The great mimic

By Dr Upul Wijayawardhana-April 2, 2020

For once, I am not referring to politicians though they can be great mimics with attended danger. I am referring to something much more dangerous, though so tiny, it cannot be seen even with a microscope. You need an electron microscope to see this tiny bomb and images captured with transmission electron microscopy show a ‘beautiful’ virus with spikes on the surface, making it look like a crown; hence, the term Coronavirus. It is a group of viruses that infect humans and animals, some having jumped from animals to humans. There are seven types of human Coronavirus, four causing mild diseases like common colds. The dangerous ones are the Middle East Respiratory Syndrome (MERS) virus, Severe Acute Respiratory Syndrome (SARS) virus and the recently detected COVID-19 virus, which is wreaking havoc around the globe causing deaths in thousands. Though MERS and SARS viruses have higher mortality rates, COVID-19 has become much more dangerous because of its’ ability to spread far and wide at great speed.

It is well recognised that the reported figures from every country is a gross underestimate, as extensive testing is not possible, not only because of resource limitations but also due to the limited availability of test kits, for which there is an ever-increasing demand. Further, for everyone with even the mildest symptom, there are many more who have no symptoms at all and this is the most dangerous group, from a community spread point of view. Unfortunately, some frontline staff, including medical specialists, have got ‘caught’, some making the ultimate sacrifice, as the virus presents in atypical ways too, at times.

The classical triad of symptoms of COVID-19 is: High fever, worsening of an existing cough or new cough lasting more than an hour, or three or more episodes of coughing in a period of 24 hours and breathlessness. The other non-specific symptoms of an infection like tiredness and malaise may also occur.

Number of patients have presented with lack of smell, some with loss of taste too, without the classical triad of symptoms. Unsuspecting doctors, who had examined these patients have developed the infection. This happened because loss of smell is not a specific symptom. Even with a common cold it is not unusual to have loss of smell or taste or both. Taste depends, to a great extent, on smell and often patients who complain that they cannot taste food, do actually suffer from loss of smell - anosmia. Though still not considered a diagnostic feature of COVID-19, as the number of patients presenting with anosmia and loss of taste is increasing, the society of ENT Surgeons in UK have issued a warning so that doctors would take adequate precautions when examining these patients.

A practical personal approach would be to consider yourself to have COVID-19 if you get fever with new cough or anosmia. Breathlessness usually occurs when the lungs are affected, which means hospital admission is necessary. This does not apply to Sri Lanka as all cases are admitted to hospital but in most countries, as the case numbers are much higher, those with no lung involvement are advised to self-isolate, at home, for 7 days. This exactly is what the British heir-to-the-throne, Prince Charles did.

Worryingly, some patients have presented as acute heart attacks with chest pain and typical ECG changes (elevation of the S-T segment in the ECG). This is totally different from those who present with COVID-19 and develop complications involving the heart, the most common being involvement of the heart muscle – myocarditis. These patients are more ill and have a much-increased chance of death but, fortunately, there have been a number of reports of success with aggressive treatment. Serial scans of the heart – echocardiograms, have demonstrated dilatation of the heart with markedly reduced contractions during the acute stage, which improve with treatment in a matter of a week or two, which is very reassuring.

Problems arise with those who present with chest pain with no other evidence of infection. The standard practice in most developed countries is, if the ECG shows evidence of an acute heart attack (S-T elevation on ECG), they would undergo coronary angiography - inserting a plastic catheter to the heart from an artery in the wrist and injecting a dye to see whether there are any blocks. If blocks are found, the artery is dilated and a stent placed to keep it open. Interestingly, these COVID-19 patients do not have any blocks, in spite of presenting with very suggestive pain and having typical ECG changes. The problem is that unsuspecting Cardiologists, who perform the angiograms, can get infected and it has happened. But with increasing awareness, Cardiologists are now taking precautions.

As the epidemic progresses, no doubt, there will be other presentations too. All this adds to the complexity of this epidemic, an enormity not seen during our lifetime. Though China and a few other counties have been able to contain the epidemic, to a degree, by the use of drastic measures, Europe and USA are still fighting against all odds, there being no silver-lining in the horizon.

It is to the credit of President Gotabhaya Rajapaksa and his government that the situation in Sri Lanka is under control. Unfortunately, he does not seem to be getting the support of some who, rather than taking medical advice, seem hell-bent on the supernatural to protect them resulting in pockets of infection. They fail to realise that their actions are prolonging the agony of all, brought on by the much-needed restrictions imposed. If not for this irresponsible behaviour, some restrictions would have been relaxed by now.

Whilst the virus is acting as a mimic, some commentators are acting as comics. They are critical of the Army being mobilised for many vital activities. Their contention is that the army is doing the work of the police and this may be an attempt at dictatorship. Seeing how stretched the police is, and considering the commendable way the army handled operations like quarantine, these criticisms ring hollow. In a dire emergency what is needed is urgent action and that exactly is what the President has done. In this scenario, the moot question is: Wonder what virus has infected the brains of those who accuse the President of attempting to be a dictator?