COVID-19 August Notes

Fat Anon’s August 2020 COVID-19 File

Fat Anon, here. I’m compiling a cheat sheet and a little report on the virus based on the latest information we have.

Zotero Library:

https://www.zotero.org/groups/2486852/covid19reviewgroup001/library

COVID-19 Transmission Notes:

-Concentrated in nasal and oral mucosa; readily aerosolized by talking, speaking, singing, shouting.
-Coughing and sneezing can spray droplets. Mask helps trap these and prevent them from traveling far.
-Aerosols can travel 15+ feet. 6-foot guideline inadequate.
-Can readily enter the body by landing in the eyes.
-Can enter the brain through the olfactory nerve.
-Potential oral-fecal transmission. May infect gastric lining if swallowed.
-Surfaces may harbor the virus for about 2 to 3 hours (tests indicating surface survival longer than this are synthetic and involve huge amounts of live virus, well beyond the amount expelled by a person).
-Fomite-to-face transmission possible, but not likely to be the main form of transmission.

COVID-19 PPE:

Nitrile Gloves – Can prevent hands from becoming contaminated, but must be donned, doffed and disposed of correctly to prevent cross-contamination.

Ear-Loop Surgical Mask – Not a respirator! Does not prevent you from inhaling aerosolized virus. Traps virus in front of your face. Your mask protects others. Single-use. Dispose after using. Do not touch the outside. Do not put it on a table next to your food. Do not wear as a chinstrap or with your nose exposed.

Cloth Mask – Better than nothing. Needs to be laundered frequently.

Goggles – May provide extra protection for the eyes. Should fit flush against the face, like swimming goggles. Must be sanitized regularly and decontaminated before removal.

N95 – Filters moderately well, but may allow some 120nm SARS-COV-2 virions through. Healthcare workers wearing these have gotten sick because they’ve been exposed to large quantities of the virus. Any kind of mask will reduce the initial dose of virus you receive and improve your outcome if you do get sick, however. Difficult to properly decontaminate. Should be considered disposable and single-use, but often in too short of supply for that.

P100 – Better than N95. Filters very well. Rubber seal must fit against face. Must be clean-shaven and fitted properly. Must be sanitized regularly and decontaminated before removal.

40mm NATO CBRN – Better than P100. Filters practically everything. Must be sanitized regularly and decontaminated before removal.

PAPR Hood/Maxair CAPR – What every single healthcare worker in contact with a COVID-19 patient should be using. Unfortunately expensive and in short supply.

COVID-19 ER Symptoms/Labs:

-Fever
-Dry, unproductive cough
-Hemoptysis
-Shortness of breath
-Body aches
-Abdominal pain
-Loss of sense of smell and/or taste
-Low blood O2 sat (<90%)
-Hypokalemia
-Abnormal AST/ALT
-High C-reactive Protein
-Elevated troponin
-Elevated D-dimer
-Elevated ferritin
-Lymphopenia
-Thrombocytopenia
-Albuminuria
-Hematuria

ER Presentation is highly variable. May initially manifest as neurological illness, respiratory disease, abdominal pain, rash, conjunctivitis, etc., depending on where the virus enters the body and incubates.

COVID-19 Pathophysiology:

-Bilateral Viral Pneumonia
-Cytokine Release Syndrome
-Pulmonary Edema
-Pulmonary Fibrosis
-Pulmonary Embolism
-ARDS
-Vascular Endotheliitis
-Viremia
-Systemic Capillary Leak Syndrome (rare)
-Antiphospholipid Syndrome
-Coagulopathy
-Shock
-Kawasaki Disease (in pediatric cases, especially)
-Acro-ischemia/Purpura (in toes)
-Dyslipidemia
-Urea Cycle Disorder
-Ammonemia (features in some cases with liver involvement)
-Hyperferritinemia
-Mild Hepatitis
-Hypokalemia (from hyperaldosteronism)
-Encephalitis/Meningitis
-Mental Issues/Impaired Consciousness
-Skeletal Muscle Injury
-Cerebrovascular Disease
-Guillain-Barre Syndrome
-Dysautonomia
-Anosmia
-Dysgeusia
-Seizure
-Stroke
-Myocarditis
-Pericarditis
-Heart Attack
-Arrhythmia
-Acute Kidney Injury
-Gastrointestinal Inflammation
-Diarrhea
-Nausea/Vomiting
-Abdominal Pain
-Testicular Inflammation
-Conjunctivitis
-Rash
-Transient Livedo Reticularis
-Bacterial Co-infections

COVID-19 Mechanisms of Action:

-RAAS dysregulation (ACE2 Down-regulation and increased Ang II activity)
-Electrolyte dysregulation
-Nitric oxide depletion
-Lipid metabolism dysregulation
-Iron metabolism dysregulation
-Interferon reduction
-Lymphocyte death
-Promotion of hyper-inflammation (cytokine storm)
-Promotion of oxidative stress
-Promotion of fibrosis
-Promotion of hypercoagulation
-Promotion of hypoxemia and subsequent hypoxemic insult to organs
-Formation of multinucleated giant cells through cell-to-cell fusion

The typical conception of COVID-19 as a “form of pneumonia” is not even a half-truth. It is a tiny portion of the actual pathology of the virus. COVID-19 is primarily a vascular disease and spreads through the body to all the major organs through the bloodstream. It kills immune cells, causes metabolic disruption, and strangles organs with a cocktail of inflammation, free radicals, scarring, blood clots, and hypoxemia, eventually leading to multiple organ failure, diffuse intravascular coagulation, and death. It also happens to cause pneumonia and ARDS. The pathology is a dead ringer for SARS and shares many of the same attributes. SARS also triggers hyper-inflammation, vasculitis, pneumonia, cytokine storms, kidney injury, and brain damage in exactly the same fashion as COVID-19.

One of the primary sites of infection in the body is the endothelial lining of blood vessels. COVID-19 causes endotheliitis, opening up gaps in the endothelium and triggering clotting, increasing vascular permeability and allowing capillaries to leak into the alveoli. It also messes with lipid metabolism and pulmonary surfactant. Oxygen has a very hard time diffusing into the bloodstream of someone with COVID-19.

COVID-19 Dietary Prevention:

-Vitamin C
-Vitamin D
-Zinc
-Arginine
-Citrulline
-N-Acetylcysteine
-NAD+
-Lactoferrin
-Dietary Nitrate

Proper diet and exercise are essential to beating COVID-19 if someone gets it. If someone has high blood pressure, diabetes, obesity, etc., those all worsen the severity of the virus. Another thing that increases the severity of COVID-19 is chronic malnutrition. Many Americans are chronically malnourished without realizing it, because we eat empty carbs and macros without enough micros. Cut the sugar, snack crackers, and other useless things out of your diet. Eat your fish and vegetables.

That’s another thing. The lockdowns prompt people to eat packaged foods high in unneeded salt and hide from sunlight while being sedentary. All of these things make you into Corona-chan’s lunch. You need sunlight, you need a proper diet, and you need exercise.

The typical highest-risk group of COVID-19 patients look like someone who is elderly, African-American, has Blood Type A, and has pre-existing conditions involving the cardiovascular system, especially hypertension, diabetes, or obesity. Having pre-existing hypertension may increase the number of ACE2 receptors in the body, giving the virus more sites to infect and increasing its replication.

African-Americans have genetic metabolic differences that make them more susceptible to COVID-19. The main issues are the deficiency in arginine, the lack of endothelial nitric oxide synthesis, and the over-production of cytotoxic peroxynitrite. This provides some clues as to how COVID-19 does so much damage. The Nicotinamide Adenine Dinucleotide-Nitric Oxide Synthase axis, and its disruption in COVID-19, is a central feature of the pathology. NADPH oxidase forms superoxide, superoxide forms peroxynitrite with nitric oxide, nitric oxide is depleted, and so forth. Angiotensin II stimulates a lot of NADPH oxidase activity.

COVID-19 Pharmaceuticals:

Hydroxychloroquine – May be effective if given early or prophylactically, in combination with zinc. Not effective if given to patients who are already in the severe inflammatory phase of the virus.

Remdesivir – Only modest effectiveness. May cause kidney failure.

Interferon – Very effective, especially if inhaled in nebulizer form.

Kaletra – Effective, but hard on the organs.

Ivermectin – May be quite effective, but needs further investigation.

Camostat – Needs further study and trial results.

Methylprednisolone – Reduces inflammation. May have long-term side effects like osteonecrosis if given in high doses.

Dexamethasone – Very effective at reducing inflammation.

Budesonide – Anecdotal effectiveness at reducing inflammation. Needs more research.

Famotidine – May help suppress inflammation in mast cells.

Tocilizumab – Blocks IL-6 activity.

Meplazumab – Blocks CD147 receptor activity.

Sartans – There is a worry that they may promote ACE2 activity and lead to severe hypotension, but blockading AT1 receptors may cut down inflammation. Could be useful, especially in patients with pre-existing hypertension.

Azithromycin – May help with the bacterial co-infections.

Inhaled Nitric Oxide – May have antiviral effects and improve patient respiration.

Hyperbaric Oxygen Therapy – Promotes nitric oxide formation in the body. Could be highly beneficial.

COVID-19 Unanswered Questions:

If excess peroxynitrite forms, does it break down tetrahydrobiopterin? Does COVID-19 cause phenylketonuria? Can sapropterin help? Typically, PKU is suspected if patients have a musty ketone smell or if it’s caught in a lab screening. However, doctors aren’t looking for it in patients’ labs, doctors aren’t actively smelling patients (they’re wearing masks that block some of the odor, if present), and, in any case, the virus itself causes anosmia, so if a healthcare worker gets sick, they may not be able to smell anything at all.

Does the interruption of nitric oxide signaling functions in the body lead to iron metabolism disruption? Iron Regulatory Factor depends on nitric oxide to function correctly. There is a scholarly work entitled Progress in Iron Research that details the interactions between NO signaling and iron metabolism. Excess free iron in the body can be very damaging.