(Ronald Cherry, MD Pulminary Diseases) USofA - COVID-19

COVID-19 Treatment Ronald R. Cherry, MD, FCCP July 26, 2020 For symptomatic outpatients, and hospitalized COVID-19 patients with moderate, severe or critical illness, with dyspnea and bilateral pneumonia, consider the following treatment options: * Hydroxychloroquine sulfate 400 mg po initially, at 12 hours, and then daily for a total of 7 doses Or Chloroquine phosphate 500 mg po initially, at 12 hours, and then daily for a Total of 7 doses “For hospitalized patients with COVID-19 who have evidence of pneumonia, we suggest hydroxychloroquine (or chloroquine) on a case‐by‐case basis.” American Thoracic Society https://www.thoracic.org/professionals/clinical-resources/disease-relatedresources/covid-19-guidance.pdf

* Zinc supplement is recommended https://www.youtube.com/watch?v=U7F1cnWup9M https://www.sciencedirect.com/science/article/pii/S0306987720306435?via%3Dih ub Chloroquine or Hydroxychloroquine therapy for COVID-19 illness in the absence of Zinc therapy is unwise since their main effects is to facilitate intracellular accumulation Zinc which inhibits RNA-dependent RNA polymerase, the SARS-CoV2 reproductive enzyme.

Taking severity of illness into account, a retrospective chart review of hospitalized COVID-19 patients in Spain found 48.8% mortality in patients not treated with Hydroxychloroquine, vs. 22% mortality with treatment, statistically significant in those presenting with milder disease, suggestive in moderate and severe disease. The authors state: “HCQ treatment was an independent predictor of lower mortality… We theorise that the antiviral effect is only effective in early stages of the disease, before the immunomodulated ADRS development…Our findings in an easily available, lowcost drug with few side effects makes HCQ/CQ a good choice to start clinical trials in hospitalised patients, and to consider an out-of-label most extended use in early

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stages of the disease.� It would have been interesting if Zinc had been added to Hydroxychloroquine in this study. https://www.preprints.org/manuscript/202005.0057/v1

A retrospective comparative study from Henry Ford Hospital in Detroit, MI found an ~50% mortality reduction in hospitalized patients suffering from COVID-19 illness when treated with Hydroxychloroquine.

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https://www.ijidonline.com/article/S1201-9712(20)30534-8/fulltext “The advantage of hydroxychloroquine is that the drug has been around for decades.

The risk profile has been very well established for treating malaria and lupus. It has also been used for rheumatoid arthritis. It is an inexpensive, commonly available drug that has a very good risk profile. If you take a look at the rheumatology literature and the lupus literature, it is very safe. In the instructions for use, there is no consideration for a QT prolongation. One study in Brazil showed that very high doses of chloroquine, not hydroxychloroquine, may be associated with an increase in arrhythmias. We have scoured the literature, and we really haven’t found any proof that in patients early in the disease, which is probably when it is most effective, that it has any kind of risk… We had extensive discussions with the FDA about safety of hydroxychloroquine before our Investigational New Drug application was granted.

We have not seen any safety concerns in the 350 participants taking medications in our trial. The main safety signal came from an uncontrolled trial of extremely high doses of chloroquine that caused arrythmias in Brazil. This has no bearing on the doses of hydroxychloroquine we are using… I have empirically treated people with a combination of hydroxychloroquine, azithromycin and zinc. That combination, at least in my hands, has been really effective.” William W. O’Neill, MD, Medical Director of the Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI https://www.healio.com/cardiology/vascular-medicine/news/online/%7Bc30ff204961b-4c2a-9bdd-3eb50a50df1b%7D/new-study-to-provide-insight-onhydroxychloroquine-for-covid-19-prevention-in-health-care-workers 3

A large retrospective chart review published in The Lancet revealed increased mortality using Chloroquine or Hydroxychloroquine, but this study has been severely criticized in its shamefully unscientific methods, and it also failed to incorporate Zinc into the treatment regimen. As a result of this flawed study the World Health Organization, and Dr. Anthony Fauci of the NIH, withdrew their support for Chloroquine and Hydroxychloroquine. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)311806/fulltext https://www.youtube.com/watch?v=IUD_wvkNhnk https://www.youtube.com/watch?v=KS-mHOtXX84&feature=emb_rel_end Despite positive results in the U.S. and foreign nations, the FDA revoked its emergency use authorization for Chloroquine and Hydroxychloroquine for treatment of COVID-19 illness, however they did not take into account the necessary combination with Zinc. One hopes the latest FDA decision was not based on or influenced by the unscientific results of the above Lancet study. Chloroquine & Hydroxychloroquine can still be legally prescribed off-label in the United States. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19update-fda-revokes-emergency-use-authorization-chloroquine-and The FDA is also warning health care providers that “co-administration of remdesivir and chloroquine phosphate or hydroxychloroquine sulfate is not recommended as it may result in reduced antiviral activity of Remdesivir.” However, the FDA admits that they are “not aware of instances of this reduced activity occurring in the clinical setting.” In any event the clinical antiviral activity of Remdesivir is low to begin with.

“Given high mortality despite the use of Remdesivir, it is clear that treatment with an antiviral drug alone is not likely to be sufficient. Future strategies should evaluate antiviral agents in combination with other therapeutic approaches or combinations of antiviral agents to continue to improve patient outcomes in Covid-19.” https://www.fda.gov/safety/medical-product-safety-information/remdesivir-gileadsciences-fda-warns-newly-discovered-potential-drug-interaction-may-reduce https://www.nejm.org/doi/full/10.1056/NEJMoa2007764 A retrospective chart review in New York found that the combination of Hydroxychloroquine + Zithromax + Zinc significantly reduced the need for ICU transfer and mechanical ventilation, and significantly reduced mortality in those suffering from COVID-19 illness.

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"As a result of in vitro evidence suggesting zinc sulfate may be efficacious against COVID-19, our hospitals began using zinc sulfate as add-on therapy to hydroxychloroquine and azithromycin. We performed a retrospective observational study to compare hospital outcomes among patients who received hydroxychloroquine and azithromycin plus zinc versus hydroxychloroquine and azithromycin alone... Zinc sulfate increased the frequency of patients being discharged home, and decreased the need for ventilation, admission to the ICU, and mortality or transfer to hospice for patients who were never admitted to the ICU. After adjusting for the time at which zinc sulfate was added to our protocol, an increased frequency of being discharged home (OR 1.53, 95% CI 1.12-2.09) reduction in mortality or transfer to hospice remained significant (OR 0.449, 95% CI 0.2710.744). Conclusion: This study provides the first in vivo evidence that zinc sulfate in combination with hydroxychloroquine may play a role in therapeutic management for COVID-19." https://www.medrxiv.org/content/10.1101/2020.05.02.20080036v1.full.pdf Three clinical studies of Hydroxychloroquine did not demonstrate improvement in COVID-19 illness. The fatal flaw in two of these studies was the fact that the Hydroxychloroquine treated patients were significantly sicker than those without Hydroxychloroquine, and the absence of concomitant therapy with Zinc. In the first NEJM study the treatment group average PaO2/FIO2 was 233 indicating the onset of ARDS, whereas the non-treatment group average PaO2/FIO2 was 360 indicating significantly less severe lung disease excluding the diagnosis of ARDS. The authors of the VA study admitted that: “Hydroxychloroquine, with or without azithromycin, was more likely to be prescribed to patients with more severe disease, as assessed by baseline ventilatory status and metabolic and hematologic parameters. Thus, as expected, increased mortality was observed in patients treated with hydroxychloroquine.� Treating sicker patients with a drug and then comparing the results with a less sick control group cannot lead to valid conclusions. The third study failed to incorporate Zinc in the treatment regimen. https://www.nejm.org/doi/full/10.1056/NEJMoa2012410 https://www.medrxiv.org/content/10.1101/2020.04.16.20065920v1.full.pdf https://www.nejm.org/doi/full/10.1056/NEJMoa2019014

A clinical study of post SARS-CoV-2 exposure revealed no prophylactic benefit from Hydroxychloroquine in preventing symptomatic COVID-19 illness, but the authors failed to include Zinc in the treatment, and they did not study pre-exposure prophylaxis. On the other hand, clinical studies in India have demonstrated good pre-exposure prophylactic effect from Hydroxychloroquine.

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https://www.nejm.org/doi/full/10.1056/NEJMoa2016638 https://theprint.in/health/hcq-breakthrough-icmr-finds-its-effective-in-preventingcoronavirus-expands-its-use/427583/ https://indianexpress.com/article/india/vadodara-administration-drive-hcqhelping-in-containing-covid-19-cases-say-docs-as-analysis-begins-6486049/ Using data obtained from the Johns Hopkins Coronavirus Resource Center, investigative journalists in France discovered a statistically significant increase in Swiss COVID-19 deaths-per-recovery after the use of Hydroxychloroquine was banned, and a return to lower death rates after the ban was reversed. The Swiss ban on Hydroxychloroquine occurred 5 days after publication of the fraudulent Lancet study.

http://www.francesoir.fr/societe-sante/covid-19-hydroxychloroquine-worksirrefutable-proof

Regarding the use of Hydroxychloroquine for treatment of COVID-19 illness, Harvey Risch, MD, PhD, Professor of Epidemiology at Yale University School of Medicine writes: “The FDA, NIH and cardiology society warnings about cardiac arrhythmia adverse events, while appropriate for theoretical and physiological considerations 6

about use of these medications, are not borne out in mortality in real-world usage of them. It would therefore be incumbent upon all three organizations to reevaluate their positions as soon as possible… Some people will have contraindications and will need other agents for treatment or to remain in isolation. But for the great majority, I conclude that HCQ+AZ and HCQ+doxycycline, preferably with zinc can be this outpatient treatment, at least until we find or add something better… It is our obligation not to stand by, just “carefully watching,” as the old and infirm and inner city of us are killed by this disease and our economy is destroyed by it and we have nothing to offer except high-mortality hospital treatment… We have to let physicians employing good clinical judgement use it and informed patients choose it. There is a small chance that it may not work. But the urgency demands that we at least start to take that risk and evaluate what happens, and if our situation does not improve we can stop it … but we will know that we did everything that we could instead of sitting by and letting hundreds of thousands die because we did not have the courage to act according to our rational calculations.” http://covexit.com/yale-epidemiology-professor-urges-hydroxychloroquineazithromycin-early-therapy-for-covid-19/ “As professor of epidemiology at Yale School of Public Health, I have authored over 300 peer-reviewed publications and currently hold senior positions on the editorial boards of several leading journals. I am usually accustomed to advocating for positions within the mainstream of medicine, so have been flummoxed to find that, in the midst of a crisis, I am fighting for a treatment that the data fully support but which, for reasons having nothing to do with a correct understanding of the science, has been pushed to the sidelines. As a result, tens of thousands of patients with COVID-19 are dying unnecessarily. Fortunately, the situation can be reversed easily and quickly. I am referring, of course, to the medication hydroxychloroquine. When this inexpensive oral medication is given very early in the course of illness, before the virus has had time to multiply beyond control, it has shown to be highly effective, especially when given in combination with the antibiotics azithromycin or doxycycline and the nutritional supplement zinc…In the northern Brazil state of Pará, COVID-19 deaths were increasing exponentially. On April 6, the public hospital network purchased 75,000 doses of azithromycin and 90,000 doses of hydroxychloroquine. Over the next few weeks, authorities began distributing these medications to infected individuals. Even though new cases continued to occur, on May 22 the death rate started to plummet and is now about one-eighth what it was at the peak…On May 27, the Swiss national government banned outpatient use of hydroxychloroquine for COVID-19. Around June 10, COVID-19 deaths increased four-fold and remained elevated. On June 11, the Swiss government revoked the ban, and on June 23 the death rate reverted to what it had been beforehand. People who die from COVID-19 live about three to five weeks from the start of symptoms, which makes the evidence of a causal relation in these experiments strong. Both episodes suggest that a combination of hydroxychloroquine and its companion medications 7

reduces mortality and should be immediately adopted as the new standard of care in high-risk patients…As all know, the medication has become highly politicized. For many, it is viewed as a marker of political identity, on both sides of the political spectrum. Nobody needs me to remind them that this is not how medicine should proceed. We must judge this medication strictly on the science…For the sake of highrisk patients, for the sake of our parents and grandparents, for the sake of the unemployed, for our economy and for our polity, especially those disproportionally affected, we must start treating immediately.” https://www.newsweek.com/key-defeating-covid-19-already-exists-we-need-startusing-it-opinion-1519535 Chloroquine and Hydroxychloroquine are safe drugs with vast clinical experience.

Like almost all other drugs their potential side effects make a fairly long list, but are still considered safe overall. Known hypersensitivity, long Q-T syndrome, history of ventricular arrhythmias, severe CHF, and significant hepatic or renal impairment appear to be the main cautions or contraindications. Retinal toxicity may occur after years of prolonged administration, with an overall risk of less than 1% with usual doses. Combining Hydroxychloroquine with Azithromycin has demonstrated more rapid clearance of SARS-CoV-2 from the respiratory tract in comparison to Hydroxychloroquine alone, but outside of critical illness should be used with caution and cardiac monitoring if the Q-T interval is long on the EKG. Chloroquine appears to be safe in pregnancy, particularly when a physician determines that the life-saving benefits to the mother outweigh a small risk to the developing fetus. Chloroquine is considered safe for the infant during breastfeeding. The current concern regarding Hydroxychloroquine and Chloroquine has become political, and is strangely overblown. These drugs are recommended by several governments around the world for inpatient therapy, and for prevention of COVID-19. As opposed to the World Health Organization, elements within the FDA and NIH, physicians fighting COVID19 in the trenches are reporting success with Hydroxychloroquine, particularly in combination with Zinc &/or Azithromycin. With so many poorly constructed, nonrandomized, retrospective chart review studies from Academic Medical Centers, one must wonder if their Hydroxychloroquine science has been corrupted by large pharmaceutical companies.

* Ivermectin up to 0.2 mg/kg po or per ng tube x 1 dose Ivermectin is an inexpensive drug with good safety profile, FDA approved and widely used to treat parasitic infections, lice and scabies since 1981, and declared by the World Health Organization to be an essential medication. Ivermectin has been found 8

to have potent in-vitro activity against SARS-CoV-2, and clinical studies appear to be very favourable in patients suffering from severe COVID-19 with mortality reduced by over 50% in those suffering from respiratory failure. Hopefully the FDA will issue an emergency use authorization for Ivermectin, but it can be prescribed off-label. https://www.medrxiv.org/content/10.1101/2020.06.06.20124461v1 https://www.sciencedirect.com/science/article/pii/S0166354220302011

* Tocilizumab A clinical study of patients with severe COVID-19 illness, consistent with cytokine storm syndrome, received treatment with the IL-6 blocker tocilizumab, 4 to 8 mg/kg

by IV infusion (maximum dose 800mg). All patients required supplemental oxygen, two required mechanical ventilation, all had worsening ground-glass opacities on chest CT and deterioration of other clinical and laboratory measures. Within 24 hours of starting tocilizumab therapy fever and elevated C-reactive protein levels resolved, and levels of IL-6 and other inflammatory cytokines declined. Use of supplemental oxygen dropped in 15 patients, oxygen saturation levels stabilized or improved in all patients, the 2 ventilated patients were weaned, and all patients subsequently were discharged alive. Another study revealed 22% mortality in severe COVID-19 illness, compared with up to 88% mortality in many other clinical reports. https://www.pnas.org/content/117/20/10970 https://journal.chestnet.org/article/S0012-3692(20)31670-6/pdf https://www.jwatch.org/na51506/2020/05/12/tocilizumab-might-attenuatecytokine-storm-covid-19

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* Anticoagulation: All hospitalized patients with COVID-19 should receive pharmacologic thromboprophylaxis with LMWH or fondaparinux, unless the patient is judged to be at increased bleeding risk. In patients with history of heparin-induced thrombocytopenia, use fondaparinux. In patients where anticoagulants are contraindicated or unavailable, use mechanical thromboprophylaxis (e.g. pneumatic compression devices). A study has demonstrated improved survival in critically ill COVID-19 patients requiring mechanical ventilation when treated with full anticoagulation; another study detected a 37% rate of pulmonary embolism in COVID-19 patients undergoing CT pulmonary angiography with a mean D-Dimer of 6432 ng/ml, and a mean D-Dimer of 1774 with negative CTA. https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation https://www.sciencedaily.com/releases/2020/05/200507194907.htm https://pubs.rsna.org/doi/10.1148/ryct.2020200308

* Remdesivir 200 mg IV on day 1 then 100 mg IV once daily for 4 to 9 days

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“Based on review of the topline data from the randomized, double-blinded, placebocontrolled trial conducted by NIAID and from the Gilead-sponsored open-label trial that evaluated different durations of remdesivir, it is reasonable to believe that the known and potential benefits of RDV outweigh the known and potential risks of the drug for the treatment of patients hospitalized with severe COVID-19.” Denise M. Hinton, Chief Scientist Food and Drug Administration https://www.fda.gov/media/137564/download https://www.elsevier.com/__data/assets/pdf_file/0008/996767/Remdesivir-DrugMonograph_270320.pdf A double-blind, randomized, placebo-controlled trial of intravenous remdesivir in adults hospitalized with Covid-19 with evidence of lower respiratory tract involvement found that survivors recover slightly faster with Remdesivir compared to placebo. Mortality was numerically lower in the remdesivir group than in the placebo group, but the difference was not statistically significant. The research authors concluded: “Given high mortality despite the use of remdesivir, it is clear that treatment with an antiviral drug alone is not likely to be sufficient. Future strategies should evaluate antiviral agents in combination with other therapeutic approaches or combinations of antiviral agents to continue to improve patient outcomes in Covid19.” https://www.nejm.org/doi/full/10.1056/NEJMoa2007764 https://medicalxpress.com/news/2020-07-remdesivir-covid-treatment.html

* Antibiotic Rx Antibiotic therapy is advised due to the likelihood of bacterial superinfection.

Cavitary lung abscesses have been observed which would necessitate anaerobic coverage. https://casereports.bmj.com/content/13/7/e237245?rss=1

* Corticosteroid therapy 11

The CDC recommend against their use: “Corticosteroids should be avoided unless indicated for other reasons, such as management of chronic obstructive pulmonary disease exacerbation or septic shock.� However, a randomized controlled study in Great Britain observed a 35% improvement in mortality for severely ill COVID-19 patients requiring mechanical ventilation, and a 20% mortality improvement in moderate cases requiring supplemental oxygen, using a daily dose of dexamethasone 6mg po or IV. The NIH and Frontline COVID-19 Critical Care Consortium recommend corticosteroid therapy for hospitalized COVID-19 patients with hypoxemia with or without acute respiratory failure. https://www.recoverytrial.net/files/recovery_dexamethasone_statement_160620_v 2final.pdf https://www.covid19treatmentguidelines.nih.gov/dexamethasone/ https://spectator.org/a-report-from-the-front/

* Convalescent plasma https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-ordevice-exemption-ide-process-cber/recommendations-investigational-covid-19convalescent-plasma https://www.uscovidplasma.org/ uscovidplasma@mayo.edu

* Dialysis or hemofiltration using the Spectra Apheresis system or the Depuro D2000 Adsorption device https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19update-fda-authorizes-blood-purification-device-treat-covid-19

* Favipiravir 12

The dosage of Favipiravir used safely in clinical trials has ranged from1,600 mg bid on day one, followed by 600 mg bid for up to 14 days to 1,800 mg po bid on day one, followed by 1,000 mg po bid for up to 14 days. Avigan, Japan’s trade name for Favipiravir, has been used there since 2014 for treatment of severe influenza, available in 200 mg tablets. Avifavir, Russia’s generic equivalent of Favipiravir, has received a temporary registration certificate from the Ministry of Health of the Russian Federation. Favipiravir is an inhibitor of RNA-dependent RNA polymerase, the reproductive enzyme of SARS-CoV-2, and has proven to be effective treatment for COVID-19 illness in Russian clinical trials. Kirill Dmitriev, CEO of the Russian Direct Investment Fund, stated: “Afivavir is not only the first antiviral drug registered against coronavirus in Russia, but is also perhaps the most promising antiCOVID-19 drug in the world.” Unfortunately, Favipiravir is not available in the United States outside of clinical trials, but will hopefully receive FDA emergency use authorization. https://rdif.ru/Eng_fullNews/5220/ https://www.trialsitenews.com/russia-ministry-of-health-approves-avifavirfavipiravir-for-covid-19-patients-cuts-duration-of-illness-by-over-50/ https://ascpt.onlinelibrary.wiley.com/doi/pdf/10.1002/cpt.1844

There are some clinical reports and laboratory studies indicating possible effectiveness for Glutathione and N-acetylcysteine (NAC - a biochemical precursor to Glutathione) in the treatment of cytokine storm in those severely ill with COVID-19 https://www.youtube.com/watch?v=OtL0B1bqXak&feature=youtu.be https://www.researchgate.net/publication/340917045_Endogenous_deficiency_of_ glutathione_as_the_most_likely_cause_of_serious_manifestations_and_death_in _patients_with_the_novel_coronavirus_infection_COVID19_a_hypothesis_based_on_literature_data_and_ow https://nypost.com/2020/05/09/new-york-mom-with-coronavirus-saved-bymedical-student-son/

A study in New York has found that hospitalized COVID-19 patients who were taking famotidine (Pepcid) had a mortality rate of 14% compared to 27% in patients not 13

taking the drug. Outpatient therapy with high-dose famotidine also suggested benefit. https://www.hospimedica.com/covid-19/articles/294782051/active-compound-inpopular-heartburn-drug-pepcid-being-tested-for-covid-19-treatment.html https://gut.bmj.com/content/early/2020/06/04/gutjnl-2020-321852.full

BiPap & CPAP support has been authorized by the FDA, but should only be used in negative pressure rooms, and with high FIO2 may suffice in lieu of intubation and mechanical ventilation, apparently also true for nasal oxygen, humidified high-flow nasal oxygen, or a 100% non-rebreather mask along with prone positioning. https://www.fda.gov/medical-devices/letters-health-care-providers/ventilatorsupply-mitigation-strategies-letter-health-care-providers https://www.nytimes.com/2020/04/14/nyregion/new-york-coronavirus.html

Mechanical ventilation may be required for ARDS with severe respiratory failure in patients suffering from COVID-19. Peak pressure should be limited at 35 cm H20.

Bi-Level pressure controlled inverse ratio ventilation is known to provide better oxygenation in severe ARDS compared to conventional SIMV with PEEP, and prone positioning may be helpful in difficult cases. Interestingly the pathophysiology of COVID-19 related ARDS is different from conventional ARDS, the former with relatively preserved lung compliance. 9% of patients with severe COVID-19 illness with bilateral pneumonia and acute respiratory failure requiring intubation and mechanical ventilation developed pneumothorax. The mortality rate for non-COVID ARDS is in the 40-50% range, but much worse in COVID-related ARDS where it is 85% (blue) without barotrauma, and 100% with barotrauma (red).

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With these grim mechanical ventilation statistics in mind I believe it is wise to treat all COVID-19 patients with shortness of breath, hypoxemia or bilateral pneumonia, whether outpatient in the emergency room or hospitalized, with an anti-viral agent, prior to the onset of acute respiratory failure. https://pubs.rsna.org/doi/10.1148/radiol.2020202352

An echocardiographic study has observed that right ventricular dilation was prevalent in hospitalized patients with COVID-19. The mechanism of right ventricular dilation is likely multifactorial and includes thrombotic events, hypoxemic vasoconstriction, cytokine milieu, and direct viral damage. Right ventricular dilation was strongly associated with in-hospital mortality in these patients. https://www.medpagetoday.com/infectiousdisease/covid19/86555 https://imaging.onlinejacc.org/content/early/2020/05/13/j.jcmg.2020.05.010

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People with type A blood are more likely to acquire COVID-19 illness, and are more likely to develop severe disease and respiratory failure, compared to those with type O. https://www.medrxiv.org/content/10.1101/2020.05.31.20114991v1 https://www.medrxiv.org/content/10.1101/2020.03.11.20031096v2

There is emerging evidence that the MMR vaccine, normally given to children, can reduce the incidence of COVID-19 illness in adults over 50, or if acquired reduce the severity of illness. If over 50 a discussion with your personal physician might be warranted. https://www.immunizationinfo.com/mmr-vaccine-may-protect-against-covid-19/ https://medicalxpress.com/news/2020-06-mmr-vaccine-worst-symptoms-covid.html https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm

An unusual syndrome similar to Kawasaki disease has been reported in COVID-19 positive pediatric patients in Europe, New York and New Orleans. Treatment with Intravenous Immunoglobulin (IVIG) and aspirin is usually successful. This unusual condition may be complicated by toxic shock syndrome requiring fluid resuscitation, antibiotics and mechanical ventilation. https://emergency.cdc.gov/han/2020/han00432.asp https://www.reuters.com/article/us-health-coronavirus-britain-children/uk-sayssome-children-have-died-from-syndrome-linked-to-covid-19-idUSKCN22A0XW https://www.nytimes.com/2020/05/05/nyregion/kawasaki-diseasecoronavirus.html

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As of 6/25/20 the CDC estimated that 20 million Americans have acquired COVID19. Considering 122,000 deaths as of that date, an overall case fatality rate of 0.6% is derived, which is 6x higher than the 0.1% case fatality rate for influenza. Of course, the fatality rate is significantly higher for the elderly and those with underlying serious medical illness, and significantly lower for the young and healthy.

These recommendations and considerations are subject to change depending on results of further scientific research, the results of ongoing controlled clinical trials, or State / Federal health recommendations.

Ronald R. Cherry, MD, FCCP

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