How chloroquine will act as a prophylactic drug and is acting as a therapeutic agent against COVID-19 infection

*How chloroquine will act as a prophylactic drug and is acting as a therapeutic agent against COVID-19 infection.*

Chloroquine acts on host target respiratory cells by:
Chloroquine increases the endosomal pH required for the virus- host target cell fusion. Increase in the pH disrupts the normal viral function.
In SARS-coronavirus, which is a sister to COVID-19, chloroquine was found to interfere with the glycosylation of cellular receptors of the virus. This interference eventually resulted in no association between the host target cell and the virus.
Chloroquine acts as an ionophoric agent for Zinc ions and thus increases the in flux of zinc ions into the cytoplasm of host target cells regardless whether the host target cells are infected or not.

All the above-mentionedgas mechanism is on the host cells and COVID-19 can not mutate and cause resistance to these 3 mechanisms. First 2 mechanisms inhibit the virus-target host cell union. Chloroquine results in disablement of ACE2 (Angiotensin converting enzyme 2) terminal glycosylation which leads to the morphological change; ACE-2 is a surface receptor found on target host cell. This results in the disruption in the association between the COVID-19 and target host cell as COVID-19 requires ACE-2 receptor to attach to a cell.     
Because the action is on the target host cell, Chloroquine won’t develop resistance therapeutically. If a person uses Chloroquine as a prophylactic agent (500mg once in a week for adults and 8.3 mg per kg once in a week for children) against COVID-19 then, it will act pre-infection and post-infection. If a person does not get exposed to the COVID-19 infection after taking Chloroquine (say for 3 weeks) and then some viruses enters and try to infect target host cells, Chloroquine mechanism “a” and mechanism “b” will prevent the union of virus-target host cell. If some of the viruses enters the target host cell, there Zinc ions are waiting to adhere to the RNA dependent RNA polymerase enzyme of the virus and stops COVID-19 polymerization intracellularly. If COVID-19 mutates inside the cell several times, even then the Zinc ions will actively inhibit the viral multiplication inside the host respiratory cells, irrespective of the viral strain. Even if COVID-19 virus manages to escape from Zinc ions trap and releases from the host target cell cytoplasm into the interstitial matrix, intercellular space, and tried to re-infect some of the healthy target host cells, Chloroquine will prevent the re-union of viral genome with target host cells via mechanism ‘a’ and mechanism ‘b’ and the infection will halt in the preliminary stages itself and complications like COVID-19 pneumonia will not develop. Chloroquine molecules will not lose its effectivity in an individual pre and post infection.
Zinc is present in ample amount in the human body. In normal conditions, the Zinc is not present in free state in the cell. The increased level of Zinc ions is not toxic to the cells and cells excrete the extra Zinc ions into the extracellular space. Zinc is commonly present in red meat, legumes, nuts, milk, cheese, eggs, whole grains etc. Garlic increases the absorption and bioavailability of Zinc inside the body. So, some persons who aren’t taking Zinc rich foods in ample amount should eat zinc supplements or garlic daily. 

Safety of Chloroquine is well tested as it is given for
Malaria prophylaxis
Autoimmune diseases like rheumatoid arthritis
Lupus erythematosus
Now a days it is indicated into the SARS infection as it is a broad antiviral agent.
Through it ionophoric action for its zinc intracellular influx, chloroquine is also used as anti-cancerous drug.

The long-term use of chloroquine (4 years together) may cause its accumulation in the eye. There are some concerns of its use in glucose-6-phosphate dehydrogenase enzyme deficient children but the recommended prophylactic and therapeutic doses, Chloroquine is safe to be used in these children. Some persons may complain of acidity and nausea, but it can be resolved if Chloroquine is taken post meal.





Prophylactic dose in malaria is 500 mg once a week in adults and 8.3 mg per kg once a week in children.
In these doses it will be effective against COVID-19 prophylaxis. The therapeutic doses against COVID-19 as used in China, America and India are Chloroquine 500mg BD for 5 days with other anti-viral drugs like Oseltamivir, Lopinavir, Ritonavir etc. and in complicated COVID-19 pneumonia cases, Chloroquine may be used for 10 or more days in the same amount.

Now comes the actual catch of its technicality to be used prophylactically against COVID-19 action. In India as it is a very cheap, safe and easily available drug and can be prescribed against the Malaria as a prophylactic drug as the summer season approaches. It will surely work prophylactically against the COVID-19 outbreak and we can use this opportunity to prescribe it in larger amount as Malaria is endemic in India. It will act on Malaria and COVID-19 infection prophylactically without it being included in the guidelines.
Trump’s excitement for chloroquine in his announcement can be related with the fact that American researchers are currently working on the Chloroquine drug. Many companies have donated chloroquine to the US for research purpose.
Hydroxychloroquine is less toxic but original Chinese work is based on chloroquine phosphate. Hydroxychloroquine can be used with equal efficacy.
If one starts prophylactically with Chloroquine, then one must stick with chloroquine and must not switch to hydroxychloroquine and vice-versa. This switch may result in increase QT interval.

*REFERENCES*
Zhu N, Zhang D, Wang W et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020
Gao, J., Tian, Z. and Yang, X., 2020. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. BioScience Trends.
Vincent, M., Bergeron, E., Benjannet, S., Erickson, B., Rollin, P., Ksiazek, T., Seidah, N. and Nichol, S., 2005. Virology Journal, 2(1), p.69.
https://youtu.be/U7F1cnWup9M






SARS-CoV-2 RNA more readily detected in induced sputum than in throat swabs of convalescent COVID-19 patients - The Lancet Infectious Diseases
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30174-2/fulltext

‏LABORATORY MARKERS IN COVID-19

‏LABORATORY MARKERS IN COVID-19 PATIENTS :microscope::syringe:
‏MOST FREQUENT
‏Decrease lymphocyte count
‏Decrease albumin
‏Decrease hemoglobin levels
‏Increase C-reactive protein (CRP)
‏Increase Erythrocyte Sedimentation Rate (ESR)
‏Increase Lactate Dehydrogenase (LDH)
‏Increase D-dimer

- Deaths from Covid-19 are due to (1) cytokine storm syndrome and (2) fulminant myocarditis.

- During a cytokine storm, an excessive immune response ravages healthy lung tissue, leading to acute respiratory distress and multi-organ failure.

- All Covid-19 patients sick enough for hospitalization should be given a serum ferritin blood test.

- Elevated serum ferritin values are a good first screening tool for the possibility of a cytokine storm syndrome in sick patients with high fevers.

- Treating Covid-19 infected patients with cytokine storm syndrome with IL-6 blockade (tocilizumab) has recently been reported in China with successful outcomes.

- Fulminant myocarditis :heart: has also been reported in patients with Covid-19

- Fulminant myocarditis is primarily caused by infection with viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock, with mortality rates as high as 50%–70%.

- Physicians should pay attention not only to the symptoms of respiratory dysfunction but also the symptoms of cardiac injury.

_\\\\______
‏Source: Lippi G, Plebiani M. Laboratory
abnormalities in patient with COVID-19 infection. Clin Chem Lab Med. 2020 Mar 3. doi: 10.1515/cclm-2020-0198 Covid-19 🦠 Update:*

Current criteria to swab for COVID-19

Current criteria to swab for COVID-19 in the UK:

Clinical : Pneumonia clinical or radiological, ARDS, Flu like illness (fever, cough whether productive or non productive, sore throat, runny nose, myalgia. Less people present initially with diarrhea 10% and they had the worst prognosis later from the Wuhan experience)
Or Epidemiological : last 14 days in tier 1 or tier 2 countries. Or contact with confirmed case of COVID-19.

-Incubation period 4 - 14 days. People are infective mostly in the first 5 days when the symptoms are milder. Deterioration happens after day 10 of the symptoms (when the body enter into the adaptive immunity stage)

-PCR for COVID19 sensitive for 70% only, may be initially negative, a repeat PCR in high suspected cases recommended in 48 -72 hours.

-CT Thorax is sensitive for 97% of cases and could help in diagnosis of patient with initial negative PCR (positive CT Thorax for COVID-19 is patchy ground-glass appearance in the lung peripheries, it does not cause cavitation or lymphadenopathy)

- Old age >70, High SOFA score, and d-dimers >1000 are risk factors for poor prognosis.
Pediatrics guidelines if needed please contact me freely and i will provide you details with evidence.

-Lymphopenia with normal WBC count is common in 80%, mild thrombocytopenia , high CRP and ferritin tract with disease severity.

-High tropronin found in half of the dead patients (perhaps as IHD was a common risk factor, likely it is troponin leakage form sepsis /strain? some reported cases for severe myocarditis). Considered as a marker for poor prognosis.

-Give empirical antibiotics in the golden hour as per the normal sepsis protocol . Blood cultures./Procalcitonin. Review ABX in 48 hours.
-NO IV Fluids, unless there is an evidence of hypo-perfusion.
-No role of steroids as it delays viral clearance, unless the patient has obstructive airway disease or Septic shock not fluid or vasopressor responsive

-Controversial role of Hydroxychloroquine: it interfers with cellular ACE receptors in the lung, hence has some anti-viral activities.

-Some Antiviral therapies like Remdesivir, combination of Lopinavir/Ritonavir/Ribavirin is of benefit in MERS, no evidence of use it in COVID-19, Clinical trials are taking place currently. If the patient deteriorated, consider them after discussion with the local ID team. No role of using Oseltamavir in COVID-19 unless influenza is considered when you admit the patient.

- Cytokines storm inhibitors in COVID-19: as the disease cause a cytokines storm (elevated inflammatory markers like CRP, ESR, ferritin), selective inhibition of cytokines Tocilizumab showed some benefit in phase 3 RCT in China. The drug was eventually licensed in China for severe COVID-19 infection.

- COVID-19 may cause secondary HLH?

-Severe respiratory failure/?ARDS: ITU for early Intubation and ventilation with low TV and allow for permissive hypercapenia, prone, paralysis, APRV, ECMO.
(HFNO and NIV is not recommended)

-Cardiac arrest in COVID-19:
Identify resuscitation status for any ?COVID-19 hospital admission.
Recognize cardiac arrest by absence signs of life and absent carotid pulse. Do not do listen and feel for breathing.
Wear full PPE (FFP3, Visor, Gloves, plastic apron) then start CPR. The likely cause is a hypoxic arrest. However, the recommendation from resuscitation council UK is to start with CRP. Early ventilation is advised.

Evaluation of Pseudocoma VS Coma

Evaluation of Pseudocoma

Difference Pseudocoma VS Coma

Here is a short table to quickly differentiate a patient with pseudocoma from true coma

Clinical manifestations of severe synthetic cannabinoid toxicity: An Update

Clinical manifestations of severe synthetic cannabinoid toxicity

Synthetic cannabinoids consist of a heterogeneous group of chemical compounds that act as agonists at cannabinoid receptors with 2 to 800 times the potency of delta-9 tetrahydrocannabinol (THC), the active component of cannabis (marijuana). They have emerged as a popular recreational drug in the United States and Europe. In an observational study of a multicenter, hospital-based registry of medical toxicology consultations, over two-thirds of 277 patients with single-agent exposure to synthetic cannabinoids had altered mental status including severe agitation, toxic psychosis, hallucinations, seizures, and coma [1]. Rhabdomyolysis and acute kidney injury were present in approximately 5 percent of these patients. There were three deaths, including a 17-year-old adolescent with sudden death after first-time inhalational use. Thus, unlike cannabis, synthetic cannabinoids have significant potential to cause serious and life-threatening toxicity among recreational users. 

Uptodate Sep 08, 2016

Congenital Lid Conditions: Ophthalmology Spot Diagnosis Series

Coloboma of the Eyelid

 A notch or defect of the lid margin

 Unilateral 

 or bilateral ; upper or lower

 Upper lid coloboma: At the junction of middle and inner thirds

 May be associated with Goldenhar syndrome

 Lower lid coloboma: At middle and outer thirds junction

 Associated with Treacher Collins syndrome

 May be acquired in traumatic cases

 Treatment: 

Urgent plastic repair at a very early age to prevent exposure keratitis and corneal ulcer.