COVID-19 Update: Elusive Complication, Remdesivir Toxicity

Caroline Cassels

July 08, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Here are the coronavirus stories Medscape's editors around the globe think you need to know about today.

An Elusive Complication

Inflammatory disease of the myocardium is a rare, chameleon-like disease, but the diagnosis is even more challenging and controversial in patients with COVID-19.

The COVID-19 literature has been peppered with reports about myocarditis accompanying the disease.

If true, this could, in part, explain some of the observed cardiac injury and arrhythmias in seriously ill patients but also have implications for prognosis.

However, endomyocardial biopsies and autopsies, the gold standard confirmation tests, have been few and far between. This has led some cardiologists to question the true rate of myocarditis with SARS-CoV-2, or even if there is definitive proof the virus causes myocarditis.

Medscape Medical News examines the challenges and controversies around diagnosing this rare, chameleon-like disease.

Remdesivir Liver Toxicity

Although the antiviral agent remdesivir has been shown to shorten recovery time in patients with COVID-19, it has also been linked to hepatoxicity, possibly in combination with P-glycoprotein inhibitors.

A case report, by Dutch investigators published in Clinical Infectious Diseases and reported by Reuters, describes the plight of a 64-year-old male patient with confirmed COVID-19 via a positive SARS-CoV-2-PCR of the nasopharynx and consolidations in both lungs on radiological assessment.

The patient was hospitalized and received oxygen therapy and a 5-day chloroquine course. On day 3, he was transferred to the ICU for mechanical ventilation.

On day 16, he started remdesivir, and 2 days later received amiodarone because of new-onset atrial fibrillation. Five days after starting remdesivir, he experienced an acute increase in liver enzymes and remdesivir was stopped immediately. This led to a rapid decrease in liver values, which eventually returned to normal levels.

Liver toxicity is a rare but severe side effect of remdesivir, said study author Emile Leegwater, Haga Teaching Hospital, The Hague, Netherlands, who recommended that monitoring liver function in patients with COVID-19 on remdesivir is "crucial," particularly when prescribing the drug in those also receiving P-glycoprotein inhibitors.

Collateral Damage?

Children may make up a significant portion of the collateral damage caused by the COVID-19 pandemic.

 A snapshot survey of 2500 pediatricians published online in Archives of Disease in Childhood in Ireland and the UK showed that over a 2-week period, delayed diagnoses in children was a contributing factor in nine deaths.

"We've found that there is great concern that children are not accessing healthcare as they should during lockdown and after," study investigator Shamez Ladhani, MRCPCH, PhD, chair of the British Paediatric Surveillance Unit, told Medscape Medical News.

Over the study period, type 1 diabetes was the most frequently reported delayed diagnosis, with 44 cases overall, 23 of which involved diabetic ketoacidosis.

After diabetes, the most commonly reported delay diagnoses were sepsis and child protection issues. Malignancy also featured prominently.

"The unintended consequences of COVID are far greater in children than the disease itself. The way we are trying to prevent this is causing more harm than the disease," said Ladhani.

Vaccine Race Hits "Wartime Speed" in China

China is forging ahead in the race to develop a vaccine to fight the coronavirus, with Sinovac Biotech's experimental vaccine set to become the country's second, and the world's third, to enter final-stage testing later this month, Reuters reports.

The country revealed it has completed two vaccine plants in just 2 months at what it described as "wartime speed."

However, the vaccine development race is not won yet. In order for China to be victorious, it has to conquer several major challenges. The COVID-19 epidemic has largely been contained in the country, hampering efforts to find study participants to conduct large-scale trials and forcing China to shift its focus overseas.

So far only the UAE, Canada, Mexico, Brazil, and Indonesia have agreed to cooperate, while the United States and European countries focus on their own efforts.

Furthermore, after several scandals over substandard vaccines in recent years, China will need to convince the world that its vaccine quality and safety are up to acceptable standards.

Mask Question Asked and Answered

To don a mask or not has been hotly debated among the public and health professionals alike. Here, Hansa Bhargava, MD, tracks the progress of 45 specialty societies, which represent 800,000 physician members, to speak with one voice and end the mixed messaging on masks once and for all.

In Memoriam

As frontline healthcare workers care for patients with COVID-19, they commit themselves to difficult, draining work and put themselves at risk for infection. More than 1700 throughout the world have died. 

Medscape has published a memorial list to commemorate them. We will continue updating this list as, sadly, needed. Please help us ensure this list is complete by submitting names with an age, profession or specialty, and location through this form

If you would like to share any other experiences, stories, or concerns related to the pandemic, please join the conversation here.

Caroline Cassels is an editor for Medscape. She has more than two decades of experience editing and reporting on health and medicine for consumer and physician audiences.

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