A message from the Clinic: Putting the pieces together

May 4, 2020
By Marcy Shortuse

BY TOM ERVIN, MD – My family enjoys puzzles; hard puzzles. The pandemic caused by COVID-19 has given a new meaning to the term “jigsaw.”

Two to three months ago, all of us were faced with a puzzle. COVID-19 was all around us, but what was it?  Pieces of all shapes and sizes were being exposed.  But was there a pattern?  What colors were alike? How many pieces were there and how do they fit together?  Were all the pieces present?  Where to start?

When faced with a challenge or a new phenomenon such as COVID-19, we naturally try to understand it in terms we are already familiar with. COVID-19 is horrible. We react by associating it with sudden catastrophes such as war, plague, or some form of celestial disaster. That form of quick thinking may give us some relief. We think we are getting a grip on what we are experiencing.

But are we?

Considering COVID-19 more slowly (thank you Pat Wallace and Daniel Kahneman), we should ask what else should we piece together to understand and assimilate what we are feeling and experiencing. Is there more to the story?  There usually is.

Viruses have produced human illness for centuries. These bundles of DNA, or in this case, RNA, have also provided new genetic information which has contributed to our evolution as a species. Like genetic information in the human cell, virus RNA can mutate with its evolution. This virus has mutated in a way which has acquired a mechanism by which it can enter and proliferate within the human cell. COVID-19 is a coronavirus (there are many) which can enter the human cell via a cell receptor particularly expressed on lung cells and vascular cells. This package of RNA, protein, and lipid membrane can then replicate causing disease.

Our reaction to the virus’ presence results in lung damage, vascular damage and activation of abnormal coagulation. The virus is then shed into organ secretions allowing for human to human transmission. This process is not different from influenza or rhinovirus but the disease response may be more severe. Normally other coronaviruses cause mild respiratory or intestinal illness. The exact reason for COVID-19’s pathogenesis is still an unidentified piece of the puzzle.

As we speak, more pieces of the puzzle are being identified. Transmission pathways are now documented and can be placed together. Prevention actions via barriers, 70 percent alcohol cleanses or vigorous handwashing are being linked together with effect. Social distancing has allowed for the outline of the puzzle to be viewed. We all know that the puzzle will be easier to solve when the edges are complete. Clues as to the reasons for the tissue damage are allowing physicians to find new therapeutic strategies to help the ill. Those pieces of the puzzle that look the same will become distinct.

This week, a new piece of the puzzle has been identified. Antibody tests, known as serologic tests, have been granted emergency use authorization (EUA) by the FDA. One such test will soon be offered by the BGHC to interested patients and their contacts if appropriate.

Serologic tests can document the presence or absence of specific immune response to COVID 19. Alone, the test cannot be used to diagnose or exclude infection with COVID-19. A positive test is very specific for anti-COVID 19 antibody (specificity), but antibodies may not be identified in all patients infected (sensitivity). A positive result, the presence of anti-COVID-19 antibodies, suggests that the person may have been infected by COVID-19.  A positive result may mean that the person is immune to COVID-19 reinfection. However, we know neither how complete this immunity is, nor how long it may last. A positive result may identify those recovered persons who can donate convalescent plasma to those suffering from severe COVID-19 infection. Nationally, these questions will be answered. Understanding the immune response will help identify the scope of the disease and hasten its control.  This test will be helpful, but the exact place for this piece in the puzzle is not yet clear.

We are dealing with another natural event.  The suddenness and huge scale of COVID-19 makes solving the puzzle even more demanding for us all. Doing the right thing collectively and encouraging our medical and political leaders to do the same will help us buy time to put all the pieces together. COVID-19 is a medical challenge which will be controlled by understanding all of its parts. Vaccines and specific antiviral therapies are critical pieces to put in place. Until then we will all need to solve what we can and do what we can without the few pieces yet unidentified.

Cover up, stay apart, practice wellness and emotional calm when you can.     

Dr Thomas Ervin is a physician at the Boca Grande Health Clinic.