TREATMENT

On the 3 rd of april 2020 the CDC issued a recomamendation that the general public, even
thosewithout symptoms, should begin wearing face coverings in public settings where social-
distancing measures are difficult to mantain in order to abate the spread of COVID-19. (1)
Because no specific antiviral treatment is recommended for COVID-19 precautions such as
social distancing, staying at home and washing our hands as often as required are the main
measures to prevent the spread of SARS-CoV-2. (1)
The disease can manifest as upper respiratory tract disease and lower respiratory tract disease
witch can be further classified as mild,severe or critical. (2)
Infected patience should receive supportive care to help alleviate symptoms. Vital organ
function should be supported in severe cases. (2)
The lessons witch must be learned from this outbreak are the lessons South Corea learned in
2015 with the MERS virus otbreak mainly that early testing and contact tracing are essential to
prevent the uncontroled spread of viruses.
One of the reasons for witch SARS-CoV-19 is so dangerous is that people are contagious before
they develop simptoms. Another one is the fact that this is a new virus and there is no imunity to
stop it from spreading.
When talking about treating COVID 19 one of themain aspects is to stop the spread of the virus
which causes it so socialdistancing is the best course of action.
Hydoxychloroquine is an antimalarial drug also used in autoimune condition. It has a verry big
potencial to penetrate cells do to its chemical structure, also it is a weak base so whence it enters
a cell and atchaces itsself to H ion it loses the ability to pass freely across membranes. (1)
Numerous collaborative efforts to discover and evaluate effectiveness of antivirals
(remdesivir), immunotherapies (hydroxychloroquine, sarilumab), monoclonal antibodies and
vaccines have rapidly emerged. Still these therapies have not been probably tested and the long
tearm effects are not known. In addition, the demand for unproven therapies can cause shortages
of medication that are approved and indicated for other diseases, thereby leaving patients who
rely on these drugs for chronic conditions without effective therapies
Searching for effective therapies for COVID-19 infection is a complex process.
The association with cytokine storm syndrome is troublesom because of its severe
consecuences. (1)
Cytokine storm syndrome is caracterised by the release of IL-6, IL-1, IL-12 and IL-18,
alongwith tumor necrosis factor alpha (TNF-α) and other inflammatory mediators. The increased
pulmonary inflammatory response may result in increased alveolar-capillary gas exchange,
making oxygenation difficult in patients with severe illness.
 The recomandation is for early screening for inflammatory markers, ferritin, CRP and D-
dimer, subsequently monitoring the trend of these markers. The goal is to initiate early and
aggressive immunosuppressive therapy.
Initialy clinicians should rule out other causes of increased inflammation and deteriorating of
clinical status such as: secondary infection, pulmonaryemboli or COPD exacerbation.
Patience witch present with an initial low ferritin levels should not automatically be ruled low
risk for development of cytokine storm syndrome because low iron levels with or without anemia
can also cause reduced levels of ferritin.
On the other hand patience with high levels of ferritin can haveothe etiologies such as:
secondary infection, hepatitis B, hepatitis C, hemochromatosis or other liver diseases.
Tisinflammatory response is a delayed response mediated by Type 1 T helper cells, causing
activation of IL-6 and other pro-inflammatory cytokines.
If left untreated the progresion of cytokine storm syndrome can lead to acute lung injury.
Patience admitted to the hospital who have an insignificant elevation of serum markers should
not automatically be started on treatment with hydroxychloroquine and azithromycin as this may
cause deleterious side effects. (1)
Prior to treatment all patience should undergo laboratory evaluation for active tuberculosis
disease or invasive fungal disease. (1)
Possible agents include IL-6 inhibitor, IL-1 inhibitors or JAK inhibitors, however randomised
trials into the best course of treatment ar not yet aveilable. (1)
REFFERENCE
COVID 19 Cytokine storm syndrome identification and treatment S. Thomas Yadegar, M.D. ,
Shahin Delkhah, M.D., Katherine G. Jacobson 6.04.2020
Hydroxychloroquine An old drug with new relevance Eugen Alexander Shippey MD, Vanya D
Wagler, DO,FACP,FACR and AngeliqueN.Collamer, MD, FACP,FACRvCleavlend clinic
Journal of Medicine