The schools are back! I bet the students are glad to be returning to something near normality. I read that the bane of mask-wearing – getting a damp face and having your spectacles steam up – may help stop transmission as the virus particles will get caught in the damp cloth. Any crumb will do… let’s see whether there is another spike which can be attributed to transmission in school, or outside the gates. I was impressed that the missing person carrying the Brazilian variant who had not correctly filled in their paperwork after returning from there has been identified, after the search narrowed to a handful of house in Croydon. Nevertheless deaths and “cases” continue to fall, which is being attributed to the New year lockdown, the increasing number of vaccinated people, but not to the natural history of a an epidemic condition. So – the lockdown is lifting, vaccinations are continuing to “ramp up” and we will see what happens to the figures. My usual comparative graph from OurWorldinData is impressive for the UK. What are we doing differently? Basically vaccinating a lot more people than the other nations shown. So I suspect that vaccination is having a major impact. The news from Italy on hospital cases is not good, reflecting the rise shown.
The BMJ carried a Clinical update this week titled “Acute Covid-19 and multisystem inflammatory disease” (Rubens et al, BMJ 2021;372:n385), to which I responded:
“The list of types of multi-system inflammatory diseases (MIS-C) is almost identical to the list of paediatric cytokine storm syndromes listed in Cron and Behrens’ textbook (1). I think this is a story of the blind men and the elephant; different observers are seeing slightly different presentations, giving them different names but not appreciating that they are all the same thing, so perhaps this article will help to bring together the different syndromes under one name.
Kawasaki disease is successfully treated with anakinra, which is a safer anti-interleukin than tocilizumab because it has a shorter half-life. So it may have a useful role in coronavirus-induced cytokine storm (it is interesting to note that it is also used in the treatment of systemic juvenile chronic arthritis, which might almost be described as a slow-burning hyperimmune response). I am not the first to suggest this in print (2).
Dr Menakaya [author of the first Rapid Response] has commented on ethnic differences in incidence. Cron and Behrens have noted (with several of the cytokine storm syndromes they have described) that this is likely to be due to a mutation on chromosome 3 which results in increased susceptibility of the ACE-2 receptor to external stimuli – which is a mutation also associated with blood group A. There may also be influence from a change on chromosome 19. I have flagged this in previous Rapid Responses as something that needs to be thoroughly researched before pinning all the blame on societal factors, which may well be relevant to infection acquisition but cannot sensibly be a reason why infection progresses to severe disease.
I suggest every clinician involved with the management of Covid-19 should read Cron and Behrens’ textbook.
References:
(1) Randy Q Cron, Edward M Behrens. Cytokine Storm Syndrome. Springer, 2019
(2) Naim Akhtar Khan. Anakinra for severe forms of Covid-19. Lancet 2020. DOI: https://doi.org/10.1016/S2665-9913(20)30273-3“
There are 43 references, but Cron & Behrens is not among them, which seems strange when the book contains much of the background and sets down the reasons for considering the different syndromes, which the authors of the paper aggregate as multisystem inflammatory disease (MIS-C), as variations on a common theme. That’s why I suggested that every clinician involved in managing Covid-19 should read it.
“The Times” today published an extract from another new book by Jonathan Calvert and George Arbuthnott called “Failure of State: The Inside Story of Britain’s Battle with Coronavirus” (Mudlark, coming out next week). I think I need to spend £20 on it before deciding whether to retitle my collected blogs (publication date still not decided) as Failure of State: the Outside Story: Fruitless Banging on the State’s Window”. Although “A New Journal of the Plague Year” is perhaps less confrontational.
Went to see the heronry below Winchelsea this morning, but most of them had gone fishing. I spotted a couple, but on blowing up my photos there were still four on their precarious nests. A fascinating sight. Does one need to go to the Serengeti when there’s nature like this on your doorstep?
The Wry Observer 