Chandra's corner - July 2020

Dr PH Chandrasekar

Coronavirus infection is subsiding in some US cities including Detroit, largely due to social distancing, while in other US cities and in several densely populated Indian cities, the incidence is climbing. Unfortunately, and as always, the poor and the destitute are disproportionately targeted, laying bare the disparities in social determinants of health around the world.

Here we are picking up the fallen pieces after COVID. Normalcy is trying to return in fits and starts. A little late, protective equipment is no longer in short supply – walking along the hospital hallways, I see only pairs of eyes everywhere, making me realize how important is the entire face for recognition of the individual. Frequently, I have no idea who is passing me by, whether to smile or not. Then it dawns on me, smiling or frowning makes no difference as the lower half of my face is not visible anyway. With all the barbershops still in quarantine, most men I pass by have unkempt overgrown hair and with the colorful masks, many appear menacing. So to avoid anyone’s wrath, I just show a hand wave at every pair of eyes I pass by.

Speaking of menace and wrath, can you guess which object was much sought after in the U.S. during the pandemic in March with so much human suffering all around us? Not the masks or any PPE, not any medicines or food supplies but guns and bullets. Sales of guns in the US went up by $2M during March alone, clearly reflecting the deep faith we have in one another and in our communities.

Our medical residents had a warm virtual graduation ceremony recently. A lot of awards were presented. Best Teacher of the Year Award went to 87-year-old Dr. Carter Bishop, a hematologist, a favorite of all residents at my University, for over half a century. He has received this award previously over 10 times. Besides his legendary teaching skills, why was he the residents’ choice this time? I was told by several residents that he volunteered to do rounds on the COVID wards during last March and April, so that residents with their young families may stay at home, away from harm’s way. Carter insisted he would do daily rounds, serving as a resident. Precious messages come to us from all directions every day.

Complications of COVID are well known inundating the medical and lay press. There are at least 8 reports (see comment: Lancet Microbe, May 2020) now documenting invasive pulmonary aspergillosis in COVID infected patients, mostly in the intensive care unit, with or without steroid exposure. Our patient had Aspergillus niger as the pathogen; her serum galactomannan was over 5 with declining values as her condition improved with azole therapy. Mold active azole saved her life. Some reports caution that serum galactomannan may not be reliable: thus in appropriate patients in whom respiratory cultures are positive for aspergillus, the organism should not be dismissed as a colonizer/contaminant and antifungal therapy is reasonable. Risks for invasive aspergillosis may include lymphopenia, steroid exposure, or treatment with anti TNF/other immunomodulatory drugs or none at all. We do know that influenza viral infection predisposes to invasive pulmonary aspergillosis. So, please warn your ICU colleagues to do tests for invasive molds (serum galactomannan, serum Beta-D-glucan and fungal stains and cultures in respiratory specimens) in COVID-infected ICU patients who continue to struggle with respiratory difficulties. In such cases, aspergillosis must be thought of, even in those without classic risk factors.

Double lung transplant in a COVID infected, otherwise healthy woman in her 20s was performed for the first time in the US, in a Chicago hospital recently. Ankit Bharat, M.D. who led the surgical team is quoted - “this was truly one of the most challenging cases. The lungs had been so severely damaged; with antibiotics failing to control secondary bacterial infections, the lungs were plastered onto the chest wall and diaphragm”. Surgery must have required tremendous patience and skill, am sure. Interestingly, the patient remains coronavirus test negative despite the immunosuppressive regimen. Transplant may be an option for ventilated, COVID infected young patients with end stage lung disease. Incidentally, Dr. Bharat is a CMC alumnus from just a few decades ago.

COVID is a new disease; the barrage of information is astounding. Information overload with unstoppable velocity is overwhelming and drowning us. I would like to share with you a quote, a prayer from Sir Robert Hutchinson (1871- 1960), published in British Medical Journal (1:671, 1953), almost 70 years ago. Hutchinson was a Scottish pediatrician, and all of you should know him as the author of Clinical Methods, a very popular, highly recommended textbook of physical diagnosis for medical students. Here goes the poem: “From inability to let well alone, from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, good Lord, deliver us.” For the majority of cases, please remember, COVID- 19 is self-limiting, hence do no harm. Drugs claiming efficacy in mild-moderate cases may have absolutely no role except to fill someone’s coffers, and perhaps inflict pain and discomfort.