Modern medicine rightly emphasizes the importance of science. However, this focus tends to divert our attention away from the true meaning of health care and towards nursing. This is captured well by the admonition of William Oursler (1849-1919) to "focus on the sick rather than their disease, a sentiment dismissed by careless practitioners as a quaint platitude."
Rediscovering how important the truth of his advice was stemmed from two specific patients who taught physicians about COVID-19 infection and challenged the expertise they thought they had in treating pneumonia.
The first COVID-19 patient admitted to our hospital was probably typical of the first patients admitted to many other hospitals at that time. He is an elderly man with pneumonia and has not yet been tested for the novel coronavirus but is presumed to be infected. He was carefully assessed by a team of experts, prescribed high-flow oxygen, and monitored in the respiratory ward, but he died unexpectedly that night.
The second patient was a middle-aged woman who was transferred to the intensive care unit for mechanical ventilation. She needed to be evaluated as the recent death was making me nervous. On the way to the ward, I pictured in my mind a patient gasping for breath, barely able to speak, chest heaving as she tried to pump oxygen into her bloodstream...
And as we put on full PPE and prepared to sedate her for immediate ventilation, we thought we were in the wrong bed. She was sitting comfortably in her chair, calling her daughter, confused by the look on my face. She might be thinking, are we being too cautious? We measured her oxygen saturation just in case, more out of instinct than concern. Judging from her appearance, I expected it to be close to normal (100%) or 75% (infected), and unfortunately, she was gone.
Doctors soon learned that many patients with late-stage COVID-19 did not show any signs of severe respiratory illness before suddenly collapsing and dying! The science behind this early lesson is now emerging and being taken seriously. Asymptomatic carriage is not uncommon in other virulent infections such as MRSA and C diff, but what is striking about SARS-CoV-2, the virus that causes COVID-19, is that it can be accompanied by potential organ damage.
The researchers found lesions (in medical terms, ground-glass opacity and consolidation) consistent with inflammation of the underlying lung tissue. This is not unique to SARS-CoV-2 infection and may occur in many other forms of lung disease. What remains a mystery is why, despite these changes, the patients did not show classic pneumonia symptoms, such as severe shortness of breath.
About a quarter of the patients in the study developed fever, cough and shortness of breath, but many did not. Idiosyncratic responses to infection are one of several puzzles about COVID-19, such as why it targets certain groups and not others, and two people with exactly the same demographics and health status can express the disease at opposite ends of the spectrum. This study highlights that the absence of symptoms does not mean the absence of harm.
The lack of symptoms in the face of active pathology poses risks to both the infected person and the public. Current advice is to encourage patients to stay at home if they are asymptomatic, making late arrival to hospital and sudden death a clear risk.
As many as 40-45% of people infected with SARS-CoV-2 remain asymptomatic and have viral loads as high as those with active disease. Combined with a significant false-negative rate of up to 20% on screening tests, the scale of the problem is amplified when people are incorrectly told they are not infected. These people are covert spreaders who can continue to spread the virus for up to 14 days, which raises obvious questions about the effectiveness of testing strategies or the use of screening measures such as temperature checks.
Pieces of evidence are slowly being pieced together, mostly from many small, disparate studies. As the quality and quantity of evidence expands, our understanding of SARS-CoV-2 will improve. Yet science still can't tell doctors how best to manage the patients in front of them.
Lesions on CT scans do not determine what treatment is needed. It still requires an individualized decision based on clinical judgment. So even as scientific understanding continues to grow, we should apply Oursler's advice with renewed faith: When treating patients, keep all five senses alert, and they will teach you what you need to know.
Asymptomatic COVID-19 infection may still cause lung damage
Research has found that one year after infection, viral damage occurs in children and lungs, leading to T cell infiltration, scarring mechanisms of lung injury. Even a mild COVID-19 infection can damage your lungs.
Based on the observation that many COVID-19 survivors later show signs of chronic lung disease, University of Iowa researchers led a study of 100 adults who continued to have COVID-19 symptoms, or post-acute sequelae of COVID-19 (PASC), more than 30 days after diagnosis.
The researchers analyzed symptoms, lung function tests and CT chest images and used machine learning to perform quantitative CT analysis. Among participants, the median age was 48 years and 66% were female.
Among patients with PASC, 67% are outpatients, 17% are inpatients, and 16% are intensive care unit (ICU) patients. The average proportions of ground-glass opacity (GGO) (fuzzy gray areas in the lungs on CT) in the total lungs of the inpatient group and ICU group were 13.2% and 28.7% respectively, which were higher than those of the outpatient group (3.7%).
The average percentage of the whole lung affected by air trapping (abnormal retention of air) was 25.4%, 34.6% and 27.3% in the outpatient, inpatient and ICU groups respectively, compared with 7.2% in the control group. Air trapping is related to the ratio of residual lung volume to total vital capacity. Quantitative analysis of expiratory chest CT images shows evidence of small airway disease.
"In survivors of COVID-19, small airway disease develops independently of the severity of the initial infection," the study authors wrote. "Long-term consequences are unknown."
"The development of small airway disease in the distal (external) airways is unknown," said Comellas, MD, a senior physician at the University of Iowa. "If a subset of patients continue to have small airway disease, then we need to consider the mechanisms behind that," he said. "It could be about reversible inflammation, it could be about irreversible scarring, and then we need to look at ways to prevent the disease from getting worse."
Repeated COVID-19 infections increase the risk of organ failure, death
Since the COVID-19 pandemic began nearly three years ago, scientists have learned that an initial infection can lead to short- and long-term health risks, affecting nearly every organ system in the body. They also determined that people may become infected with COVID-19 a second or third time despite acquiring natural antibodies to and receiving vaccine and a booster vaccine after the first infection.
Now, a new study from Washington University School of Medicine in St. Louis and the St. Louis Veterans Affairs Healthcare System shows the health consequences of reinfection. Researchers found that repeated SARS-CoV-2 infections are associated with significant additional risks of adverse health outcomes across multiple organ systems, including hospitalization; illnesses affecting the lungs, heart, brain, blood, musculoskeletal and gastrointestinal systems; and even death. Reinfection can also lead to diabetes, kidney disease and mental health problems.
The findings were published in the November 10 issue of the journal Nature Medicine.
Limiting exposure to the virus is especially important as the United States enters winter, as new variants are emerging and have led to rising infections in some parts of the country. People should do their best to prevent reinfection by taking precautions, such as staying home when sick. Additionally, get a flu shot to prevent illness. We really need to do our best to reduce the possibility of a double pandemic of COVID-19 and influenza this winter.
In the study, researchers analyzed approximately 5.8 million deidentified medical records in a database maintained by the U.S. Department of Veterans Affairs , the largest integrated health care system in the United States. Patients are of various ages, races and genders.
The researchers also created a controlled dataset that included 5.3 million people who had not tested positive for COVID-19 infection between March 1, 2020, and April 6, 2022. Over the same time frame, the researchers also compiled a control group of more than 443,000 people who tested positive for one COVID-19 infection, and another group of nearly 41,000 people who had two or more infections recorded, with a few even infected four times.
The study also considered COVID-19 variants such as delta, omicron and BA.5. Negative results were seen between unvaccinated people and people who had been vaccinated before being reinfected.
Overall, researchers found that people who were reinfected with COVID-19 were twice as likely to die and three times more likely to be hospitalized compared with people who were not reinfected. In addition, compared with patients who had only been infected with the virus once, people with repeated infections were 3.5 times more likely to develop lung disease, three times more likely to develop heart disease, and 1.6 times more likely to develop brain disease.
The researchers concluded: "Our findings have broad public health implications because it tells us that strategies to prevent or reduce the risk of reinfection should be implemented. "Going into winter, people should be aware of the risks and remain vigilant to reduce the risk of infection or reinfection with SARS-CoV-2."
How even mild COVID-19 infection can damage your lungs
Asymptomatic COVID-19 infections can still cause lung damage
Repeat COVID-19 infections increase risk of organ failure, death
COVID of any severity may lead to long-term small airways disease
