Snapshot A 68-year-old man presents to the emergency department with cough and shortness of breath. The patient reports going to an urgent care approximately 2 weeks ago for abdominal pain. He has a medical history of hypertension, hyperlipidemia, and severe asthma. His temperature is 101°F (38.3°C), blood pressure is 158/95 mmHg, pulse is 100/min, and respirations are 26/min with an oxygen saturation of 85% on 6L nasal cannula. The patient is subsequently intubated, and a CT of the chest demonstrates ground glass opacities, fine reticular opacities, and vascular thickening. A nasal swab is positive for SARS-CoV-2. Introduction Overview a betacoronavirus that is designated as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19) a positive sense single-stranded RNA virus SARS-CoV-2 is in the same subgenus as severe acute respiratory syndrome corona virus (SARS-CoV) enters cells via the angiotensin-converting enzyme 2 receptors, especially on epithelium that line the respiratory tract TMPRSS2 primes spike protein on SARS-CoV-2 for entry the incubation period is thought to be 2-14 days post-exposure illness severity of this infection ranges from mild to critical mild (~81% of cases) no dyspnea severe (~14%) dyspnea respiratory rate ≥ 30/min hypoxia critical (~5%) respiratory failure shock multiorgan dysfunction Epidemiology incidence United States cases worldwide cases risk factors close contact with suspected or confirmed cases of COVID-19 residence or travel to areas with high incidence of COVID-19 Transmission person-to-person transmission thought to mainly occur via respiratory droplets the virus can be released into the air when the infected person coughs or sneezes the virus reaching the host's mucous membrane can result in infection can also be transmitted longer distances via airborne route studies suggest that droplets may get aerosolized and be carried > 6 ft (2 meters) with speaking, coughing, or sneezing fomite transmission touching an infected surface and subsequently touching one's eyes, nose, or mouth can result in infection therefore, disinfectant is recommended fecal-oral transmission the SARS-CoV-2 RNA has been detected in stool, so fecal-oral transmission is possible Prognosis unfavorable factors older age (≥ 65 years of age) more likely to develop severe disease chronic medical conditions diabetes cardiovascular disease hypertension chronic lung disease chronic kidney disease cancer body mass index ≥ 30 kg/m2 immunocompromising conditions transplant patients on immunosuppressant drugs certain laboratory derrangements ↑ D-dimer ↑ ferritin and C-reactive protein ↑ creatine phosphokinase ↑ troponin ↑ lactate dehydrogenase ↑ prothrombin time acute kidney injury severe lymphopenia Presentation Symptoms fever (~99% of cases) fatigue (~70%) dry cough (~60%) myalgias (~35%) dyspnea (~30%) sputum (~27%) anosmia (10-50%) patients may develop gastrointestinal symptoms nausea (~12%) diarrhea (~19%) Imaging Chest CT findings ground-glass opacification (GGO) consolidative abnormalities may or may not be present more likely to affect both lungs, particularly in the lower lobes and in a peripheral distribution Studies Reverse-transcription PCR (RT-PCR) for SARS-CoV-2 procedure collection of a nasopharyngeal swab orophaygneal swab can also be collected (not essential) sputum collection in patients with a productive cough Serum labs WBC count variable (leukopenia, leukocytosis, and lymphopenia) lymphopenia is more common lactate dehydrogenase and ferritin level are commonly elevated IL-6 may be elevated Differential COVID-19 Differential DiagnosisVirusFeverCoughFatigueMyalgiaHeadacheRhinitisSore ThroatCOVID-19↑↑↑↑↑↑↑↑↑↑↑Rare↑↑Influenza↑↑↑↑↑↑↑↑↑↑↑↑↑↑↑↑↑Common coldRare↑↑↑↑↑↑↑↑↑↑↑↑↑ Treatment A registry of clinical trials can be found here lopinavir-ritonavir a combined protease inhibitor remdesivir a novel nucleotide analog that impairs RNA-dependent polymerases IL-6 pathway inhibitors tocilizumab siltuximab sarilumab Medical supportive care and quarantine indications for mild cases patients are quarantined to their homes and symptomatically managed hospitalization with potential oxygen supplementation or mechanical ventilation indications for severe disease, characterized by hypoxia (O2 saturation ≤ 94% on room air), an oxygen requirement, or ventilatory support hospitalized patients with severe disease but not yet on oxygen supplementation remdesivir only hospitalized patients with severe disease who are receiving supplemental oxygen (including high-flow oxygen and non-invasive ventilation) low-dose dexamethasone AND remdesivir hospitalized patients with severe disease who require mechanical ventilation low-dose dexamethasone only Prevention Hygiene and isolation should be in accordance with state and local health department recommendations and regulations Hand hygiene should be washed with water and soap or virucidal hand disinfectant avoid face touching Respiratory hygiene maintain 6 feet of distance from others masks (N95 respirators) and face shields or goggles for health care personnel or persons taking care of infected individuals in a health care facility or home Face coverings the CDC and WHO recommend wearing masks when in public spaces and when in the presence of individuals outside of one's household Social and physical distancing Avoidance of crowds and non-essential travel Screening for infection in high-risk settings (e.g. nursing facilities, college campuses, hospital employees) testing-based screening is advantageous compared to symptom-based screening in that it allows identification of asymptomatic infections Vaccines primary antigenic target: surface spike protein multiple vaccine candidates have shown efficacy without major adverse effects in early-phase human clinical trials two mRNA vaccines have over 95% vaccine efficacy in preventing symptomatic COVID-19 BNT162b2 (Pfizer-BioNTech) COVID-19 mRNA vaccine two intramuscular injections administered 3 weeks apart mRNA-1273 (Moderna) COVID-19 mRNA vaccine two intramuscular injections administered 4 weeks apart Complications Acute respiratory distress syndrome has been associated with older age (≥ 65 years of age) diabetes mellitus hypertension Pneumonia Septic shock Cardiac arrhythmia Cardiac injury Sources Note, this page is not meant to diagnose or treat patients but more as an evolving source of information For more information, please see the following sources Center for Disease Control National Institutes of Health World Health Organization