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The Evolution of COVID-19: How the Virus Impacts the Entire Body

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Coronavirus
8 min read
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It’s July 2020 and we are currently living through a global pandemic. Six months since the first case of coronavirus was recorded in India in end January 2020, there is much that we DON’T know about the novel coronavirus.

But there’s also a lot that we DO know.

FIT tracks the evolution of the virus - and our understanding of it - in these 6 months.

An Unusual Disease

While COVID-19 is a serious, unprecedented disease, Dr Sumit Ray, a critical care specialist in Delhi who runs a COVID ICU, says much of the patterns are the same as other viral infections. Since it a novel virus, some of the general symptoms are exaggerated as doctors are still finding more information on the linkages between symptoms and causes.
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In the beginning, as the world tried to understand the disease, we saw it as a primarily respiratory disease. So breathing difficulties were expected, and the lungs were expected to be the first and worst hit.

But COVID-19 has moved in strange ways, with effects on the human body going beyond that of typical respiratory illnesses. As we have begun to understand it, it has come to light that Sars-CoV-2 can wreck havoc on various organs from the brain to the liver. Another important learning is that the severity of the disease is not always related to the severity of various symptoms, especially neurological ones.

The associated outcomes of COVID-19 are still not yet fully understood, but there have been a few studies that point to acute kidney damage in some COVID-19 patients. Some studies suggest that the virus is worse for people with cardiovascular problems, and that heart failure sometimes does occur in severe, hospitalised patients. “Patients with novel coronavirus disease 2019 (COVID-19) experience various degrees of liver function abnormalities,” says another study, but it remains to be seen is if this a symptom of COVID-19, or of the drugs given in the treatment plan or any other reasons.

But Dr Sumit Ray, a senior consultant of Critical Care Medicine explains that these associated effects are common in all severe viral infections.

“Did you know that a large subset of dengue patients die from liver damage? Every severe viral disease has liver damage.”
Dr Sumit Ray, Senior Consultant, Critical Care Medicine, Holy Family Hospital

He says that from 1 June to 14 July, his ICU in Holy Family, Delhi, treated 108 COVID-19 patients. “Most of them had raised liver enzymes, not acute liver damage. Often the drugs used in the treatment like remdesevir and tocilizumab are associated with liver damage.”

Brain Damage and COVID-19

Several studies have shown how the virus can often trigger neurological symptoms in our bodies, or what is known as encephalopathy or general brain damage. This study, published in the New England Journal of Medicine documents the various symptoms ranging from delirium and confusion to various cognitive difficulties. Estimates vary, but roughly 50 per cent of patients worldwide experience some kind of neurological issues. A resident doctor in Mumbai who wished to stay anonymous said that “We are seeing many cases of confusion, disorientation and delirium in our ICUs. This could also be due to a lack of proper oxygen due to the breathlessness one feels when infected.”

Again Dr Ray says,

“Critical care is a complex process. If not handled properly, most patients in any disease on critical care do go into delirium. It is a common thing.”
Dr Sumit Ray, Senior Consultant, Critical Care Medicine, Holy Family Hospital

There are emerging studies of the possibilities of strokes in young COVID-19 patients as well, and the worsening of dementia and similar conditions in those who have it.

"We were seeing patients in their 30s, 40s and 50s with massive strokes, the kind that we typically see in patients in their 70s and 80s," said Pascal Jabbour from Thomas Jefferson University to PTI. Worryingly the chances of a stroke are even in those COVID positive patients who are not showing other symptoms, but it is important to remember that these are all preliminary studies and more data is needed before one can make conclusions. The important takeaway is that these issues are occurring more frequently in younger patients.

Another big worry is that some COVID cases are linked to an inflammation in the brain (called encephalitis). Acute disseminated encephalomyelitis (ADEM) is where you have lesions in your brain, coupled with the lower oxygen levels.

This virus has presented the world with many problems, and because it is a new strain, scientists and researchers worldwide have been racing to keep up with the spread.

One of the issues here is the lack of enough, reliable data and one big reason for this is that many countries (including India) did not test enough so far. This is of course due to several policy lags, issues in developing and deploying the tests but this has meant that many people experience symptoms of COVID-19 without being tested. What do we make of these numbers then?

Changing Profiles, Age Groups

At first, we thought this was simply a more aggressive type of coronavirus, a more charged form of the flu. But Sars-CoV-2 has a number of unusual traits - which means that the types of patients we were seeing have changed as well.

At first, the World Health Organisation said that the people on high alert were the elderly and those with underlying co-morbidities underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer.

And while, for the most part, this does seem to be the case, but more and more young patients are getting infected and showing strange symptoms. We spoke about neurological disorders, but a worrying aspect is an inflammatory response in the brain of patients below 10 years.

A condition called pediatric multisystem inflammatory syndrome, is increasingly found in children in the US in New York, California and Lousianna and in Europe in Italy, France and Switzerland. A study in The Lancet compared the symptoms to a childhood illness called Kawasaki disease. “Kawasaki disease shock syndrome (KDSS) was defined by presence of circulatory dysfunction, and macrophage activation syndrome (MAS),” they wrote. So far this is rare, and the children who do have it have recovered, but there has been a spike in such cases since the pandemic began as compared to the previous years.

On the topic of inflammation, there is much buzz around the cytokine storm, or the overzealous response of our immune system to COVID-19. While unusual in such high numbers, this is a known reaction. “It’s a new virus, so we can assume our immune system will go in overdrive in identifying and fighting it.” We don’t recognise the virus, there is no immunity against it. And so a cytokine storm does make sense as a biological reaction. “Of course, we did not expect it to happen so much and COVID is causing more cytokine storms, but scientifically this is the pattern our body takes when it encounters a new virus,” says Dr Ray.

Diabetes and COVID-19

As the disease has progressed, one of the most common risk factors in India is diabetes. Now our country has a high diabetic burden but Dr Ray told us that most severe patients were diabetic or pre-diabetic.

“Diabetics are more prone to this disease in India and abroad, along with the otherwise obese. More than 80% of the patients in my COVID ICU are diabetic. What is the immune response that they have that gives them this? We are trying to find out.”
Dr Sumit Ray, Senior Consultant, Critical Care Medicine, Holy Family Hospital

“People with diabetes are not more prone to COVID-19 than the general population. However, if they get COVID-19, they are at increased risk of developing more severe or advanced stages of the disease. Hence, glycemic control is of primary importance. Any infection is likely to increase the blood sugar levels and uncontrolled diabetes can further lead to worsening of the infection,” says Dr Ranjit Unnikrishnan in the Journal of Diabetology.

Reportedly, patients who don’t have a history of diabetes or are not diagnosed with the condition are now presenting with high blood sugar. But again, this is NOT unusual.

“Sugars going out of control is true of all severe patients, in any critical patient.”
Dr Sumit Ray, Senior Consultant, Critical Care Medicine, Holy Family Hospital
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Another hypothesis, he tells me, is that the virus attaches itself to the ACE receptors in the pancreas and may cause a degree of lack of control of sugars.

“One of the main protocols of critical care is sugar control, but this is nothing new or dramatic,” says Dr Ray. He adds that it took the world a little time as the spread was so quick, it took some time to connect the dots but some things about the disease are known. “It’s not entirely new, we know the basic patterns but some reactions and nuances need to be monitored.” Most of the case fatalities seem higher because we are looking at them as absolute numbers, the actual percentage is not that high he says.

Blood Clotting is the Main Issue

“The main issue in COVID-19 is that it is affecting blood vessels and causing the clotting of blood. This occurs in sepsis too, and in COVID-19 the vessels getting damaged lead to a lack of oxygen being delivered to organs, which then causes adverse reactions.”
Dr Sumit Ray, Senior Consultant, Critical Care Medicine, Holy Family Hospital

The proportion and severity of patients getting clotting is “significantly higher in COVID-19”, says Dr Ray. This is one of the factors of high mortality.

The walls of the blood vessels are also getting damaged and getting prone to blockages he adds. “This leads to a small subset of patients getting strokes and heart attacks.”

A quick reminder on oxygen transfusion: once released from the lung, oxygen is picked up by air sacs and transferred to the blood vessels and tissues and it then energises all our organs.

COVID-19 and H1N1 both have a subset of patients with damage to their lung tissue. The difference in COVID-19 is damage to small blood vessels that get clotted, and hamper the diffusion of oxygen into the organs. “What happens is that the oxygen from our lungs is diffused into blood vessels and then tissues and smaller vessels and it is these vessels that are getting clotted.”

“The problem in COVID-19 is two-fold. Not only is the lung tissue damaged, the clotting of the vessels also adds to the lack of oxygen being delivered. This can lead to multi-organ failure.”
Dr Sumit Ray, Senior Consultant, Critical Care Medicine, Holy Family Hospital

Much We Know, Much to Learn

Our understanding of the virus has grown in leaps and bounds since January. There is more awareness and while healthcare workers are still battling it out everyday, there is more preparedness.

Still, COVID-19 is a tricky virus, and the more we study it, the more we know about its various reactions. Globally, there are efforts to gather accurate data and find out as much as we can to control the severity of the disease. In India, we are almost reaching 1 million cases, and the need for scientific studies into the disease cannot be overstated.

(At The Quint, we are answerable only to our audience. Play an active role in shaping our journalism by becoming a member. Because the truth is worth it.)

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Topics:  Coronavirus 2019   COVID-19 

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