HAS UNDERTREATMENT OF SEVERE COVID ILLNESS BEEN WIDESPREAD? A PEDIATRIC RHEUMATOLOGIST’S PERSPECTIVE

Abstract

This article addresses the possibility that undertreatment of patients with severe COVID illness has been widespread and has resulted in a high number of preventable COVID deaths. In most cases of COVID infection (perhaps as many as 98 % of those infected) the immune system safely and efficiently neutralizes the virus, such that the patient is either asymptomatic or experiences only mild moderate symptoms (which may be temporarily miserable, but not life threatening or organ threatening and do not require hospitalization). A small percentage of patients with COVID experience severe illness, and in most of these cases the most threatening aspects of the illness appear to be due to an excessive immune reaction to the virus - hyperinflammation and “cytokine storm.” This hyperinflammatory state/cytokine storm is not new or unique to COVID infection. For years it has been known that life threatening hyperinflammation and cytokine storm occur with many bacterial infections and with many other viral infections, including seasonal influenza infection. Over the past four decades, pediatric rheumatologists have developed extensive experience with excessive immune reactions (hyperinflammation/cytokine storm), including how to bring them under control. Much of this experience has come from managing systemic onset juvenile idiopathic arthritis that has become complicated by macrophage activation syndrome and “cytokine storm.” The pediatric rheumatology approach to hyperinflammatory states is characterized by: early, appropriately compulsive, anticipatory, serial monitoring; prompt and appropriately bold immunosuppression of hyperinflammation, carefully using corticosteroid and anti cytokine therapies (e.g. anakinra); and careful, anticipatory, tailored adjustments along the way - always balancing concerns about risks versus benefits. In this article it is suggested that the pediatric rheumatology approach to control of hyperinflammatory states be applied to the management of severe COVID illness.