Do any of the infectious disease experts at CHLA have any thoughts on the treatment proposed by some physicians of Hydroxycholoquine, Azithromycin and Zinc? I was sent a short video of an MD in NY who claims to have 900 pts with covid-19 (either lab or clinically diagnosed- I know this is suspect) and he claims that he has treated with Hydroxychoroquine 200mg bid for 5 days, Azithromycin 500mg qd x 5days and Zinc 220mg daily x 5 days. His claim is that he has had no deaths and only 3 pts who have needed to go on a ventilator. It sounds almost to good to be true, his claim is that it doesn't prevent illness or symptoms but prevents death and most intubations. I haven't heard anything for or against by local ID experts and would be interested in CHLA's ID experts thoughts as it relates to pediatric patients. Not sure of the availability but if my child or relative was getting sick with covid-19 I would want to try something other than just providing supportive care and waiting.
Despite the enthusiasm from the White House for hydroxychloroquine (HCQ), physicians generally demand more scientific rigor before confidently prescribing drugs. The jury is very much still deliberating whether HCQ with or without azithromycin has benefit. An early non-randomized trial from Marseilles, France suggested the combination is helpful (https://www.ncbi.nlm.nih.gov/pubmed/32205204). A randomized controlled study from China found a mild clinical benefit (https://www.medrxiv.org/content/10.1101/2020.03.22.20040758v2). However, a more recent study from Paris suggested no benefit (https://www.sciencedirect.com/science/article/pii/S0399077X20300858?via%3Dihub) and cited older studies of chloroquine for other respiratory viruses which could actually be deleterious. These studies are all very small, and the reports are preliminary.
There is potential for cardiotoxicity (prolonged QT and/or QRS) especially when combining HCQ and azithromycin. While many centers, including CHLA, are currently willing to use HCQ for sicker patients out of desperation in the hope for benefit, I am unaware of any reputable sources who have published experience using HCQ with or without azithromycin in the outpatient setting for COVID-19. Of note, we have only used the combination for one patient who had underlying asthma. The patient recovered and was discharged, but management of the asthma seemed to have far more impact on recovery than the HCQ and azithromycin.
Has Covid-19 been linked to a Raynaud's type syndrome? A family contacted me about their 14yo today - NOS, but wondering if they should put their son on aspirin b/c of things they had read? Thanks!
The child is getting tested so it should be interesting. I did find a photo online that looked a bit like it that was called "acral ischemia". His symptoms come and go repeatedly throughout the day, and he complains of pruritis more than pain; he also prefers to keep his feet cold, as that seems to help? Obviously that doesn't sound very Raynaud's-like...
I think there is a question whether COVID19 affects reactivity of vasculature, esp, pulmonary vasculature/embolism. I am not sure there are well defined studies in this area. I have not heard anything about aspirin.
We were actually talking to a pulmonary adult radiologist at USC about this
Do we have any reason to think that the Point of Care, rapid finger stick tests for COVID-19 (the lateral flow immunoassay, CLIA-waived types) are as accurate as the ELISA IgG type test that CHLA is doing in its lab? Some practices are starting to offer this to their patients, but the official word on this is just not there to support the reliability of these tests. Thanks.
According to Dr. O'Gorman, our lab director, the sensitivity of the POC tests is low and not reliable. He will go over that information on the webinar on April 28 at 4 pm and answer questions
Can you comment on the new finding linking COVID to a possible kawasaki-like syndrome? I have had calls with kids with high fevers for a few days followed by a rash and I am still thinking Roseola first but should I be testing this kids for covid or doing any heart echos??
Is there a general rule as to how long a nasal PCR test (or NAAT test) can remain positive after the onset of the illness? Can they remain positive for weeks? Even a few months? I'm asking regarding SARS CoV-2 as well as for other viruses. We had a patient who came in with fever and respiratory symptoms, nasal RT-PCR was negative for SARS CoV-2, but nasal respiratory panel was positive for rhinovirus. A few weeks later, the patient tested positive for SARS CoV-2 by CHLA's IgG serology test. I wonder if the rhinovirus was perhaps a leftover "shedding" from a prior URI, and not the cause of the more recent acute illness. Thanks.
To address the specific question, the SARS-Cov-2 RT-PCR is very sensitive. Since the patient was symptomatic but the RT-PCR was negative, it is extremely unlikely that the viral illness was COVID-19, and far more likely that it was in fact, rhinovirus. However, because of the positive antibody test later, it is 97% likely (the specificity of the test) that the patient was exposed to SARS-Cov-2 in addition to rhinovirus at some point, and either had symptoms mild enough to not be noticed, or was asymptomatic.
There isn’t any way from a single antibody test to tell when that asymptomatic infection with SARS-Cov-2 might have happened.
We have examples of positive SARS-CoV-2 by RT PCR positive for up to 7 -8 weeks.
Has there been any follow up testing on people who are known antibody positive? Do we know that their titers remain high or is it possible they drop with time (I'm talking weeks to months, not years)?
It is too soon to say, so the answer is we don’t know. From previous experience with coronaviruses, including SARS-Cov-1, typical duration is about 2 years. It remains to be seen if SARS-Cov-2 follows this pattern.
Are there any covid antibody testing/ testing studies being done locally? Think this is the next step
No I will check in with ID
From lab director at CHLA:
We are working on bringing serology testing up here but it is not currently available. Not sure if other labs have it yet.
Will update group as we get more information.
Still in progress, but expected very soon.
A question from a HN physician:
Do any of the infectious disease experts at CHLA have any thoughts on the treatment proposed by some physicians of Hydroxycholoquine, Azithromycin and Zinc? I was sent a short video of an MD in NY who claims to have 900 pts with covid-19 (either lab or clinically diagnosed- I know this is suspect) and he claims that he has treated with Hydroxychoroquine 200mg bid for 5 days, Azithromycin 500mg qd x 5days and Zinc 220mg daily x 5 days. His claim is that he has had no deaths and only 3 pts who have needed to go on a ventilator. It sounds almost to good to be true, his claim is that it doesn't prevent illness or symptoms but prevents death and most intubations. I haven't heard anything for or against by local ID experts and would be interested in CHLA's ID experts thoughts as it relates to pediatric patients. Not sure of the availability but if my child or relative was getting sick with covid-19 I would want to try something other than just providing supportive care and waiting.
Dr. Neely's response
Despite the enthusiasm from the White House for hydroxychloroquine (HCQ), physicians generally demand more scientific rigor before confidently prescribing drugs. The jury is very much still deliberating whether HCQ with or without azithromycin has benefit. An early non-randomized trial from Marseilles, France suggested the combination is helpful (https://www.ncbi.nlm.nih.gov/pubmed/32205204). A randomized controlled study from China found a mild clinical benefit (https://www.medrxiv.org/content/10.1101/2020.03.22.20040758v2). However, a more recent study from Paris suggested no benefit (https://www.sciencedirect.com/science/article/pii/S0399077X20300858?via%3Dihub) and cited older studies of chloroquine for other respiratory viruses which could actually be deleterious. These studies are all very small, and the reports are preliminary.
There is potential for cardiotoxicity (prolonged QT and/or QRS) especially when combining HCQ and azithromycin. While many centers, including CHLA, are currently willing to use HCQ for sicker patients out of desperation in the hope for benefit, I am unaware of any reputable sources who have published experience using HCQ with or without azithromycin in the outpatient setting for COVID-19. Of note, we have only used the combination for one patient who had underlying asthma. The patient recovered and was discharged, but management of the asthma seemed to have far more impact on recovery than the HCQ and azithromycin.
Has Covid-19 been linked to a Raynaud's type syndrome? A family contacted me about their 14yo today - NOS, but wondering if they should put their son on aspirin b/c of things they had read? Thanks!
@Bhavana Arora Hi! Do you have any thoughts on the question above?
I reached out to ID and will post when I get their response
The child is getting tested so it should be interesting. I did find a photo online that looked a bit like it that was called "acral ischemia". His symptoms come and go repeatedly throughout the day, and he complains of pruritis more than pain; he also prefers to keep his feet cold, as that seems to help? Obviously that doesn't sound very Raynaud's-like...
I think there is a question whether COVID19 affects reactivity of vasculature, esp, pulmonary vasculature/embolism. I am not sure there are well defined studies in this area. I have not heard anything about aspirin.
We were actually talking to a pulmonary adult radiologist at USC about this
Thank you! I'll let the family know - and will report back with the test result.
Do we have any reason to think that the Point of Care, rapid finger stick tests for COVID-19 (the lateral flow immunoassay, CLIA-waived types) are as accurate as the ELISA IgG type test that CHLA is doing in its lab? Some practices are starting to offer this to their patients, but the official word on this is just not there to support the reliability of these tests. Thanks.
According to Dr. O'Gorman, our lab director, the sensitivity of the POC tests is low and not reliable. He will go over that information on the webinar on April 28 at 4 pm and answer questions
Can you comment on the new finding linking COVID to a possible kawasaki-like syndrome? I have had calls with kids with high fevers for a few days followed by a rash and I am still thinking Roseola first but should I be testing this kids for covid or doing any heart echos??
Thank you for your input
Is there a general rule as to how long a nasal PCR test (or NAAT test) can remain positive after the onset of the illness? Can they remain positive for weeks? Even a few months? I'm asking regarding SARS CoV-2 as well as for other viruses. We had a patient who came in with fever and respiratory symptoms, nasal RT-PCR was negative for SARS CoV-2, but nasal respiratory panel was positive for rhinovirus. A few weeks later, the patient tested positive for SARS CoV-2 by CHLA's IgG serology test. I wonder if the rhinovirus was perhaps a leftover "shedding" from a prior URI, and not the cause of the more recent acute illness. Thanks.
Will check in with ID and lab director
From Dr. Neely and Dr. O'Gorman
To address the specific question, the SARS-Cov-2 RT-PCR is very sensitive. Since the patient was symptomatic but the RT-PCR was negative, it is extremely unlikely that the viral illness was COVID-19, and far more likely that it was in fact, rhinovirus. However, because of the positive antibody test later, it is 97% likely (the specificity of the test) that the patient was exposed to SARS-Cov-2 in addition to rhinovirus at some point, and either had symptoms mild enough to not be noticed, or was asymptomatic.
There isn’t any way from a single antibody test to tell when that asymptomatic infection with SARS-Cov-2 might have happened.
We have examples of positive SARS-CoV-2 by RT PCR positive for up to 7 -8 weeks.
Perfect. Thank you!
Has there been any follow up testing on people who are known antibody positive? Do we know that their titers remain high or is it possible they drop with time (I'm talking weeks to months, not years)?
Answer from Dr. O'Gorman and Dr. Neeley
It is too soon to say, so the answer is we don’t know. From previous experience with coronaviruses, including SARS-Cov-1, typical duration is about 2 years. It remains to be seen if SARS-Cov-2 follows this pattern.
@Emily Bruckner
Hi Dr. Bruckner, please see the response to your question above. Thanks, Sara