrees of activity. Often our immune system reacts to them differently: it considers some pathogens more dangerous and reacts sharply (with significant hyperthermia), while others do not, reacting weaker.
- Taking medications
Chronic use of nonsteroidal anti-inflammatory drugs blocks the production of prostaglandins and cyclooxygenase, substances involved in the inflammatory response and the resulting hyperthermia. Also, undergoing chemotherapy for cancer often weakens the immune system, which contributes to the penetration of infection and its blurred course.
Although no one keeps official statistics, there are many people in our country who do not have hyperthermia. Disruption of internal biochemical processes is observed in those suffering from immunodeficiency, severe chronic (oncological, etc.) diseases. This can lead to disruption of the immune response or metabolic processes that provide an inflammatory response in the body.
Often body temperature does not increase in older people due to the predominance of catabolism (the breakdown of substances) over anabolism (the synthesis of substances) and the reduced production of inflammatory substances as a result.
There are also people with congenital damage to the pituitary gland (as a malformation or exposure to intrauterine infection), which can lead to a lack of hyperthermia.
In people at risk, we can suspect infectious diseases based on other symptoms: cough, general weakness, chills, increased sweating and fatigue, runny nose, conjunctivitis, rash. Further, the diagnosis is established through laboratory and instrumental research methods.
Advice: if you are not included in the above risk groups, then you have nothing to worry about. But if you have other symptoms of an infectious disease (described earlier), you better consult a doctor, since an increase in body temperature does not always develop from the very beginning of the disease.
Alexander Samsonov,
PR Director of Alltime.ru:
“I have been sick without a fever every cold and flu season since I started getting vaccinated against influenza, pneumonia and ARVI. She noted in her effect that if the disease is not prevented, it will be tolerated more easily and without complications. In my case - without fever.
I determine that I am sick by a runny nose, weakness, fatigue, and cough. My head hurts more than usual and my eyes hurt. Well, in short, everything is like with ARVI, but without fever and in such a light, blurry format. I carry it on my feet.
At the same time, relatives at home and colleagues at work during the same period are completely ill.”
Amira Khamurzaeva,
project manager at the PR agency Asmus, author of the Instagram blog @beautyunearthl:
“Usually all the signs of illness are there: chills, runny nose, cough, even a sore throat; it feels like the temperature is under 40, but the thermometer shows a maximum of 36.8. It wasn’t always like this; when I was a child, I was sick like everyone else. And there was a fever. And for the last eight years everything has gone away without a fever, but I haven’t gone to the doctors because of this. The disease is easier to bear, but lasts longer.”
Kristina Boyko,
student:
“The last time I was sick with a fever was five years ago. The therapists who observed her did not reveal anything unusual and attributed it to psychosomatics. I myself noticed that I get sick only during periods of internal crises. I learned to perceive all ailments not as a virus, but as a signal from the body that I need to slow down and rest.”
Veronica Batmanova,
Internal Communications Manager in Admitad:
“A few months ago I felt that I was getting sick. A colleague suggested drinking six to eight capsules of ant tree bark (per day), shared the pills and said that it helps her a lot against viruses and she doesn’t get sick. I didn't really get sick that time.
After that, I also decided to order ant tree bark on Iherb. If you read the reviews, it helps with everything. The last time I got sick was last week, but I endured everything quite easily and without fever, I was at home for three days.
I don’t know if it’s self-hypnosis or not, but I really started getting sick less.”
Yulia Khisamutdinova,
PR specialist
“When I was 14 years old, I had surgery on my lung to remove a tumor. After this, it was necessary to see a doctor and have x-rays taken regularly. The operation took place in December, in August I went to the local pediatrician for a referral to the regional hospital, where I was being observed, and at the same time complained of a cough from somewhere deep in my soul (before that I had had a cold).
The pediatrician said that I had residual effects from a cold and prescribed drops for a runny nose. I did all the tests and x-rays at my place of residence, and when I showed them at the regional hospital, they told me that I had pneumonia. No fever.
So I don’t know whether the tumor saved me (without it, an x-ray would not have been ordered and they would not have sent me to the regional hospital), or, on the contrary, I got sick because my body was weakened after the operation.”
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Source: https://flacon-magazine.com/rubric/people/pocemu-my-boleem-bez-temperatury
“Don’t miss difficult patients”
— Remember how you worked during the rise in the incidence of coronavirus infection.
— Previously, we, pulmonologists, did not even have to use protective shields. During the swine flu epidemic, masks were used. And then at eight in the morning everyone put on anti-plague suits and wore them all day, with difficulty distinguishing each other. It's hot, there's a hail of sweat. After fifteen minutes of talking with the patient, there is no longer enough air. But this is how you understand your patients who have difficulty breathing!
Pulmonology of the 2nd City Clinical Hospital of Minsk switched to normal operation from Monday. At first we faced a large influx of patients. The emergency department doctors have a huge workload. And the employees of our department came out on Saturdays and Sundays to help - to conduct examinations, maintain documentation, and most importantly, to correctly sort patients according to severity. The most important thing was not to miss severe patients, because with covid pneumonia, life-threatening deterioration can develop very quickly.
It happened that you would examine a patient in the emergency room - his condition was not bad, there was no respiratory failure, but when he entered the department, he suddenly became ill and was suffocating. We were helped out by a pulse oximeter - a device that determines saturation, that is, oxygen saturation in the blood. It was measured in all patients in the morning and evening so as not to miss respiratory failure. And for those patients who caused concern - four times a day. If the saturation fell below 95 percent during the day, the resuscitation specialists took them to their place for intensive therapy.
Although at first patients arrived en masse, the capital's bed capacity coped with their influx.
No one was lying in the corridors, as we saw on TV in other countries. One day, about two hundred Minsk residents were admitted to our emergency department, but they were all diagnosed and distributed to departments.
The unknown scared many patients. There were impressionable people who had neither pneumonia nor COVID-19, but developed psychosis: they screamed that they were dying and demanded hospitalization at all costs. But when patients saw that many were recovering and being discharged, the psychological atmosphere changed.
— According to reports from the Ministry of Health, our mortality statistics for COVID-19 are only patients “with many concomitant diseases” and the elderly.
- This is true: people with diabetes, survivors of heart attacks, strokes, arterial hypertension, cancer patients after chemotherapy. Their immunity is weakened and cannot cope with the attack of the new virus. The common influenza virus is also life-threatening for such categories of patients. Also, with covid pneumonia and cardiovascular problems, thrombosis or thromboembolism develops - blockage of blood vessels occurs. To prevent this, we used low molecular weight heparins, which thin the blood.
If a person is generally healthy, his body has successfully coped with coronavirus infection. We even noticed that if someone in the family gets sick
Incubation period
Its duration depends on the state of each person’s immune system. The first symptoms may appear 1-14 days after the virus enters the body. But as medical statistics show, the most common symptoms, which are fever, sore throat, cough and general malaise, appear on the 4-6th day, and after about 7-10 days they completely disappear. At the same time, the patient feels fine, but this does not mean that he is healthy. The infection continues to actively develop, and after a certain period of time the patient’s clinical picture may deteriorate sharply.
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According to medical prescriptions
— Have you ever seen patients with organ transplants?
- Yes. A man who even had a kidney transplant twice. I was very worried about him. When he was discharged, he admitted: he thought that he would not leave the hospital. He had a temperature of 40 degrees, which did not subside for more than half a month. And then a turning point occurred, the temperature dropped, and the patient began to recover.
— What, in your experience, helped him and other difficult people to get out?
— Strict adherence to medical prescriptions. For Covid patients with lung damage, the prone position is very important: 15 hours a day you need to lie on
Why do you think worse when you have a cold?
A depressed psycho-emotional state during illness can occur due to chemical signals that the immune system sends to the brain.
The most unpleasant thing about any cold is probably not a cough or a runny nose, but what is called “fog in the head”: a constant feeling of apathy, fatigue, inability to concentrate on anything, etc. Reasoning in the spirit that the disease takes away strength, they don’t explain anything, because it is not clear how it takes away strength for mental work, how it deprives us of emotions, how it manages to put us in a depressed state of mind?
Blood vessel of the brain; the cells of its walls (green) are distinguished by ultra-dense intercellular contacts. (Photo by CJGuerin, PhD, MRC Toxicology Unit.)
Fish brain vessels. (Photo by The Why Files / https://www.flickr.com/photos/ [email protected] /16755909571.)
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Obviously, the disease somehow affects our brain. But if we are talking about the same cold, then the rhinoviruses that cause it multiply in the mucous membrane of the nasopharynx; they do not need the brain at all. Maybe it's all about the immune response to the disease? Although there is a so-called blood-brain barrier between the brain and the circulatory system, which does not allow pathogens or immune cells and molecules to enter the brain, exceptions sometimes still occur: there are now several examples that signals from the immune system can still pass through the barrier.
Thomas Blank
) and his colleagues from the University of Freiburg, the Ruhr University and the University of Heidelberg conducted several experiments with mice infected with a short-term viral infection. Since the researchers were interested in the behavior and general psychological state of the animals, they were subjected to the following test: sick mice were put in a trough of water, from which it was very difficult to get out without outside help, and they watched what they would do.
Healthy animals tirelessly tried to get to land, despite the futility of attempts, but sick animals quickly gave up the fight and simply tried not to drown while swimming in the “pool.” That is, sick animals became more apathetic, more indifferent, and more depressed.
As the authors of the work write in their article in the journal Immunity
, in response to infection, mouse immunity increased beta-interferon levels. In general, interferons are one of the main antiviral agents: firstly, they force immune molecules to attack viral proteins, and secondly, interferons act on infected or threatened cells, suppressing protein synthesis in them, launching a self-destruction program, etc. .
It turned out that beta-interferon, which is now being discussed, is able to bind to the receptors of the cells that make up the blood-brain barrier in the blood vessels of the brain. When this receptor was switched off in mice, the animals became more resistant to the inhibitory effects of the disease.
Once infected (RNA molecules were used as an infection, which act on the immune system in the same way as a virus), the mice showed greater persistence in trying to get out of the water onto land; and at the same time, they had better memory - when a platform was made in a water maze on which one could get out, mice without the receptor were better able to remember where it was.
At the molecular-cellular level, the following happened in the brains of animals: due to the virus, immunity was said to increase the level of interferon beta, which acted on vascular receptors and thereby stimulated the synthesis of a small immune protein, CXCL10.
This protein from a group of cytokines weakened the ability of hippocampal neurons to remember (as we know, the hippocampus is one of the main memory centers). On the one hand, we see how the immune signal passes through the notorious blood-brain barrier - with the help of interferon receptors on barrier cells and the CXCL10 protein, which works on the other side of the barrier. On the other hand, immunity does affect the activity of neurons; Although the authors of the work are talking only about hippocampal cells and the ability to learn, it is quite possible that the same or similar immune signal can reach the neural circuits that control emotions.
True, some researchers speak about the results obtained with a certain degree of skepticism. For example, Robert Dantzer
) from the Oncological Center named after. MD Anderson at the University of Texas says that immune signaling cytokines, which include CXCL10, act locally at the site of infection, and therefore there are certain doubts that the same CXCL10 can go somewhere far into the bowels of the brain. Although it may well be that some other signaling molecules are involved here, reacting to CXCL10 and spreading its influence to “remote territories.”
Here you also need to keep in mind that there are other types of immune response when the antiviral properties of interferon are not needed; and, for example, with inflammation caused by bacteria, some other mechanisms may be triggered, which also lead to general lethargy.
From an evolutionary point of view, everything is correct here: psychological inhibition does not allow the patient to expend energy that may be needed to fight the infection. But in general, it would be nice if we could interrupt the immune signals that force us to plunge into such “infectious depression” - now we live easier than hundreds of thousands of years ago, and perhaps the immune system no longer needs to worry so much about saving energy to fight the virus.
Finally, exactly the same signs of a depressed psycho-emotional state occur in cancer patients and patients with autoimmune disorders who are treated with immunotherapy - and for them, some kind of remedy to get rid of the immune “fog in the head” would also be very useful.
Based on materials from Science.
Are children more susceptible to coronavirus? And what is Kawasaki syndrome? Scientist answers August 11, 2020, 1:33 pm
Kazakhstanis were frightened by reports of a new dangerous syndrome occurring in children with coronavirus. Nazarbayev University professor, host of the Belka and Strelka podcast and MedSupportKz volunteer scientist Dana Akilbekova spoke about how children suffer from coronavirus and what complications may arise during the illness.
Continuation
1. When is Kawasaki-like syndrome expected to peak, the doctor said
Children make up only a small portion of confirmed COVID-19 cases, with less than 2 percent of reported infections in China, Italy and the United States occurring in people under 18. Children under 18 also make up less than 2 per cent of Covid-19 hospital admissions in the UK.
The National Center for Public Health reported that since the beginning of the pandemic, 5.1 thousand children under 14 years of age have been infected with coronavirus. Later, official representative of the Ministry of Health Bagdat Kodzhakhmetov said that since March 13, 2,257 cases of children infected with coronavirus infection have been registered in Kazakhstan, of which 114 children are now in the hospital.
The first study to show this unusual trend was done in China. It included about 2,100 children aged two to 13 years old who were infected with COVID-19. It was shown that more than 90 percent of children experienced no symptoms or mild or moderate symptoms.
In the US, among children under age 18, only 73 percent had symptoms of fever, cough or shortness of breath, compared with 93 percent of people ages 18 to 64, and less than 6 percent of children required hospital treatment, compared with 10 percent of adults. In New York, only three children have died from COVID-19 infection among more than 5,443 deaths.
Why do children react differently to coronavirus?
For many infectious diseases, there is a U-shaped risk curve, with the youngest and oldest in society most vulnerable. COVID-19 does not follow this path— even babies and newborns who are infected usually have only mild symptoms . Doctors still don't understand the virus too well to draw any conclusions about how young children avoid serious consequences from the disease.
But researchers have their own theories. One is that children's lungs may contain fewer ACE2 receptors . This is an enzyme that is involved in the transport of amino acids, but at the same time is the entry point into the cell of some coronaviruses, including SARS-CoV and SARS-CoV-2. It has been suggested that SARS-CoV-2 infection may downregulate ACE2, leading to pulmonary edema and myocarditis.
Another theory suggests that for an unknown reason, young children do not have an aggressive immune response, known as a “cytokine storm,” an overreaction of the immune system to the virus that leads to the development of severe inflammatory processes affecting both the lungs and the liver and kidneys. It is the most severe complication of COVID-19.
It is this intense immune reaction that can act like friendly fire in the lungs, making breathing even more difficult in an already difficult situation for the body. Why children do not have overreactive immune responses is not yet clear, but it may be because their systems are not prepared to launch such a powerful immune response. Children's immune systems develop over time, and in the first years of life, children do not have the same robust immune response as older children .
In the context of respiratory diseases, this is good news, since viruses such as influenza often attack the very young and very old more aggressively, given their more vulnerable immune systems. Apparently not in the case of coronovirus. But sometimes a child's body reacts differently to this virus, causing a condition similar to Kawasaki disease.
Pediatric multisystem inflammatory syndrome (PIMS) associated with coronavirus
In April, researchers in the UK and several European countries with large numbers of COVID-19 cases discovered a new inflammatory syndrome in children that was similar to Kawasaki disease , a rare syndrome known to affect young children. The condition, which the researchers called pediatric multisystem inflammatory syndrome (PMIS), is temporally associated with SARS-CoV-2.
In England, there have been fewer than 200 cases (out of 313,000 people infected) with varying symptoms and severity of PMV, and most children have recovered. In the Italian region of Bergamo, a 30-fold increase in Kawasaki cases was found. The new condition is very rare, but children can tolerate it extremely hard; without treatment, there is a risk of serious complications, but early detection and treatment lead to positive results and full recovery.
On August 8, in Aktobe, multisystem inflammatory syndrome was reported in two children aged 5 and 15 years. They were admitted in serious condition, but have already been transferred to the general ward; there is no threat to life. On August 10, the Ministry of Health reported three cases of registration of Kawasaki syndrome - in Nur-Sultan, Almaty and Petropavlovsk.
PMVS affects older children more often than Kawasaki disease, averaging nine versus four years, and more often presents with abdominal pain and diarrhea along with general symptoms such as persistent fever . Blood tests also show different results: patients with PMV show more inflammatory markers and cardiac enzymes, indicating that the heart is in a state of overload.
Kawasaki disease damages the coronary artery in such a way that as the child grows, the artery does not grow accordingly. This results in a decrease in the amount of blood that can reach the heart. Immune therapy helps alleviate these problems, which is why it is also used in patients with PMS, although treatment should be carefully monitored as the differences between the two diseases have not yet been studied, according to experts. Kawasaki disease is treatable and causes significant heart damage in about 25 percent of cases; without intervention, many patients with PMVS suffer the same severe heart damage that they can go into shock.
Kawasaki disease is a mystery. It has a well-defined set of symptoms, including a persistent high temperature, bloodshot eyes, redness around the mouth, a rash on the body, and redness and swelling of the legs and arms . In the United States, only a few thousand cases of Kawasaki are diagnosed annually (out of a population of 328 million). Partly because of its rarity, doctors still don't know exactly what causes the disease, but the dominant theory is that a pathogen, most likely a virus, pushes a child's immune system into overdrive, causing inflammation throughout the body . This inflammation can be successfully treated with intravenous antibody-based immunoglobulin, but if left untreated, it can cause permanent damage to the heart.
Link between Kawasaki disease and COVID-19
Before the COVID-19 pandemic, there were several research papers suggesting that other types of coronaviruses could cause Kawasaki disease.
In June, Italian scientists recorded a 30-fold increase in the incidence of Kawasaki syndrome. They link the SARS-CoV-2 epidemic to the high incidence of severe Kawasaki disease and believe that a similar outbreak of Kawasaki disease is expected in countries involved in the coronavirus pandemic.
It is possible that SARS-CoV-2 affects children prone to Kawasaki disease differently depending on genetics. Some can clear SARS-CoV-2 infection without any inflammatory response. But there are also cases of developing a disease similar to Kawasaki. Others may experience an inflammatory reaction slightly different from Kawasaki disease. Scientists are currently conducting whole-genome sequencing studies in children with different types of PMVD, as well as in children who were diagnosed with Kawasaki disease before the COVID-19 pandemic, to look for differences and similarities.
What parents need to know
Parents may be scared that there is so little information available about Kawasaki disease and PMVD. But most experts are inclined to believe that there is no reason to panic. Children remain much less likely than adults to develop a serious COVID-19 infection . Only about 2 percent of confirmed COVID-19 cases in the U.S. have been among children under 18, according to the U.S. Centers for Disease Control and Prevention. Even among children with COVID-19, PMVS is a very rare complication.
However, parents should not delay seeking medical attention if they see any symptoms of Kawasaki disease in their children. With prompt treatment, most children should recover without complications.
Pediatricians in many countries agree that it still makes sense to assume that children may be as vulnerable to infection as adults, and that they can spread the virus as effectively as adults, even if they have no symptoms.
This material was specially prepared by volunteers from Medsupportkz. This is a project of 95 young Kazakh scientists at different stages of their careers, who work both at Kazakh universities and abroad. Specialists help translate important studies for Kazakh doctors, prepare leaflets for Kazakh citizens and debunk popular myths about medicines. Here are their pages on Instagram and Telegram.
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