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May 21, 2020

Unless you study immunology you probably have never heard of “cytokine storm.” In fact, you probably never heard of “cytokine.” As we approach different methodologies for treating sick patients with Corona-19 virus, you will begin hearing this term in the media.

Here’s an analogy I present to patients; There is a burglary at the local bank. The sirens alarm the police and a quick response begins. The police arrive with multiple cars and perhaps armored vehicles. The police catch the criminal, takes him or her to jail and the case is closed.  That would be considered a normal response to an invasion.

Suppose the burglar sets off the bank alarm, the police come followed by SWAT, the CIA and FBI and soon armored tanks are surrounding the bank. Later, fighter jets launch laser guided missiles onto the bank destroying everything within 5 blocks. A massive fire erupts and many innocent people die. We would consider that excessive force associated with massive collateral damage.

The body’s immune system works very much like how society handles a burglary, a riot, or war. Very much like the Army, Navy, Air Force and Marine Corp and Coast Gard, the immune system has a variety of cells that carry out specific functions. If a splinter causes infection in our finger, there will be a defense response that is very limited. If we get pneumonia, however, a more massive defense system is launched to prevent death and to resolve the pneumonia. If we get a parasitic infection, other specific cells are involved to resolve the infection. Viral infections involve another subset of cells for defense. All of the various defense systems in our body are coordinated by chemicals called cytokines. Certain cytokines are produced to fight a minor infection whereas other cytokines are secreted by immune cells to fight major infections. Other cytokines are produced to fight cancer cells.

The commonality amongst the many types of cytokines is that they produce inflammation. Swelling, redness, itch, pain, pus development, mucous secretions and leakage from blood vessels or lung tissue all result from inflammation. Such inflammation is good since it is essential to destroy viruses, bacteria, parasites and cancer cells. However, inflammation is like a sharp cutting knife; it is essential in cutting your food but it can also cut YOU!

A cytokine storm is when there is an invasion (in this case, Corona-19 virus) and cytokines OVER REACT, causing a similar situation like I described with the massive unnecessary disruption of the bank robbery. When cytokines over react, there is massive swelling, pain, leakage and cell death. Since Corona-19 virus loves the lung tissue initially, much of the healthy lung tissue is destroyed in the process of fighting the virus. When healthy lung tissue dies, we can’t breathe.

Since our lungs are vital organs, when they are heavily destroyed, we die. If we survive long enough, other tissues are destroyed in the liver, kidney or blood vessels leading to strokes, kidney and/or liver death. The intense inflammation of blood vessels can cause clots anywhere in the body.

Most of the world’s research is now focused on how to block or slow down certain cytokines to decrease massive inflammation. In a sense, it is the body’s inflammation that kills us and not necessarily the virus. We already have an array of medications that are aimed at certain cytokines and hopefully, we will have a treatment plan that will decrease mortality and shorten morbidity. At that point, our fear of the virus will subside since, if stricken by the virus, we know our chances of dying would become very unlikely.

Hospitals now know how sneaky the virus is. It implants itself into the mouth and nose, travels down to the lung and very quietly “sets up camp.” This is when there is NO hint of us being sick; no fever, malaise or anything! Yet, there is an enemy in our lungs doing damage. After so much destruction has occurred and the immune systems recognizes the threat, the “cytokine storm” erupts. There is so much collateral damage during this war that death is a result of the massive destruction and not the virus.

My hope is that over the next 3 months the death rate from COVID-19 approximates that of influenza virus. Now that this illness is being treated early with cytokines inhibitors and/or antiviral drugs, I hope to see the number of ICU admissions (and hence death) decrease.

One very early detector of the disease being present before symptoms erupt is measuring the oxygen level in the blood. This is easily done by a pulse oximeter (approximately $35.00-$50.00 at the drug store) that is routinely done in the ER. We now realize the oxygen level drops to dangerous levels even before we have cough chest pain or fever. It is becoming the ideal screening tool and not temperature taking.

…will talk later…. Dr. D.

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