Anosmia and ageusia as clinical manifestations of COVID-19

Anosmia and ageusia as clinical manifestation of COVID-19
Virginia Thornley, M.D.s
April 24, 2020

photo credit CDC by Unsplash

COVID-19 can present with a variety of symptoms and is not necessarily limited to fever and respiratory symptoms. As the pandemic continues, more observations of the wide spectrum of clinical presentations are seen. Two of these are anosmia and ageusia-loss of smell and taste.

A very recent study came out April 22, 2020, comparing patients with COVID-19 and influenza with 79 cases including 40 controls. New onset smell and taste disorders (STD) were found to be more common as initial clinical symptoms compared to controls with influenza (1). In the group with COVID-19, 35% had acute onset as the first symptom, 70% had loss of smell, 90% had loss of taste, and 12.9% had nasal obstruction. 40% recovered after 7.4 days(1).

Anosmia or lack of smell has been reported in several countries U.K., France, United States, South Korea, Italy and Iran (2).

There are case reports on 2 patients with COVID-19 infection one who died, showing anosmia in the absence of respiratory symptoms. It is thought to be related to inflammation of the olfactory nerves (3).

There are now randomized controlled clinical studies showing that anosmia and ageusia can be an initial clinical symptom of COVID-19. There are case reports that it can be the only symptom.

Disclaimer: Information only not advice talk to your doctor.

1. Beltram-Corbelliini, A., Chico-Garcia, J.L, Martinez-Poles, J., Rodrigiez-Jorge, F., Natera-Villalba, E., Gomez,Corral, J., Gomez-Lopez, A., Monreal, E., Parrra-Diaz, P., Cortes-Cuevas, J.L, Galan, J.C., Fragola-Arnau, C., Porta-Etessam, J., Masjuan, Alonso-Canovas, A., Acute-onset small and taste disorder in the context of COVID-19: a pilot multi-center PCR-based case-control study. Eur J Neurol 2020 Apr 22. doi: 10.1111/ene.14273
2. Heidari, F., Karimi, E., Firouzifar, M., Khamushian, P., Ansari, R., Mohammed Ardehali, Heidari, F. Rhinology, 2020, Apr 22. doi: 10.4193/Rhin20.140
3. Villalba, N.L., Maouche, Y., Ortiz, M.B.A., Sosa, Z.C., Chahbazia, J.B., Syrovatkova, A., Pertoldi, P., Andres, E., Abrar-Ahmed, Z, Anosmia and dysgeusia in the absence of other respiratory diseases: should COVID-19 infection be considered? Eur J Case Rep Intern Med. 2020. 7(4):001641 doi: 10.12890/2020_001641


A review of the literature: cytokine storm in COVID-19 and novel treatments and trials

Virginia Thornley, M.D.
April 13, 2020

COVID-19 is now a global pandemic. The world is in the midst of a virus that is still an unknown entity. Here, we look at the published research of what we know so far.

Cytokine storm
COVID-19 or the coronavirus is thought to incite a cytokine storm. On review of the literature for severe influenza, a cytokine storm refers to the release of cytokine factors triggered by infection or drugs. It is caused by the breakdown of infected white blood cells through apoptosis causing the release of cytokine factors that lead to a release of even more white blood cells. First, there are infected white blood cells then pro-inflammatory cytokines react. These lead to increased expression of anti-viral, proinflammatory apoptotic genes resulting in tissue damage. There are simultaneous regenerative processes occurring. Usually, the repair is complete. In some cases, it results in severe tissue damage and excess inflammatory responses resulting in alveolar damage. The excessive cytokine-induced inflammation can leak systemically resulting in widespread organ failure (1).

photo credit: CDC through Unsplash

Therapies including IL-6 inhibitors and convalescent plasma
In one report, there is some treatment targeting the cytokine storm which is thought to make some progress including interleukin-6 (IL-6) antibody inhibitors, stem cell therapy as well as transfusion of plasma in convalescence(2). Currently, there are clinical trials at Mount Sinai Hospital in New York City to look into the use of convalescent plasma. There are ongoing trials for interleukin-6 inhibitors by drug companies Sanofi and Regeneron.

While chloroquine is recommended by expert Chinese consensus after extensive discussion, there are, however, no large human randomized controlled clinical trials yet in COVID-19 showing sufficient scientific evidence that it definitively works(3). Many clinical studies for drugs are ongoing at the time of this writing.

While there are no studies specifically on the effect of non-steroidal anti-inflammatory drugs on COVID-19, however, there are suggestions it could potentially blunt the immune system from fighting the virus (4). In a UK publication in the BMJ 2020, doctors and scientists believe that NSAIDs in the setting of respiratory failure in COVID-19 could potentially lengthen the time of recovery. Thoughts are that the respiratory illness may be prolonged with the use of NSAIDs. This stemmed from a comment made by an infectious disease doctor in the south of France where 4 individuals with COVID-19 appeared to worsen with the inclusion of NSAIDs in the treatment protocol. Ibuprofen was deleted from treatment protocols in patients with infections in France as of 2019 with paracetamol used in its place. This was supported by expert figures in the UK (4).

Hydroxychloroquine and azithromycin
One small study of 20 patients was recently published showing some improvement of patients on a combination of hydroxychloroquine and azithromycin (5).

Because this is a novel virus, research is still ongoing and fluid. Larger human studies are needed. There are larger trials ongoing for various drugs. So far most of the research that has been published is in a small number of patients.

Disclaimer: This is information only not advice, please consult with your physician

1. Liu, Q., Zhou, Y. & Yang, Z. The cytokine storm of severe influenza and the development of immunomodulatory therapy. Cell Mol Immunol 13, 3–10 (2016).
2.Chen, C., Zheng, X.R., Ju, Z.Y., He, WF. Advances in the research of cytokine storm mechanism induced by Corona Virus Disease 2019 and the corresponding immunotherapies. Zhonghua Shao Shang Za Zhi. 2020 Mar. 1;36(0):E005
3.Expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Mar 12;43(3):185-188. doi: 10.3760/cma.j.issn.1001-0939.2020.03.009.
4. BMJ 2020;368:m1086 doi: 10.1136/bmj.m1086
5. Gautret, P., Lagier, J., Parola, P., Hoang, V.T., Meddeb, L., Mailhe, M., Doudier, B., Courion, J., Giordanengo, V., Viera, V., Dupont, H., Honore, S., Colson, P., Chabriere, E.,La Scola, B., Rolain, J., Brouqui, P., Raoult, D. Hydroxychloroquine and azithromycin as a treatment of COVD-19: results of an open-label non-randomized clinical trial, Int. J. Antimicrobi Agents. 2020, Mar 20doi: 10.1016/j.ijantimicag.2020.105949 [Epub ahead of print]

Disclaimer: This is information only not advice, please consult with your physician


Review of literature: introduction and clinical presentations of COVID19

Review of literature: introduction to the COVID19 and clinical presentations

credit: photo by CDC by Unsplash

Virginia Thornley, M.D.
April 2, 2020

A new virus emerged in Wuhun, China in December 2019. But the information is still emerging on how to treat it and the exact pathophysiology.

The coronavirus is a type of virus that can infect both animals and humans.
It was named COVID19 for corona virus disease 2019 and renamed SARS-CoV2 which was discovered in the epithelium of the respiratory system of patients from Wuhun, China (1).

COVID19 first occurred December 7, 2019 in the markets of Wuhun, China. The pathogen is the SAR-CoV2. The intermediate host is thought to be the Pangolin. It is a type of RNA virus. The original host is an animal but it jumped to humans. The species pathogen is the B-corona virus. The latency period is about 2-7 days infecting people who have never been exposed to it before(1).


Clinical presentation
The infection is classified as mild, moderate, severe and critical. Mild cases present with fever, respiratory symptoms and no pneumonia on imaging studies. Moderate is described as those with fever, respiratory symptoms and pneumonia on imaging studies. Severe cases present with respiratory failure with a respiratory rate greater than 30/minute, oxygen saturation or O2 saturation of less than or equal to 93mmHg, PaO2/FiO2 of less than 300mmHg. Critical cases include one of the following: need for mechanical ventilation, shock or organ failure requiring ICU admission. There can be dyspnea leading to acute respiratory distress syndrome (ARDS), metabolic abnormalities that are refractory to correction, shock and thrombosis(3).

The SARS epidemic which occurred in 2003 affecting China extending to other other Southeast Asian countries, by contrast, lasted 7 months affecting 8096 people resulting in 774 deaths. There was a high mortality rate among hospital personnel of about 21% (1). The COVID19 started December 7, 2019 and is still ongoing at the time of this writing. At the time of this writing, there are 1,040617 affected with 55,188 deaths(2). The numbers continue to climb. It was declared a pandemic by the WHO. Most clinical cases are elderly, however, the coronavirus could be seen in those with diabetes mellitus and hepatitis B. An immunocompromised state is also a risk factor. Male to female ratio based on studies in China is 2.7:1. Mortality rate is 2.1%

1. Xu, J., Zhao, S., Teng, T., Abdalla, A.E., Zhu, W., XIE, L., Wang, Y., Guo, X. Systematic Comparison of Two Animal-to-Human Transmitted Human Coronaviruses: SARS-CoV-2 and SARS-CoV. Viruses. 2020, Feb. 22;12(2).
2. Worldometer, Coronavurus pandemic 2019
3. Feng, Y., Liu, N., Hu, J., Wu, l., Su, G., Zhong, N., Zheng, Z. 4S Respiratory rehabilitation guidelines for patients with pneumonia infected by new Coronavirus. Chinese Journal of Tuberculosis and Respiratory Diseases, 2020, 43: Pre-published online. DOI: 10.3760 / cma.j.issn.1001-0939.2020.0004

Photo by CDC on Unsplash