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APRIL 11, 2020 -- A physician couple who both had COVID-19 had very different responses — one ending up in intensive care, the other asymptomatic.
Their story, one of two people living together but with such different responses to the infection, illustrates how much is still to be learned about COVID-19, says Noopur Raje, MD, professor of medicine at Harvard Medical School and director of the Center for Multiple Myeloma at Massachusetts General Hospital (MGH) in Boston.
"After experiencing #Covid_19 from the patient/caregiver end despite both of us being physicians at a major academic medical center, this has been a challenge like no other I have experienced," Raje (@NoopurRajeMD) wrote on Twitter.
She outlined their experiences in a Twitter thread, and elaborated in an interview with Medscape Medical News.
Raje says that she wants clinicians to know how symptoms can evolve both quickly and suddenly.
She recalls how for 10 days, she cared for her COVID-19–positive husband at home, separated from him by a floor in their Boston townhouse and wearing a surgical mask and gloves to bring him food and fluids, as he was too weak to help himself.
Despite the high fevers, chills, extreme fatigue, and dramatic weight loss, Raje says she felt reasonably confident that her husband was getting better. His temperature had dropped from around 103 to 101, his heart rate was in the 80s, and his blood pressure was "OK," she recalls.
But then Jag Singh, MD, an otherwise healthy 55-year-old Harvard professor and cardiologist, started to cough — and everything suddenly changed.
The cough sounded chesty, and he was weak and unwell. They decided that he needed medical help.
"I was planning on driving him to the hospital, but I ended up having to call 911, although we literally live across the street," she said.
"We have stairs here and I wasn't sure that he would be able to make it coming down with me trying to help him, so the safest thing was for me to call for help."
Singh was admitted straight to the medical intensive care unit (MICU) while his wife waited at home.
"I was blown away when I saw Jag's x-ray and CT scan and the bilateral pneumonia he had developed," she commented. "I would not have believed it, the way he was clinically — and seeing that x-ray.
"Honestly, when I took him in to hospital, I thought he'd be there a couple of days — over the weekend — and I'd get him back Monday. But it didn't turn out that way. He was there for about 9 days."
That first night in the hospital, Singh consented to intubation — should he need it. "He called me then," said Raje. "I said we've got to do what we've got to do, it's OK — it is what it is, and we'll do whatever it takes."
He remained in the MICU overnight and through the next day, still breathing on his own, but with the looming prospect of mechanical ventilation.
"The good news is he maintained his oxygen saturations throughout," said Raje. "I was able to see his vitals with EPIC [remote monitoring]...It was crazy," she recalls. "Seeing a respiratory rate of 26 was difficult. When you see that you worry about somebody tiring with the breathing. His inflammatory markers kept climbing, his fevers persisted."
Thankfully, he never needed the ventilator.
But by this time Raje had another worry: She, too, had tested positive and was now alone at home.
"I was unable to talk to my extended family as they all looked to us as physicians for support," she tweeted. Both children came to Boston to see her, but she saw them only through a window.
Alone, she waited for the same symptoms that had slammed her husband; but they never came — something she wants caregivers to know.
"The fear and anxiety of taking care of somebody who's COVID-positive...I am hoping that can be alleviated a little bit at least," she said. "If you've been taking care of someone, chances are you're probably positive already and if you're not sick, the chances of you getting sick are really low, so don't be afraid to take care of that person."
Singh is recovering well at home now, almost a month into his illness. During the interview, conducted via Zoom, he could be heard coughing in the background.
While in the MICU, Singh was treated with azithromycin and hydroxychloroquine — standard at MGH for critically ill COVID-19 patients — and he was also enrolled into a double-blind, randomized, placebo-controlled trial of the investigational agent remdesivir (Gilead).
Raje is not sure what, if anything, helped him turn the corner.
"I saw his inflammatory markers get worse actually — I don't think we can know if the drugs made a difference," she says. "His first dose of hydroxychloroquine was Friday night when he was admitted, and the markers continued to climb until the next Thursday."
In particular, his C-reactive protein (CRP) kept rising, reaching the 260 to 270 mg/dL range, "which to me was scary," she said. "I do think he had a cytokine storm going, but I didn't see those results."
"Understanding the immune compartment is going to be so, so critically important and what it is that we can do to boost folks' immune systems," she said.
"If you have a very high viral load and your immune system is not 100% even though you're otherwise healthy, you might be the person who ends up with that more serious response to this virus. Trying to study this in a focused way, looking at the immune compartment, looking at the antibody status, looking at the viral load — there's so much more we need to look at. Until we get the vaccine, which is probably a year-and-a-half away, we need to look at how can we develop that herd immunity so we don't have folks getting as critically ill as they do."
Despite feeling perfectly healthy, Raje is still at home. Three weeks after her first test she is still testing positive for COVID-19, waiting for two consecutive negative results 72 hours apart before she is allowed back to work at the hospital.
When she gets the green light, she plans to go work on the COVID-19 floor, if needed. "Its people like us [who have had COVID-19] who have to get back in the trenches and do the work now," she says.
"My biggest concern is that it's a very isolating experience for the COVID-positive patient. We are doing complete-barrier nursing — they are completely alone. The only person who ever walks into the room is the nurse — and the physician goes in once a day. It's so important that we don't lose sight of compassion," she says.
"That's why, in terms of alleviating anxiety, it is so important we do antibody testing so that people can actually go in and take care of these folks."
"Look for Red Flags"
Raje wants physicians to warn their self-isolating patients and caregivers to look for red flags. "There are primary care physicians who reached out to me [after my tweets] and said 'when someone calls me and says it's been 5-7 days and I am still not feeling well, I am going to look at that more seriously.'
"Part of me wanting to share this experience was basically to dispel the notion that 2 weeks into this you're going to be fine," she said, because it is not widely appreciated, she feels that "in week 2 you could become pretty sick."