Uphill task of solving the Covid-19 symptoms puzzle

When it comes to the symptoms Covid-19 patients exhibit, discussions often revolve around a binary situation, you either get mild and recover quickly, or you get really sick and wind up in the ICU.

From Dr Chibanzi Mwachonda’s description, “the waxing and waning nature of the symptoms can put one in a state of apprehension".

“Those with no symptoms at all should count themselves lucky...One hour you are fine, next hour your body is acting up. But, overall I’m quite stable with mild symptoms,” he said while describing how his body was reacting to the Sars-Cov-2 virus infection which causes Covid-19.

Save for a niche group who end up in the ICU needing oxygen supplementation or ventilation, hundreds of symptomatic Kenyan patients echo Dr Mwachonda’s story. Since the coronavirus pandemic first began, evidence has emerged showing that the list of lingering illnesses from Covid-19 is longer and more varied than most doctors and scientists could have imagined.

Ongoing problems include fatigue, a racing heartbeat, shortness of breath, achy joints, foggy thinking, a persistent loss of sense of smell, and damage to the heart, lungs, kidneys, and brain.

INFLAMMATORY REACTION

Dr Yubrine Moraa, an internal medicine physician, explains that these illnesses have become so varied and increasingly complex. For instance, she explains: “We have seen patients come in with personality changes, meaning that the disease has interfered with their central nervous system.”

At the onset of the pandemic, doctors learned that Sars-Cov-2 can disrupt an array of tissues in the body. This is because the virus uses a spike protein on its surface to latch onto cells’ ACE2 receptors (Angiotensin-converting enzyme 2) receptors, a protein on the surface of many cell types including the lungs, heart, gut, kidneys, blood vessels, and nervous system, among other tissues—and thus, are vulnerable to Covid-19. 

Sars-CoV-2, the virus which causes the respiratory illness can harm other parts of the body like the heart and the brain. In two studies published in the journal JAMA Cardiology showed that respiratory droplets, but it can also sometimes cause diarrhea and other gastrointestinal symptoms.

One of the studies, which included patients aged 45 to 53 from the University Hospital Frankfurt Covid-19 registry in Germany, found that, among 100 adults who recently recovered from Covid-19, 78 per cent showed some type of cardiac involvement in MRI scans and 60 per cent had ongoing inflammation in the heart.

The patients were recruited for the study between April and June. Most of the patients (67 per cent) recovered at home, with the severity of their illness ranging from some being asymptomatic to having moderate symptoms.

Using data from blood tests, a biopsy and magnetic resonance imaging (MRI) of the heart from 50 healthy individuals and 57 with a pre-existing health condition, the scientists found that people infected with Covid-19 had some heart complications regardless of whether they had an underlying condition or not.

PERMANENT DEFORMITY

As the number of confirmed cases of Covid-19 surges past 18 million globally and deaths near 700,000, clinicians and pathologists are beginning to get a clearer picture of the extent of the damage wrought by the coronavirus as it tears through the body.

Dr Geoffrey Kulabusia, a medical immunologist at Egerton University, says the virus is “exhibiting very complex symptoms which we are now learning can cause permanent deformity to the body organs". Even worse is the fact that most of these difficult to identify symptoms can only be detected when the patient is hospitalised.

Scientists are increasingly realising that although the lungs are ground zero, the reach of the virus can extend to many organs including the heart and blood vessels, kidneys, gut, and brain. Autopsies on 38 brains, 87 lungs, and 42 hearts at New York City’s NYU Langone Health showed that some organs had far too many of a special cell rarely found in those places.

In an interview with Washington Post last month, pathologist Amy Rapkiewicz, who directs autopsies at NYU Langone Health, noticed something she had never seen before, yet it seemed vaguely familiar. The novel coronavirus seemed to amplify their effect, causing dangerous clotting.

Among the most important findings, consistent across several studies, is confirmation the virus appears to attack the lungs the most ferociously. They also found the pathogen in parts of the brain, kidneys, liver, gastrointestinal tract, and spleen and in the endothelial cells that line blood vessels, as some had previously suspected. Researchers also found widespread clotting in many organs.

NO EVIDENCE

Another unexpected finding was that oxygen deprivation of the brain and the formation of blood clots may start early in the disease process. That could have major implications for how people with Covid-19 are treated at home, even if they never need to be hospitalised.

The brain and heart, however, yielded surprises. When it comes to the heart, many physicians warned for months about a cardiac complication they suspected was myocarditis, an inflammation, or hardening of the heart muscle walls — but autopsy investigators were stunned that they could find no evidence of the condition.

But, a team of doctors at Northwestern University Feinberg School of Medicine and the University of California, Los Angeles, who co-authored an editorial that accompanied the two new studies in the journal JAMA Cardiology, said there was concern about heart failure related to Covid-19.

"We see the plot thickening and we are inclined to raise a new and very evident concern that cardiomyopathy and heart failure related to Covid-19 may potentially evolve as the natural history of this infection becomes clearer,"  Dr Clyde Yancy and Dr Gregg Fonarow wrote in the editorial.

LOOKING TO AUTOPSIES

For a long time, autopsies have been used by pathologists to determine the cause of death, for legal purposes, and for education and research. In diseases like Ebola and HIV/Aids, they can help a family learn more about the disease processes that caused a patient's demise.

However, Kenya is yet to carry out any study on patients who have died from the disease. “We need to involve pathologists to analyse how the disease is manifesting in our patients. We need to get specimens,” said Dr Kulabusia.

To properly document the precise impact of the virus in the body, survivor studies have been developed. Last month, researchers across the UK launched a study that will follow 10,000 survivors for one year to start and up to 25 years. The scientists hope not just to understand the disease’s long shadow, but also to predict who’s at highest risk of lingering symptoms and learn whether treatments in the acute phase of illness can head them off.