Updated Epidemiology COVID-19 in Gansu Province, China - Juniper Publishers

 Juniper Publishers- Open Access Journal of Case Studies

Updated Epidemiology COVID-19 in Gansu Province, China

Authored by Shisan Bao

Abstract

The outbreak of COVID-19 became a pandemic around the world with huge morbidity and high mortality. Gansu Province is in a remote region in northwest China with a population of 26.4 million within its area of 425,900km2, but the population density in the CBD of the capital city, Lanzhou, is even bigger than Beijing. The geographic importance of Gansu is due to being a key transportation hub connecting to five provinces in northwest China. Fortunately, only a total of 92 indigenous COVID-19 cases are confirmed in Gansu till now, including both primary and secondary patients, which is considered to be a consequence of the strict screening approach applied in Gansu during the period of outbreak. Consequently, the emergency response measures to COVID-19 were able to be decreased from level 1 (top) to level III (low). Furthermore, there are some reverse transmission cases from other countries during March 2019. There were 37 confirmed COVID-19 infections among 311 evacuated Chinese from Iran. Gansu authorities undertook full preparation in advance, involving high level, streamlined cooperation between the transportation department, quarantine department and medical resource department. In addition to these organized returnees from Iran, 10 COVID-19 patients were confirmed amongst independent travellers from abroad, who unfortunately were able to scatter within the community, causing a significant potential risk to spread COVID-19. These data highlight the need for an exceptionally high level of vigilance and for a pre-emptive response, to prevent reverse infection occurring within a community where the pandemic had been successfully controlled.

Keywords: COVID-19 outbreak; SARS-CoV-2; Asymptomatic cases; Imported cases

Abbreviations: COVID-19: Coronavirus Disease 2019; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; QR code: Quick Response Code

Introduction

SARS-CoV-2 is a new virus responsible for the outbreak of COVID-19, which has been transmitted to almost every country around the world within two months since it was first identified in Wuhan, Hubei Province, China in December of 2019 [1]. Globally, 210 countries and territories have reported a total of 2,259,001 confirmed cases of COVID-19, and a death toll of 154,390 deaths up till 18 April 2020 [2]. Additional confirmed cases are being identified internationally at a rapidly growing rate.

Although Gansu Province is located in a rather remote region in China, geographically Gansu is a key transportation hub connecting to five provinces in northwest China. Furthermore, Gansu has complex terrain with mountains, plateaus, plains, and the Gobi desert [3]. The population of Gansu is 26.4 million, residing within its area of 425,900km2 [4]. Interestingly, the population density is relatively low in Gansu, however, the population density in the Central Business District of Lanzhou (Capital of Gansu) is ～50,000/km2, which is more than many of the highly dense cities in China, such as Beijing and Shanghai [5], due to its location within a narrow river valley. Gansu is about 1400km from Wuhan, the pandemic epicentre within China, consequently it has been relatively less affected by COVID-19. However, the complex geographical factors mentioned above have the potential to increase the risk of COVID-19 spread and the difficulty of prevention and control.

Discussion

Since the first case of COVID-19 diagnosed on 23 January 2020 in Gansu Province, there have been in total 92 indigenous confirmed cases in Gansu till now (18 April 2020) [6]. During the early phase of the epidemic the patients were mainly primary patients, who had travelled from COVID-19 epidemic areas, but in the second phase the patients were mainly secondary patients who had never left Gansu Province but were infected by the primary patients [7]. The relatively small number of COVID-19 cases in Gansu is probably due to the strict screening approach during the period of the outbreak, which has largely come under controlled [8], mainly as a consequence of the implementation of a series of measures, including mandatory wearing of facemasks, and extremely strict limitations on outdoor and group activities, particularly mandating almost no public and/or private social gatherings [9]. As a consequence of this largely successful containment strategy, the emergency response measures to COVID-19 were decreased from level 1 (top) to level III (low) on 2nd March 2020, because there had been no new confirmed COVID-19 case for 16 consecutive days [10]. These data provide a clear example of the critical impact of incoming travelers, mostly asymptomatic at the time of travel, initiating the local epidemic within a discrete and geographically defined population, and the effectiveness of a robust containment strategy when rigorously applied within that population.

As the epidemic progressively came under controlled in China, alarmingly rapid spread of the virus occurred within Italy and Iran [11]. In order to seek shelter from the risk of exposure to the SARSCoV2 virus and to ensure access to adequate medical resources, overseas Chinese sought to return to China from these and similar high-risk regions. As the designated province for receiving evacuees by the Chinese authority, 311 evacuated Chinese citizens from Iran were sent to Lanzhou, using two charter planes [12], and shortly after arrival 37 evacuees were confirmed to have a COVID-19 infection [13]. Local Gansu authorities undertook full preparation in advance for the evacuation, involving high level, streamlined cooperation between the transportation department, quarantine department and medical resource department, to make sure these people would not contact any others and would be effectively quarantined within designated hotels, to isolate for 14 days. However, in addition to these organized returnees from Iran, 10 COVID-19 patients were confirmed amongst independent travelers from abroad, including oversea students, general travelers, and business workers [14]. Unfortunately, many of these infected returnees were able to scatter within the community without being quarantined, which caused a significant potential risk to spread COVID-19. The failure to quarantine many of these returnees was largely due to their early return, when the epidemic was not considered to be serious outside of China, or in some cases, they were exhibited an asymptomatic infection [15]. These data highlight the need for an exceptionally high level of vigilance and the need for a pre-emptive response, to prevent reverse infection occurring within a community where the pandemic had been successfully controlled, from returnees from other international locations, where the extent of infection at those distant sites had not yet been fully realized.

After many weeks of the lockdown all over China, especially in Hubei Province, the Chinese government has launched a health QR code system on the smartphone to keep the virus from further spreading, as China eases the lockdown allowing residents to restart normal activities, e.g. working and studying [16]. The green code means individuals are ok to participate these activities without risk of infection. However, it has been noticed that one asymptomatic person with a green code from Hubei Province was subsequently confirmed as a COVID-19-infected patient in a hospital in Lanzhou on 28 March 2020 [17]. Furthermore, other asymptomatic cases in other regions are constantly being reported. A recent report has shown that there is no difference in the secondary infection rate within the population following exposure to confirmed cases exhibiting symptoms compared to asymptomatic cases [18]. Consequently, the Chinese government has urged responsible authorities to focus on detection of asymptomatic cases and authorities have begun to report asymptomatic cases from 1st April 2020 [19]. In an attempt to address the issue of asymptomatic carriers, Australia has proposed a system of sentinel testing of people, where random, but potentially risky, individuals will be tested irrespective of having any symptoms. The aims of this measure will be, firstly, to attempt to gauge the extent of asymptomatic carriers, and secondly, to attempt to detect infection clusters before any symptomatic individuals develop symptoms, to then guide targeted testing amongst the contacts of that sentinel individual [20]. A good example of this approach from Australia would be to test several sentinel staff members from every aged care facility, irrespective of symptoms. Clearly, if a sentinel staff member is determined to be an asymptomatic carrier, authorities would then target testing and robust quarantine within the affected aged care facility.

The most important task for the Chinese authorities is to identify these potential COVID-19 risk populations, including local residents and/or overseas returnees, using a more sensitive diagnostic approach and probably also to offer some more flexible quarantine locations to deal with people who have been determined to be within an infection cluster. These data highlight the substantial difficulties associated with the detection of, and the disastrous potential for spread from, asymptomatic carriers.

Conclusion

In conclusion, COVID-19 is has been well controlled within the defined population of Gansu Province of China, which represents an interesting case study of epidemic spread and the effectiveness of a range of responses to that spread. However, continuing robust vigilance, combined with aggressive control measures remains essential, particularly in relation to documented cases of reverse transmission from returning overseas Chinese citizens and other travelers, and/or asymptomatic SARS-CoV-2 virus carriers, who should be taken care of rigorously to ensure the final complete success of pandemic containment to preventing second outbreak of COVID-19.

 

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Malignant Arterial Hypertension Revealing Focal Segmental Hyalinosis - Juniper Publishers

 Juniper Publishers- Open Access Journal of Case Studies

Malignant Arterial Hypertension Revealing Focal Segmental Hyalinosis

Authored by N Mahoungou Mackonia

Abstract

Malignant arterial hypertension (MAH) is a hypertensive emergency associated with grade III or IV retinopathy. Focal segmental hyalinosis (FSH), of late onset, is one of its rare entities, with an incidence of 7 per million, responsible for 15-20% of nephrotic syndromes in adults. We report a case of segmental and focal hyalinosis in a 27-year-old patient with no previous history of malignant hypertension, who consulted us for neurosensory signs and ocular redness. The clinical examination showed a hypertensive peak at 240/150mm Hg with myocardial hypertrophy confirmed by electrocardiogram and transthoracic echo. A fundus examination completed by an optical coherence tomography revealed a KIRKENDAL stage III retinopathy associated with an occlusion of a branch of the central retinal vein. An impure nephrotic syndrome associated with renal failure was observed. A biopsy of a fragment of renal parenchyma supplemented by pathology was performed in favour of FH with chronic tubulointerstitial disease. The patient was managed urgently with nicardipine 3-5mg/hr by electric syringe within 24 hours, followed by a triad of antihypertensive drugs consisting of amlodipine, indapamide and Ramipril at full dose combined with prednisone 60mg/day for 4 months with a 6 month taper. The evolution was marked by a normalisation of the renal function, disappearance of the proteinuria and even a normalisation of his eye fundus after one year. FSH constitutes a group of heterogeneous pathologies with multiple causes, of which malignant hypertension is a secondary one, requiring not only symptomatic but also etiological management.

Keywords: Malignant arterial hypertension; Focal segmental hyalinosis

Abbreviations: MAH: Malignant Arterial Hypertension; FSH or FH: Focal Segmental Hyalinosis; BP: Blood Pressure

Introduction

Malignant arterial hypertension (MAH) is a nosological entity defined by an abrupt rise in blood pressure (BP>180/110mm Hg) associated with grade III or IV retinopathy [1]. It is a hypertensive emergency with a poor prognosis, which has become exceptional nowadays in countries with adequate medical coverage [2]. Malignant hypertension causes multivisceral failure as a result of ischaemia secondary to multiple lesions in the vascular endothelium. Focal segmental glomerulosclerosis, which occurs later than retinal and cerebral damage [1], is one of its consequences. This entity is rare with an incidence of 7 per million, responsible for 15 to 20% of adult nephrotic syndromes [3]. We report a case of segmental and focal hyalinosis in the setting of malignant hypertension.

Case Report

We report the case of a 27 year old patient, with no particular personal or family history and a body mass index of 23kg/m², hospitalized in the cardiology department for malignant hypertension (hypertension). The diagnosis was made in the presence of headaches, dizziness, palpitations, ocular redness and a sudden drop in visual acuity, which led to a consultation in ophthalmology. The clinical examination revealed a hypertensive peak of 240/150mm Hg with a heart rate of 70 beats/min and discrete oedemas of the lower limbs, whitish in colour, taking the cup. left ventricular hypertrophy was found on electrocardiogram confirmed by transthoracic echocardiography (SIV/VGTD=13mm; PP/VGTD= 13mm). A workup was performed, including a fundus, supplemented by an optical coherence tomography (OCT) scan, showing bilateral papilledema; central hemorrhage predominantly in the left eye; macular edema more to the right and occlusion of a branch of the central vena mater. The biological work-up showed an impure nephrotic syndrome with 24-hour proteinuria at 6.6g/24h, microscopic haematuria (15,000 red blood cells/field) on cytobacteriological examination of the urine, renal failure at 23.5mg/l, GFR at 35.5ml/mn/m² and urea at 0.81g/l with hypo albuminemia at 27g/l and hypo complement C3 at 0.25g/l and hypertriglyceridaemia at 3g/l. A biopsy of a fragment of the renal parenchyma, completed by a pathological assessment, was carried out in favour of a focal segmental hyalinosis (FSH) with chronic tubulointerstitial damage. The workup for secondary FH was normal, including: methoxylate levels, thyroid hormones, plasma renin, blood aldosterone, blood cortisol, blood glucose, complete serology and complete immunology. Abdominal ultrasound, renal artery Doppler and renal bladder ultrasound were normal as was the abdominopelvic CT scan. The diagnosis of FSH probably secondary to malignant hypertension was made. The patient was admitted to hospital as an emergency, conditioned with monitoring ; Loxen at 3mg/hr to 5mg/hr by electric syringe over 12hrs with an increase of 0.5mg/15min was administered, then relayed by amlodipine 10mg/day, Ramipril 10mg/day and bisoprolol 2.5mg/day. Atorvastatin was administered at 40mg/dr followed by corticosteroid therapy with prednisone 60mg/dr (1mg/Kg/dr) for 4 months with gradual taper for 6 months combined with vitamin D, calcium, potassium supplementation and gastric dressing with pantoprazole 30mg/dr were administered. The patient was admitted to hospital for one week and then discharged with a blood pressure of 130/70mmHg with close monitoring for 1 year. The evolution is marked by an improvement in visual acuity, neurosensory signs and a balance in blood pressure. On the biological level, there was an improvement in renal function (creatinine level at 12mg/l with a GFR of 77ml/mn) with disappearance of the 0.2g/l proteinuria and an improvement in his eye fundus.

Discussion

Focal segmental hyalinosis (FSH) is a rare kidney disease with an incidence of 7 per million. It affects both children and adults with peaks at 6-8 and 20-30 years of age, respectively [3]. FSH is the leading cause of nephrotic syndrome in the United States (accounting for approximately 35% of cases). It is somewhat less common in Europe, 12% in Spain. In 2010, in France, 2.2% of incident patients with end-stage renal disease have FSH (Kidney Registry 2010) [4,5]. FSH is responsible for 15-20% of adult nephrotic syndromes [3]. The onset of nephrotic syndrome in FH is due to a disturbance of renal function because of glomerular damage and scarring. The disease is due not only to glomerular sclerohyaline lesions which may be associated with immunological deposits (IgM, C3) within these lesions, but also to podocyte damage, resulting in the loss of the physical integrity of the filtering barrier. A protein produced by podocytes, called integrin αvβ3, is crucial in 'gluing' podocytes to the structure of the glomeruli.

Dysregulation of the αvβ3 integrin pathway could lead to glomerular filtration dysfunction. Damaged glomeruli allow the passage of large molecules, especially proteins. Nephrotic syndrome is often impure, i.e. associated with hypertension and/or haematuria and/or organic renal failure [3,6,7].

FSH may be primary without any cause found, in which case, AH progressively sets in with the renal disease thus worsening the prognosis, or it may be secondary in relation to several pathologies including viral, drug-induced, genetic, AH, etc.; in this case, AH precedes the clinical picture [4,7]. Thus, malignant hypertension can cause a variety of lesions, including glomerular endothelial and epithelial cell damage, glomerular hyperfiltration, increased renin-angiotensin-aldosterone system, and endothelial-epithelial interaction, leading to the development of secondary FSH and proteinuria, but less so than in the primary forms [7,8]. Only a few clinical studies describe the development of FSH in malignant hypertension and these studies have reported that it can occur in primary malignant hypertension with nephrotic-like proteinuria, and may contribute to renal dysfunction [8]. Early treatment of hypertension is essential with a blood pressure target of 130mmHg systolic and 80mmHg diastolic for patients with significant proteinuria > 1g/24h. High-dose corticosteroid therapy is the first-line treatment of choice in primary FH [9]. But the rare genetic forms are rather cortico-resistant [7].

Our patient was 27 years old, the age favorable for peak FH as reported in the literature. He presented with FH secondary to malignant AH, which can be explained by a very prominent and prominent AH, rarely seen in primary FH. Although no etiology of malignant AH was found in our patient, the evolution was marked by an improvement of the clinical picture under 3 antihypertensive drugs and corticotherapy.

Conclusion

Malignant hypertension is a serious disease with several complications including FSH. The aetiologies are multiple and must be found. The management must be done urgently because it conditions the vital prognosis of the patient.