Covid-19 新冠病毒 感染症的近期 更新訊息 2021-02-19
UpToDate 2020-12-17 最新研究彙整：
https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-clinical-features
*** 新冠肺炎的無症狀病人，大約佔所有確診者的 30 - 40%。
*** 新冠肺炎的有症狀病人：81% 輕症，無肺炎或輕微肺炎。
14% 重症，呼吸困難，低血氧，或 >50% 在 24 - 48小時內出現肺影像異常。
5% 危急，呼吸衰竭，休克，或多重器官衰竭。
死亡率 2.3%
輕症與重症無死亡案例。
●Mild disease (no or mild pneumonia) was reported in 81 percent.
●Severe disease (eg, with dyspnea, hypoxia, or >50 percent lung involvement on imaging within 24 to 48 hours) was reported in 14 percent.
●Critical disease (eg, with respiratory failure, shock, or multiorgan dysfunction) was reported in 5 percent.
●The overall case fatality rate was 2.3 percent; no deaths were reported among noncritical cases.
*** 重症的危險因子：
● 年紀大： 70歲以上比較危險，比較嚴重。小孩與青春期通常輕症。
● 有共病較危險：
• 心血管疾病 Cardiovascular disease
• 糖尿病 Diabetes mellitus
• 高血壓 Hypertension
• 慢性肺疾 Chronic lung disease
• 癌症 Cancer (in particular hematologic malignancies, lung cancer, and metastatic disease) [66]
• 慢性腎病 Chronic kidney disease
• 肥胖症 Obesity
• 抽菸 Smoking
● 社經背景與性別：
男性得病率與危急率較高。
黑人、西班牙裔、南亞種族得病率與死亡率較高。
社經地位無差別。
● Laboratory abnormalities 檢驗異常 預後較差
•Lymphopenia 淋巴球低下
•Thrombocytopenia 血小板低下
•Elevated liver enzymes 肝酵素升高(肝功能異常)
•Elevated lactate dehydrogenase (LDH) 乳酸脫氫酶升高
•Elevated inflammatory markers (eg, C-reactive protein [CRP], ferritin) and inflammatory cytokines (ie, interleukin 6 [IL-6] and tumor necrosis factor [TNF]-alpha) 發炎標誌升高
•Elevated D-dimer (>1 mcg/mL) D-D 雙合試驗升高
•Elevated prothrombin time (PT) 凝血酵素原時間升高
•Elevated troponin 肌鈣蛋白升高
•Elevated creatine phosphokinase (CPK) 肌酸磷酸激酶升高
•Acute kidney injury 急性腎損傷
● Viral Factors 病毒 RNA量多則比較嚴重
*** CLINICAL MANIFESTATIONS 臨床表現：
● Incubation period 潛伏期： 大部分 4 - 5 天，很少超過 14天。
● Initial presentation 初期表現：
初期較多咳嗽、肌肉痛、頭痛，其他如：腹瀉、喉嚨痛、嗅覺或味覺異常。
肺炎是較嚴重感染的表徵，主要包括：發燒、咳嗽、呼吸困難、與肺部影像雙側浸潤。
統計 37萬人的症狀：
●Cough in 50 percent 咳嗽
●Fever (subjective or >100.4°F/38°C) in 43 percent 發燒
●Myalgia in 36 percent 肌肉痛
●Headache in 34 percent 頭痛
●Dyspnea in 29 percent 呼吸困難
●Sore throat in 20 percent 喉嚨痛
●Diarrhea in 19 percent 腹瀉
●Nausea/vomiting in 12 percent 噁心，嘔吐
●Loss of smell or taste, abdominal pain, and rhinorrhea in fewer than 10 percent each 嗅覺或味覺喪失，腹痛、流鼻水，小於 10%
● Course and complications 病程與併發症：
●Respiratory failure – Acute respiratory distress syndrome (ARDS) is the major complication
呼吸衰竭
●Cardiac and cardiovascular complications – Other complications have included arrhythmias, acute cardiac injury, and shock
心血管併發症
●Thromboembolic complications – Thromboembolic complications, including pulmonary embolism and acute stroke
血栓栓塞併發症
●Neurologic complications – Encephalopathy is a common complication of COVID-19, particularly among critically ill patients
神經學併發症，最常見腦炎
●Inflammatory complications – Some patients with severe COVID-19 have laboratory evidence of an exuberant inflammatory response, with persistent fevers, elevated inflammatory markers (eg, D-dimer, ferritin), and elevated proinflammatory cytokines; these laboratory abnormalities have been associated with critical and fatal illnesses
發炎併發症
●Secondary infections – Secondary infections do not appear to be common complications of COVID-19 overall, although data are limited [143,144]. In a review of nine studies, mainly from China, the reported rate of bacterial or fungal coinfections was 8 percent (in 62 of 806); these included mainly respiratory infections and bacteremia
二次感染。不常見，但有報告 8% 有細菌或黴菌的同時感染。
● Recovery and long-term sequelae 恢復與長期後遺症：
● 輕症者常在二週內恢復。
● 重症常需要二至三個月恢復。
● 最常見的持續症狀包括：疲倦、呼吸困難、胸痛、咳嗽、與認知異常。
某些資料顯示有可能有呼吸異常與心臟後遺症。
● 有些病人恢復之後，呈現持續或是反覆的核酸檢驗陽性。
雖然復發或重新感染的可能性不能完全排除，但是證據顯示可能性不高。
● LABORATORY FINDINGS 檢驗表現 (與前述差不多)
● IMAGING FINDINGS 影像表現
● Chest radiographs – 胸部X光
香港的研究，20%病人的整個病程胸部X光都正常。
Common abnormal radiograph findings were consolidation and ground-glass opacities, with bilateral, peripheral, and lower lung zone distributions; lung involvement increased over the course of illness, with a peak in severity at 10 to 12 days after symptom onset.
● Chest CT – 胸部電腦斷層
雖然胸部電腦斷層比胸部X光靈敏，但胸部電腦斷層仍然無法得到疾病的確診。
● Chest CT in patients with COVID-19 most commonly demonstrates ground-glass opacification.
胸部電腦斷層常見的表現：
●Ground-glass opacifications – 83 percent
●Ground-glass opacifications with mixed consolidation – 58 percent
●Adjacent pleural thickening – 52 percent
●Interlobular septal thickening – 48 percent
●Air bronchograms – 46 percent
● Lung ultrasound – 肺部超音波 – 其他檢查無法取得時可做。
● SPECIAL POPULATIONS 特殊族群
● Pregnant and breastfeeding women — 懷孕與哺乳婦女
預防、評估、診斷、治療與一般人差不多。
● Children — 小孩 — 有症狀的不多，另看專文。
● People with HIV — 後天免疫不全病毒 HIV 感染者 另看專文。
SUMMARY AND RECOMMENDATIONS 總結與建議
●The clinical spectrum of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection ranges from asymptomatic infection to critical and fatal illness. The proportion of infections that are asymptomatic is uncertain, as the definition of "asymptomatic" varies across studies and longitudinal follow-up to identify those who ultimately develop symptoms is often not performed. Nevertheless, some estimates suggest that up to 40 percent of infections are asymptomatic. (See 'Asymptomatic infections' above.)
感染者由無症狀，危急，至病危都有。
●Most symptomatic infections are mild. Severe disease (eg, with hypoxia and pneumonia) has been reported in 15 to 20 percent of symptomatic infections; it can occur in otherwise healthy individuals of any age, but predominantly occurs in adults with advanced age or certain underlying medical comorbidities (table 1). In North America and Europe, Black, Hispanic, and South Asian individuals are also more likely to have severe disease, likely related to underlying disparities in the social determinants of health. (See 'Severity of symptomatic infection' above.)
大部分輕症。
●The incubation period from the time of exposure until the onset of symptoms is four to five days on average, but may be as long as 14 days. (See 'Incubation period' above.)
潛伏期 大部分 4 - 5 天，但可以長到 14天。
●Cough, myalgias, and headache are the most commonly reported symptoms. Other features, including diarrhea, sore throat, and smell or taste abnormalities, are also well described (table 3). Pneumonia, with fever, cough, dyspnea, and infiltrates on chest imaging, is the most frequent serious manifestation of infection. There are no specific clinical features that can yet reliably distinguish COVID-19 from other viral respiratory infections. (See 'Initial presentation' above.)
●Certain laboratory features, such as lymphopenia, elevated D-dimer, and elevated inflammatory markers have been associated with severe COVID-19 (table 2). (See 'Laboratory abnormalities' above.)
●Acute respiratory distress syndrome (ARDS) is the major complication in patients with severe disease and can manifest shortly after the onset of dyspnea. Many other complications have been reported, including thromboembolic events, acute cardiac injury, kidney injury, and inflammatory complications. (See 'Course and complications' above and "Coronavirus disease 2019 (COVID-19): Critical care and airway management issues", section on 'Clinical features in critically ill patients' and "Coronavirus disease 2019 (COVID-19): Hypercoagulability" and "Coronavirus disease 2019 (COVID-19): Evaluation and management of cardiac disease in adults" and "Coronavirus disease 2019 (COVID-19): Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis".)
●Persistent symptoms following acute COVID-19 are discussed in detail elsewhere. (See "Coronavirus disease 2019 (COVID-19): Evaluation and management of adults following acute viral illness", section on 'COVID-19 recovery'.)
●The possibility of COVID-19 should be considered primarily in patients with compatible symptoms (table 3), in particular fever and/or respiratory tract symptoms, who reside in or have traveled to areas with community transmission or who have had recent close contact with a confirmed or suspected individual with COVID-19. If possible, all symptomatic patients with suspected SARS-CoV-2 infection should undergo testing. Testing for and diagnosis of COVID-19 are discussed in detail elsewhere. (See "Coronavirus disease 2019 (COVID-19): Diagnosis", section on 'Diagnostic approach'.)
有類似症狀即需考慮是否為新冠病毒 Covid-19 感染
●When COVID-19 is suspected, infection control measures should be implemented. Infection control in the home and in health care settings is discussed in detail elsewhere. (See "Coronavirus disease 2019 (COVID-19): Infection control in health care and home settings", section on 'Infection control in the health care setting'.)
懷疑新冠病毒 Covid-19 感染即需採取感控措施。
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*** Covid-19 新冠肺炎的嚴重病人，使用 Bevacizumab (Avastin) 治療可以改善病況。
https://www.nature.com/articles/s41467-021-21085-8.pdf
http://www.tccf.org.tw/old/medecine/nm_29.htm
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*** Covid-19 新冠肺炎的輕症病人，大約 1/3病人會有持續 6 週的症狀。
瑞士日內瓦的醫院統計 669位新冠肺炎的輕症病人，發現大約 1/3病人會有持續 6 週的症狀，
14% 疲倦，12% 喪失嗅覺，9%呼吸急促，6% 持續咳嗽，3%頭痛。
https://www.acpjournals.org/doi/10.7326/M20-5926
2021-02-19
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