The Corona Blitzkrieg: The Developed World on its Knees
Through the last decade, exultations in the developed world were obvious, the developed world was talking about personalized and precision medicine, the enthusiasm to change the natural course of diseases with human efforts was palpable, and the developed world had started exulting itself at finally having overtaken the scourge of epidemics of infectious disease. These were like famous last words until the Corona blitzkrieg struck. Blitzkrieg is a German word for “lightning war,” a calculated war tactic which employs the elements of surprise, speed, and superiority in material and firepower and creates psychological shock and complete disorganization in enemy forces. SARS-CoV2 did exactly that and within 3 months has changed the face of the world. It has created havoc in health care networks in most affluent countries, with unnerving ferocity it has devoured the health supply lines, and set the scientists and research community scampering for solutions which seemingly mutate faster than the virus itself.
Although COVID has been a respiratory disease, yet its malevolence seems to have grazed the gastrointestinal (GI) tract too. Samanta et al in a comprehensive review have lucidly presented the GI associations and GI manifestations of Coronavirus. They have done a meticulous job by looking at every aspect including mechanisms of viral entry, the significance of ACE-2 and TMPRSS2 and diarrhea, the impact on natural course of preexisting GI diseases, and the possible methods to break transmission lines.
The first COVID case in India was reported on January 30, 2020, 100th case on March 14, 1,000th case on March 29, and 10,000th case on April 13, and 20,000th case on April 21, 2020.
Yet, we are not aware of how many of them have had GI manifestations. In India, we do not have a national registry for COVID cases in patient with underlying GI or liver diseases; maybe it would be prudent if the GI societies make such a registry.
As it would appeal to common sense, patients on immunomodulators for preexisting diseases like inflammatory bowel disease (IBD) and autoimmune hepatitis should be prone to both infection with SARS-CoV2 as well as a more severe COVID course. Yet, this again remains a conjecture and the real-world data which is emerging does not provide strong support to this. An international registry has been established for IBD patients with COVID. As per this registry as of April 22, a total of 704 COVID-19 cases from 38 countries have been reported. The observed overall case fatality rate in patients with IBD is approximately 4% which is similar to patients without any disease. Interestingly, the case fatality rate was 8% for patients on 5-ASA/sulfasalazine, 12% for patients on steroids, 4% for those on budesonide, and 1 to 3% for those on biologicals. The last update from this registry also suggest that many IBD patients with symptom flares may actually have COVID-19, so this is something to keep in our differential with our patients during this pandemic.
Do we have the answers? It is amazing that despite 3 months of pandemic and despite the complete unswerving attention of the entire clinical and scientific community, we are grappling for answers and that too with all the crucial aspects of COVID.
Fecal viral shedding has been noted, yet the quantitative magnitude of viral load is much less than respiratory viral load, raising questions on whether it has the capacity to cause infection. Hence, the question of fecal transmission still remains open.
Does infection lead to formation of protective antibodies? This is one question on which hangs the future of the world.
Do patients with GI manifestations have a worse outcome?
Do asymptomatic with fecal shedding require a prolonged quarantine period?
Protean manifestations (neurological, myocarditis, diarrhea, acute hepatitis, hyperamylasemia) are emerging and many more will be added to the list.
Are patients on immunomodulators and immunosuppressants more prone to viremia?
Is it that only certain class of immunosuppressant (steroids, azathioprine) is more prone to infection with SARS-Cov2?
Is colonoscopy a high-risk procedure and does every endoscopy require preprocedure testing for COVID?
However, the baffling issues related to therapy: a constant see saw of evidence generated from observational or small sample-sized trials and the writing on the wall at present is (Recent IDSA statements):
(i) Limited and heterogeneous clinical evidence on the efficacy of hydroxychloroquine in treatment of COVID-19.
(ii) Among patients who have been admitted to the hospital with COVID-19, it recommends the use of any of these interventions only in the setting of a clinical trial (hydroxychloroquine, combination of lopinavir/ritonavir, tocilizumab, COVID-19 convalescent plasma).
(iii) The bottom line: No therapy has been shown effective to date.
Myriad social issues and the social stigma.
Ironically, COVID has achieved, what was the ultimate goal of most humanists that the “world should be one.” When John Lennon wrote the best-selling single of his solo career “Imagine” and sang “Imagine all the people, Sharing all the world… And the world will live as one,” it never imagined that this way it could happen: the world is one as there is a single-point focus for the person on the streets to the caregivers to the academicians to the global leaders and nothing in recent times has so completely occupied the mental and physical framework of billions of human beings on earth as the present predicament. And with collective effort we should overcome this scourge and until then would be what Robert Frost most appropriately said “We dance round in a ring and suppose, But the Secret sits in the middle and knows.”
16 May 2020 (online)
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- 1 Samanta J, Dhar J, Khaliq A, Kochhar R. 2019 Novel Coronavirus infection: gastrointestinal manifestations. J Digest Endosc 2020; 11: 13-18
- 2 Available at: https://www.worldometers.info/coronavirus/country/india/. Accessed April 25, 2020
- 3 Available at: https://covidibd.org/current-data/ Accessed April 23, 2020
- 4 Bhimraj A, Morgan RL, Shumaker Ah, et al. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. Last updated April 21, 2020. Available at: www.idsociety.org/COVID19guidelines. Accessed April 28, 2020