MARKERS OF SEVERITY IN COVID-19 INFECTION

By: DR. JONATHAN MACATIAG IV

Case Vignette:

 NE, 29/M, from Pasig came in for 5 day history of difficulty of breathing, associated with fever,
non-productive cough, dysgeusia, anorexia, nausea. No known comorbidities. Denies vices
 At the ER, BP 110/8-, HR 126 RR 30s, T 38.0 C
 O2 Sats: 81% (normal sat is 94-100)
 Awake in distress, oriented to 3 spheres, GCS 15
 Anicteric sclerae pinkish palpebral conjunctivae
 Equal chest expansions, bilateral crackles
 Distinct heart sounds, tachycardic, regular rhythm, no murmurs
 Soft non tender abdomen
 Full equal pulses, no edema

 Elevated WBC count, not typical for patient with viral infection, usually the predominant will be
lymphocytes but for this patient he had neutrophilic predominant and WBC count
 This patient will also have concomitant bacterial infection
 Everything is normal for chemistry, no kidney or liver injury
 But for the markers, his d-dimer is elevated, elevated LDH, elevated HSCRP and Ferritin
 For chest Xray there’s bilateral infiltrate of the patient
  This is for patient with respiratory distress (covid-19 infection)
 Whitening of bilateral lung area, we can say the patient is in acute respiratory syndrome
1. Acute Respiratory Failure, Type 1 from:
a. COVID 19 pneumonia, confirmed critical, t/c in ARD
b. CAP HR
c. Rule out Pulmonary embolism (wells score 2)
He was then admitted at ICU

 Markers persistently elevated

 Started dexamethasone (corticosteroid for patient with covid 19) 6 mg IV OD x 10 days
 Ideally for Tocilizumab but not available
 Remdesivir (RNA polymerase inhibitor) 200 mg in 250 cc pNSS x 2h infusion on D1, then 100
mg in 250 cc pNSS x 2h infusion OD on D2 to D5
 The patient expired (died)
COVID 19 INFECTION

 Caused by SARS-CoV2
 Happened on March 12,2020- pandemic (by WHO)
 200 countries affected
 10 M confirmed cases as of 2020
 Case fatality rate- 2-3% up to 49.0% in critical patient
 In the Philippines there are already near 4 million cases (3,906,269) but with also a lot of
recoveries with 62,304 deaths
 As of the latest statistics there are still a number of patient infected with Covid 19 with 11,995
cases
PATHOPHYSIOLOGY OF COVID 19 INFECTION

 COVID 19 is a respiratory disease, through respiratory droplets

 Once we inhale the virus they infect the lung cell they use the ACE 2 inhibitor
MARKERS OF SEVERITY

 The higher the age the poor prognostication, also for those with multiple comorbidities (diabetes,
etc) also for those patient that are obese
 COMMONLY REQUESTED TEST:
 CBC
o If ALC (Absolute lymphocyte count) <0.8, poor prognostic marker
o In the patient before he had high WBC count which could explain by a possible bacterial
infection, we can see neutrophils are elevated and patient is anemic
o But for CBC we look at absolute lymphocyte count
o Those with lymphopenia they have poor prognostic marker
 CRP
o Can be used to tract mortality risk
o If patient have high CRP then they have increase mortality risk
o If low or normal, consider other cause of acute respiratory failure or mild disease
 D-dimer
o If >2.4, increased risk of ICU stay
o They would have increase risk for mortality
o Patient with cancer have increase risk for thrombosis because of hypercoagulation state
the same with patient with COVID 19
o Patients are prone to develop pulmonary embolism in covid 19 ( when clots from other
parts of the body will lodge on the pulmonary vessel)
o If d-dimer is elevated for 10-20 we request for pulmonary imaging to look for pulmonary
embolism
  LDH
o If >245 IU, poor prognostic marker
o If >400, increased risk of ICU stay
 Ferritin
o Storage form of iron in the body
o If >1000 ng/mL, watch out for cytokine storm
o Inflammatory marker

LABORATORY MARKERS

 Those value with p values <0.5 are significant

 Lymphocyte is no longer consider marker
 Those with high neutrophils and WBC count are classified as sever
 Those with low platelet can be used for marker of severity
 IL 6 and IL 8 are included
LOCAL STUDIES

 In patient with diabetes and hypertension, leukemia, cancer, heart disease, coronary syndrome,
chronic lung disease, chronic smoker, chronic kidney disease they are seen more often in severe
room
 Neutrophils, d dimer, ferritin, CRP are all significantly higher
MANAGEMENT

 Lots of cytokine involve in patient with covid 19 (IL 1P, IL 17C)

 Initially there is really no proven treatment for covid, we just manage conservatively, like
intubation, or antibiotics for bacterial infection
 Mostly supportive
 They look at different cytokine barriers
 Tocilizumab very common drug to use in covid 19 infection (IL-6 inhibitor)

 Separate ward for those with covid-19 infection

 In patients who came presenting with respiratory syndrome they routinely test them with RT-PCR
result will take 4-8 hours
 Then classify the patient
 Those patient who had ? their respiration rate is <30
 No comorbidities, patient are young classified as mild
 If patient is elderly have pneumonia these are moderate
 For severe, those are dyspnic, couldn’t even talk, have no sepsis or acute respiratory syndrome
 For patient with who eventually intubated or in shock those are critical