COVID-19 AND ERYTHROCYTE AGGREGATES: AN INTENSIVIST’S EXPERIENCE WHEN BEING AFFECTED

COVID-19 pandemic has killed over 258,000 individuals till date. Healthcare providers are profoundly vulnerable to be contaminated as opposed to taking every single careful step. Although the respiratory tract and the lungs are the target organs some complications may develop even at the introductory phase of this sickness course. Haemoconcentration with raised serum ferritin level is one of the dangerous conditions that might be occurred from chronic hypoxia and severe dehydration because of increased insensible loss. Recent posthumous pulmonary tissue studies revealed that the viral infective mechanism, as well as the miniaturized erythrocyte aggregates, are additionally a significant contributing phenomenon to create acute respiratory distress syndrome (ARDS). Haematological issues require to deal proactively alongside other vital organs protection protocols for better outcomes. This article will depict the disease sequence of an intensivist working in a COVID unit after being infected by COVID-19.


INTRODUCTION
A 35-year-old male intensivist, youthful and lively, having no comorbidity, no absence of confidence and inspiration. He was at the frontline of the fight against the deadly COVID-19 not long after the discovery and authority revelation of the primary case in Bangladesh on 8 March 2020. 1 Of course, he was dynamic, light-footed and vigour in the Critical Care Centre (CCC) of a Level IV tertiary hospital where a COVID unit is 2 initiated as of late. A portion of the staffs of this unit additionally associated with the Emergency and Casualty division. Be that as it may, they carefully followed the prudent orders and utilized individual defensive gear while on their obligations. This case report will portray the ailment course of a fully complied intensivist working in a COVID unit after being tainted by COVID-19 out of a propelled medical focal setting of Bangladesh.

THE CASE
Despite his adherence to the principles and conventions of contamination control in the hospital, in the main days of the episode, he had a gentle dry hack and runny nose. There was tiredness that was somewhat uncommon in his everyday life. He additionally felt light myalgia and bone torments for days. However, he thought those might be because of ongoing additional overwhelming obligations and physical depletion. He took ostensible analgesics (paracetamol) and antihistamine orally. It diminished muscle torment and rhinorrhoea as well. However, he felt abnormal tiredness and light cough by even nominal physical activities like attending the patients. At that point on that night, in the wake of coming back from the hospital to his dormitory, he felt hot and he discovered his body temperature at 102 degrees Fahrenheit estimated by a clinical thermometer. At that point, he turned out to be very disturbed and informed it to his senior in-control. His in-charge exhorted him to report to the fever clinic of the emergency division for affirmation. He got conceded in the segregation unit at that night on 6 April 2020 and was given the accompanying introductory treatment:  Tab. Paracetamol 500 mg for fever  Tab. Fexofenadine 120 mg 1+0+1 is an antihistamine  Tab. Montelukast 10 mg 0+0+1 3  Oral rehydration saline (ORS) and water as much as he drinks to keep up haematocrit level typical  Tab. Vitamin C 1+1+1 to increase immunity  Tab. Zinc 1+0+1 to increase immunity Relevant investigations were in progress. His nasopharyngeal sample was sent quickly for real-time polymerase chain reaction (RT-PCR). Colleagues were guaranteeing him that it will be negative, nothing to be stressed and it's a simple viral fever. In any case, following a couple of hours, he turned out to be seriously stunned after understanding that his sample was certain for COVID-19. He got a condition of thought block assuming the upcoming consequences of this novel coronavirus disease. He was moved to a cubicle of the corona unit and following administration was included: His weakness increased on the next day and he began to feel initial breathlessness on mild activities, then even on rest. His oxygen saturation was estimated 83-84% by pulse oximetry. At that point, he was given high stream humidified oxygen by ventimask at a rate of 6-8 L/min. It increased his saturation a little (92-93%). He developed bilateral crepitation in both lung fields that gave him feelings of suffocations and chest tightness.
As of then he was going to be intubated and went on mechanical ventilation. That made the intensivist exceptionally tense and anguished, to be sure. However, the invasive episodes of interventions could be avoided as the condition was not deteriorated further. At that point, he adopted a periodical change of his posture at his own to take advantages of ventilation in prone and lateral positions. He was then got management of negative fluid balance just to maintain a normal or near-normal range of haematocrit value. Then he was given the following to prevent the thromboembolic phenomenon:  Deferoxamine (an iron-chelating agent)  Prophylactic enoxaparin (low molecular weight heparin) 40 mg Three to four days after the fact, his clinical conditions began to improve and the lung fields were seen well on the accompanying chest Computed Tomographic films. At that point, he rehearsed chest physiotherapy at his own and he found the breath-holding exercise the most productive. At this stage, his oxygen saturation raised to 95-96% with oxygen at a rate of 2 L/min. He was feeling better step by step and announced relieved after discovering two consecutive RT-PCR negatives on 22 nd day (29 April 2020) and released from the hospital.

DISCUSSION
The novel disease course teaches us some important issues. A study on 7,015 confirmed cases demonstrated that it is rapidly transmitting and has a short and variable incubation period (5-14 days). The onset chiefly occurs among young to middle-aged adults (average age of all cases was 44.24 years old). 2 Healthcare personnel are the most vulnerable group of people to be infected by COVID-19. 3 The inadequacy of proper testing facilities at the mass level is predominant as like as many developed countries.
Standard personal protective equipment (PPE) supply and competent compliance to the 6 protocols are also in lacking. 4 Working in the emergency and outpatient department is the most susceptible area of contamination. 5 Sadly, it is reported that some patients are carrier without any symptoms, while many of them ignore or deliberately hide their complaints mimicking the initial signs and recent exposure of COVID patients to their primary physicians. 6 Then again, doctors and paramedics working in the emergency department must be wary and should attempt to maintain a strategic distance from aerosol-generating procedures (AGP) as much as possible. 7 Hyperpyrexia doesn't relief for about a week instead of utilizing the highest dose of analgesics. This causes excessive perspiration and insensible loss of volume which may contribute to developing severe dehydration. 8 Dry cough, throat and chest pain produces irritability and discomfort which instigate to spit more. On top of these, hypoxia initiates excessive red blood cell production and an increased level of serum ferritin. 9 In this way, hypoxia and increased haematocrit are a vicious cycle. These entire phenomena may ignite the risk of thromboembolism because of haemoconcentration. It is also detailed that, among subjects not treated with heparin, mortality raised agreeing with D-dimer levels. 10 The management may remain stay occupied with the hyposaturation and the chest films and this aspect of complication may be unintentionally ignored while treating the COVID-19 patients. Rather, microthrombus, stroke and pulmonary embolism are the potential reasons for the sudden death of these patients. It warrants early detection and appropriate management for better results. Recent studies indicated that erythrocyte aggregates maybe one of the potential causes of ARDS ( Figure 1

Figure 1:
Axial CT pulmonary angiography in lung window, from a 75-year-old man, who was diagnosed with COVID-19. Images show multifocal predominantly peripheral groundglass opacities in the right lung base (a-c), with associated vacuolar sign (black arrowheads, a), fibrous streaks (white arrowheads, b), and vascular dilation sign (black arrow, c) suggestive of SARS-CoV-2 infection. In the soft tissue window, a filling defect partially outlined by contrast agent was found in the lateral branch of the right middle lobar artery, indicating acute pulmonary embolism (white arrow). Acute pulmonary embolism was unlikely to be caused by in-situ thrombosis due to interstitial COVID-19 injury since the parenchyma in the right middle lobe was normal (b Although the lung is the target organ of COVID-19 however other vital organs functions are to be monitored proactively. Liver enzymes and serum creatinine are to be checked routinely. 13 Respiratory invasive interventions are tried the most to be avoided. Self-adopted chest physiotherapy, incentive spirometer and lateral and/or prone decubitus have shown effective fruitfulness. 14 Patients must be consoled to forestall psychological injury as it's an obscure and unique disease 8 process. 15 They might be encouraged by an audio-visual display to perform these useful exercises in the wards and at home.

CONCLUSION
Intelligent suspicion, inquisitiveness; caregivers safety; early detection, isolation and proactive concise management are the key instruments to win the battle against COVID-19. The issue of erythrocyte aggregates shouldn't be missed anyway. Take hold of the ailment before it assumes control over you. The final victory could be accomplished only after the innovation of an effective vaccine against this lethal virus which is in the pipeline.