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With prof. dr hab. n. med. Michał Pirożyński, a specialist in internal diseases and lung diseases from the Department of Anaesthesiology and Intensive Therapy at the Medical Center of Postgraduate Education in Warsaw, we talk about COVID-19 and the accompanying acute interstitial pneumonia.
- Infection with SARS-CoV-2 coronavirus in some patients may lead to interstitial pneumonia. Prof. Michał Pirożyński explains what the disease is and what its consequences may be
- The expert also explains what the course of the COVID-19 disease can be and how it is diagnosed
- Prof. Pirożyński warns that the infection can lead to irreversible changes in the lungs. “Fibrosis can lead to acute respiratory failure,” says the doctor
- You can find more about the coronavirus on the TvoiLokony home page
Monika Zielenniewska, Medonet: According to the Wuhan statistics presented in the media, about 80 percent of deaths from COVID-19 were related to acute interstitial pneumonia, caused by the coronavirus. What kind of illness is that?
Prof. Michał Pirożyński: Acute interstitial pneumonia belongs to a group of diseases that occur within the parenchyma of the lungs, especially in the space around the alveolus.
And the parenchyma of the lungs is it?
The lung parenchyma has a spongy structure and consists of small bronchioles that supply air to the alveoli. On the other hand, the alveoli, which are surrounded by the capillary network, are the place of gas exchange (oxygen, carbon dioxide) between the atmospheric air and blood. Interstitial lung diseases are characterized by a progressive reconstruction of structures, which in extreme cases may lead to a complete disturbance of gas exchange. This results in patients with progressive breathlessness, due to the impediment to the transfer of oxygen from the air to the red blood cells.
How can this type of pneumonia be described?
There are acute symptoms, especially flu-like symptoms. These are muscle aches, cough, sore throat, general malaise. These symptoms are accompanied by rapidly increasing dyspnoea. The patient’s body tries to balance the need for oxygen with accelerated breathing and an increase in heart rate. Reconstruction of the lung parenchyma, combined with the destruction of the alveoli and their fibrosis, leads to progressive respiratory failure. And this requires the use of assisted ventilation, i.e. treatment with a respirator.
Are these symptoms not like the SARS epidemic that started in 2002 in China?
In fact, samples of pulmonary parenchyma from patients infected with the SARS-CoV-2 virus causing the disease known as COVID-19 showed changes very similar to those found in patients with SARS (Severe Acute Respiratory Distress Syndrome caused by SARS virus). Inflamed bubbles ceased to fulfill their primary function – gas exchange. The progressive disease led to the appearance of fibrosis and irreversible changes in the lungs.
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What is the mechanism of follicular fibrosis?
In the early stage of the disease, there is swelling of the inter-alveolar space, protein-rich exudate into the lumen of the alveoli, severe congestion and inflammation of the pneumocytes (cells lining the alveolar wall), characterized by the presence of fibrin. We also observe the infiltration of giant multinucleated cells. As the inflammatory reaction develops, the pneumocytes peel off. This process is accompanied by the production of hyaline membranes, formed as a result of abnormal protein metabolism. These changes aggravate gasometric disturbances, as some pneumocytes participate in gas exchange. The process of fibrosis, which begins with their desquamation, leads to irreversible structural changes – pulmonary fibrosis. And this, in turn, leads to acute respiratory distress (ARDS).
Let’s recall what we already know about the Wuhan coronavirus?
SARS-CoV-2 virus has not been observed in humans so far, so we do not have natural immunity. The possibility of transmission, i.e. the transmission of infection from a sick person to other people, has been proven. Infection occurs especially in confined spaces, which are clusters of large groups of people. With the exhaled aerosol (sneezing, coughing, talking), the virus spreads to the respiratory tract of other people. This observation contributed to reducing the number of people staying in one room to a minimum, avoiding mass events and any gatherings, especially in closed rooms. The infection is transmitted by droplets when we inhale the aerosol produced during talking, singing, screaming, sneezing and coughing aloud. The virus has also been excreted by the ingestion (via faeces). Thus, thorough hand washing remains the main method of preventing transmission of infection at this time.
What is the course of COVID-19 disease?
It is quite violent because the symptoms build up quickly. The first symptoms are increased body temperature, dry cough, a feeling of general discomfort, signs of inflammation of the upper respiratory tract associated with obstructed airflow through the nose, and a sore throat. There are also vomiting and diarrhea. According to data from China, more than 80 percent of infections are mild. It has been observed to be even milder in children.
So how is this disease diagnosed?
After the doctor determines the essence of the ongoing process, treatment is carried out in a hospital setting. The tests that bring the correct diagnosis closer include, apart from collecting the medical history, examining the patient and imaging tests. Imaging tests include: chest X-ray and high-resolution tomography of the chest. They are very helpful in diagnosis. In computed tomography, initially clear changes of the milk glass type are visible. Later, they are consolidated. In patients with advanced disease, exudative lesions are visible, covering most of the lung parenchyma. Unlike other viral lung diseases such as SARS and MERS, a CT scan in patients with COVID-19 is very useful in identifying early lung lesions. It is emphasized that as many as 85 percent of COVID-19 patients have changes in chest radiographs, and as many as 75 percent of these changes are bilateral, with a peripheral location, next to the chest walls. Bilateral changes distinguish patients with COVID-19 from patients with SARS / MERS. The diagnosis is also confirmed by the results of histological examinations of lung parenchyma samples taken during bronchoscopy (transbronchial lung biopsy) or surgical lung biopsy.
Have any effective treatments been developed?
In the present, initial period of the pandemic, we do not yet know about appropriate treatment. Work on the selection of therapy is still ongoing. More than 200 clinical trials have been registered in China alone to select medicinal products for the treatment of SARS-CoV-2 infection. The work is focused on antiviral drugs as well as on the group of drugs called protease inhibitors. Medicinal products with immunomodulatory effects that enhance the immune system, such as interferon, chloroquine and immunoglobulins, are also being assessed. It seems that steroids may only be of potential use in the later course of the disease.
Approximately 26% patients with COVID-19 require hospitalization in intensive care units, and 20 percent. of them develop acute respiratory failure. In the case of the most severe course, replacement ventilation therapy is required. According to data from the first weeks of the epidemic in Wuhan, replacement ventilation required from 7 to 12 percent. sick.
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I read that some people may develop lung defects after they recover?
The formation of structural changes in the form of permanent defects in the pulmonary parenchyma has not yet been confirmed on larger material. We do not have data on this.
And do we know anything about pulmonary fibrosis that are persistent or progressive after recovery?
There is no information so far on the chronic changes remaining after the acute period of infection in convalescents. In the course of infections with other corona viruses – SARS, MERS – the presence of air traps (SARS) and fibrosis (MERS) are observed. So far, in patients with COVID-19, none of these changes have been described yet.
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Could COVID-19 leave survivors in cured patients with any other permanent health problems that will exclude them from active life in the future?
There is no data on this so far.
And what diseases from which the patient already suffers are the greatest threat in the event of infection with the SARS-CoV-2 virus?
According to data from Wuhan, the most vulnerable patients are the elderly and people with chronic diseases, such as cardiovascular diseases, diabetes and chronic respiratory diseases.
Why? What happens then?
The COVID-19 disease is especially dangerous for the elderly, mainly because of their deteriorating immune function with age. As the years go by, the human immune system is less able to identify bacteria, fungi and viruses. In the case of COVID-19, we must remember that the virus itself damages the patient’s immune system, thus worsening its immunity. Since there are fewer or weaker cells recognizing SARS-CoV-2, the easier it is for viruses to overcome the immune system, and immune disorders worsen the prognosis of patients, e.g. sepsis develops more easily.
Also check:
- A doctor infected with the coronavirus describes the fight against the disease day by day
- How does the coronavirus attack the body? Here’s what happens in the human body then
- “Coronavirus will look for the lungs of seniors”. Doctor’s advice for the elderly
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