On 26th September 2020, my 79-year-old mother casually complained of anorexia and weakness for the past few days. The next day, while administering pre-dinner insulin to her, my 19-year-old son perceived that she was febrile to touch. Her body temperature, checked orally, was 101.4 degrees Fahrenheit. On inquiring about other symptoms, she divulged that she felt restlessness on the previous day and was relieved by vomiting out the food she had ingested. She denied any complaint of breathlessness and cough, although my son had heard her coughing inside the washroom. She remarked that as insignificant. Given the ongoing COVID-19 pandemic, I isolated her into one room and my 86-year-old father into the other room on our house’s ground floor. The rest of the family——my radiologist wife, 14-year-old daughter, and son—got shifted to the first floor. We rendered the whole house airy by keeping all windows and door shutters open, keeping all exhaust fans and ceiling fans switched on and switching all the air conditioners off. My wife and I wore face masks and protective goggles all the time while working in the kitchen on the ground floor. While attending to my parents, I wore a face shield, cap, and gown additionally. The next day, a private laboratory technician took nasopharyngeal swabs and blood samples of my parents. Reports were ready by the 30th morning (table). Both parents tested positive for the SARS Cov 2 RNA by RT PCR. Now I kept both in the same room. Communicating with them from a distance wearing a face mask was a frustrating experience, as both have hearing disabilities. To mitigate this frustration, I tried to communicate with them by phone on some occasions. My father, a stable COPD patient, reported a recent mild worsening of the cough. My mother’s general condition worsened. She complained of profound fatigue, marked anorexia, and a peculiar unpleasant symptom of “my stomach is shriveled up.” She vomited daily. Her SpO2 was 86-88%. She denied having breathlessness. Her past history was remarkable for few longstanding diseases: Type 2 Diabetes mellitus( taking 12-16 units Insulin daily); Hypertension ( on Telmisartan 80mg, Chlorthalidone 12.5mg, Amlodipine 5mg daily); Paroxysmal Atrial Fibrillation( on Amiodarone 100mg daily); Amiodarone associated Hypothyroidism( on Levothyroxine 37.5 mcg daily); Rheumatoid Arthritis( on Prednisolone 1-2.5mg, Leflunomide 20mg, Hydroxychloroquine 400mg daily); Neurogenic bladder and sacral anesthesia due to stable discogenic lower cord myelopathy. My mother pleaded with me not to admit her to the hospital. I decided to manage them at home. Fear of contracting COVID-19 was so high in the society that all my known paramedic colleagues expressed their inability to help me insert intravenous(IV) cannulas and administer parenteral medicines. I was out of practice for the past 20 years, since my residency days, in carrying out these important tasks. With my mentor’s telephonic encouragement, I secured the IV lines and administered Remdesivir1, Dexamethasone, and antibiotic Intravenously and Enoxaparin subcutaneously every day from 30th September to 4th October. I gave Oxygen therapy to my mother through a nasal cannula and kept her SpO2 between 92-95%2, encouraging her to lie in a supine position. During the daytime, I nursed them in the open veranda of the house (Photo), believing that chances of contracting the infection in the open space are meager.3 During the nighttime, both went back to their room, where my less unwell father nursed my mother. After two days of starting treatment, mother became afebrile. Her other symptoms— lethargy, listlessness, “shriveled up stomach”—- did not improve much. She would get irritated while I coerced her to eat. She continued to puke daily. On 6th October, her condition worsened. She got restless, complained of central chest soreness, and vomited. She was not able to pass urine. Her blood pressure dropped to lower than her usual. Her pulse was irregularly irregular, indicating Atrial Fibrillation. I transferred her to the hospital, which she reluctantly agreed to. The cardiologist confirmed AF by Echocardiography and ECG. HRCT of her chest done on the same day showed bilateral resolving atypical pneumonia of moderate severity. (Photo) By the same evening, I got her back home. By glucometer, she had marked hyperglycemia with a blood sugar of 438 milligrams per decilitre. I administered IV fluids, persuaded her to take oral liquids, and gave her subcutaneous insulin every 4 hours, nearly like following Montefiore DKA protocol.4 By late night her blood glucose reached below 200 mg per decilitre, she passed urine, her pulse got regular, and she could sleep well. She got stabilized, but her vomiting and gut symptoms persisted. On reviewing COVID-19 literature, I noted that 10% of patients with this disease have gut-only involvement clinically with small bowel segmental dilation and stenosis.5 I gave her oral Domperidone, a gut prokinetic, 10 mg thrice a day with only a thick liquid diet. Her vomiting ceased. On 3rd day of this new regimen, she started demanding solid food. From 12th October onwards, she maintained her SpO2 between 93-96% while breathing ambient air. She revealed that all these days, she had “foggy consciousness.” She could recollect the events patchily in the wrong temporal order. None of the others in the household developed COVID-like symptoms, and my wife and I tested negative for Coronavirus. It was a challenge to maintain optimal care to COVID-19 patients while protecting other household members. After more than three weeks of disease onset, mother still tested positive for SARS Cov 2 RNA.
Gut symptoms can be the predominant symptoms of COVID-19 disease. These need separate symptomatic treatment.
Sick COVID-19 patients, not requiring ventilatory support, can be cared for at home if local governments organize and mobilize available human healthcare resources in localities. That is not my gut feeling, but my experience.
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