Kyle Habet, MD.
In Belize we have been COVID-19-free since May 5th. While we only have to deal with inconvenience of wearing face masks in ninety-degree weather, the rest of the world has been at war with an invisible enemy that has taken hundreds of thousands of lives.1 During this fight, new information is emerging every day. Treatment options are being explored, new symptoms have been reported and vaccines are being tested, and some are yielding positive results! In this article, we will discuss briefly what information has been discovered over the past couple days.
We have discussed some skin findings in COVID-19 in our last article, however at the time it was uncertain which of these symptoms were clearly linked to Coronavirus Disease. Researchers in Spain have described and established five dermatologic patterns in which COVID-19 may manifest.2
- Acral edema and erythema has been describe in 19% of patients.
- Vesicular eruptions (looks like chickenpox) have been reported in 9% of patients.
- Urticarial lesions have been reported in 19% of patients.
- Maculopapular rash was reported in 47% of patients.
- Livedo reticularis or necrosis in 6% of patients.
(See gallery below)
Some lesions manifest prior to symptoms but most present during the course of illness.2 One study has reported that conjunctivitis (known as pink eye) may be the only symptom of COVID-19 in some cases.3
Observations have been made that patients with low vitamin D levels upon admission to a hospital due to COVID-19 is associated with worse outcomes.4 Countries where vitamin D deficiency is common have reported some of the highest mortality rates from COVID-19 leading to plausible speculation on the role that vitamin D may play in susceptibility and recovery.5 Even in pre-COVID days, studies have looked into the benefits of vitamin D. One study established that patients that took vitamin D supplements have fewer respiratory tract infections than those that do not.6 Whether vitamin D provides a true protective role against COVID-19 is unclear however, Dr JoAnn Manson of Harvard Medical School and chief of the Division of Preventive Medicine at Brigham and Women’s Hospital in Boston suggests taking a vitamin D supplement and exercising outdoors to boost vitamin D reserves is encouraged.7 Infected patients with low vitamin D levels upon admission that receive early vitamin D supplementation does not improve outcomes so it appears that vitamin D levels pre-Covid-19 infection is the important takeaway.4 Remember, the message here is that vitamin D may be a predictor of mortally if infected; it will not make you immune to COVID-19.
The majority of deaths due to COVID-19 are patients with underlying diseases like hypertension and heart failure and patients over the age of 65. The one common denominator in patients that died under the age of 60 was a BMI of over 30 (Normal BMI is between 18.5-24.9). Patients aged < 60 years with a BMI between 30 and 34 were 2.0 times more likely to be admitted to acute and critical care, respectively, compared to individuals with a BMI < 30.8
There is a race to find a vaccine for COVID-19 and many different approaches have been taken.9 Some are experimenting with live attenuated vaccines (using a live non-infectious version of COVID-19) similar to the MMR (measles, mumps and rubella) vaccine. Others are taking more interesting approaches which involve gene therapy and are the first vaccines to be showing positive results in human trials.10 The vaccine is still in the clinical trial phase but it has been reported that participants in the trial develop a robust antibody response against COVID-19 after immunization.11 This would be the first vaccine of its kind. We may be on the brink of a major scientific feat!
1. WHO Coronavirus Disease (COVID-19) Dashboard. Accessed May 23, 2020. https://covid19.who.int/?gclid=CjwKCAjwk6P2BRAIEiwAfVJ0rPUIekgTdLer9znZqbiZ_ymqEYHPV6splfUAHsKf1GruRIQt8Mz3vBoCwLAQAvD_BwE
2. Casas CG, Català A, Hernández GC, et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. n/a(n/a). doi:10.1111/bjd.19163
3. Scalinci SZ, Trovato Battagliola E. Conjunctivitis can be the only presenting sign and symptom of COVID-19. IDCases. 2020;20:e00774. doi:10.1016/j.idcr.2020.e00774
4. Early High-Dose Vitamin D3 for Critically Ill, Vitamin D–Deficient Patients | NEJM. Accessed May 23, 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa1911124?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
5. Vitamin D and Inflammation – Potential Implications for Severity of Covid-19 – Irish Medical Journal. Accessed May 23, 2020. http://imj.ie/vitamin-d-and-inflammation-potential-implications-for-severity-of-covid-19/
6. Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. 2017;356. doi:10.1136/bmj.i6583
7. Does Vitamin D Protect Against COVID-19? Medscape. Accessed May 23, 2020. http://www.medscape.com/viewarticle/930152
8. Lighter J, Phillips M, Hochman S, et al. Obesity in Patients Younger Than 60 Years Is a Risk Factor for COVID-19 Hospital Admission. Clin Infect Dis. doi:10.1093/cid/ciaa415
9. Le TT, Andreadakis Z, Kumar A, et al. The COVID-19 vaccine development landscape. Nat Rev Drug Discov. 2020;19(5):305-306. doi:10.1038/d41573-020-00073-5
10. National Institute of Allergy and Infectious Diseases (NIAID). Phase I, Open-Label, Dose-Ranging Study of the Safety and Immunogenicity of 2019-NCoV Vaccine (MRNA-1273) in Healthy Adults. clinicaltrials.gov; 2020. Accessed May 22, 2020. https://clinicaltrials.gov/ct2/show/NCT04283461
11. First COVID-19 Vaccine Tested on Humans Shows Early Promise. Medscape. Accessed May 23, 2020. http://www.medscape.com/viewarticle/930714