Question normal

CPT Dorothy Daniel, MD and Dr. Christina Schofield, MD FACP FIDSA
Madigan Army Medical Center

The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S.
Government.

1:
Date of Presentation: March 25, 2020
53 year old female with a history of hypertension on losartan presenting with 1 week of anosmia, sinus pressure and dry cough. She is a health care worker and had been in contact with patients infected with SARS-CoV-2 within the last 2 weeks. Patient reported that her first symptoms were sinus pressure and congestion, with loss of smell and diminished taste. She then felt feverish, with temperature peaking to 99.7 F. Other associated symptoms included myalgia, headache and dry cough.
PCR for SARS-CoV-2 returned positive 1 week after onset of symptoms.
Patient continues to have persistent anosmia and dry cough approximately 1 week after her test result.

2:
Date of Presentation: March 27, 2020
63 year old male with a history of hypertension on candesartan and COPD presenting with 2 weeks of anosmia, shortness of breath and productive cough. He did not have known exposure to SARS-CoV-2. Patient reported onset of respiratory symptoms with concurrent chills. He did not check his temperature at home. He also felt extremely fatigued and lost his appetite.
PCR for SARS-CoV-2 returned positive 2 weeks after onset of symptoms.
Patient reported improvement of symptoms and appetite by time of testing.

3:
Date of Presentation: March 26, 2020
63 year old male with a history of Type II diabetes and hypertension on losartan presenting with 3 days of anosmia, dry cough and nausea. The patient’s wife and co-workers had recent upper respiratory symptoms as well. Patient denied fevers/chills and shortness of breath.
PCR for SARS-CoV-2 returned positive 3 days after onset of symptoms.
Patient is early in his clinical course, but remains stable at home without development of shortness of breath.

4:
Date of Presentation: March 26, 2020
46 year old female with a history of sickle cell trait and factor VII deficiency presenting with 4 days of anosmia, dry cough and fatigue. She reported travel to New York City in the days preceding symptom onset. She experienced chills, with temperature peaking at 99.6 F. She then developed nausea and diarrhea.
PCR for SARS-CoV-2 returned positive 4 days after onset of symptoms.
Patient is early in her clinical course, but remains stable at home without development of shortness of breath.

5:
Date of Presentation: March 22, 2020
43 year old female with a history of epilepsy and Celiac disease presenting with 1 week of anosmia, dry cough and fatigue. She denied specific sick contacts or known exposures. She experienced chills, with temperature peaking at 99.2 F. She did not have shortness of breath or GI upset.
PCR for SARS-CoV-2 returned positive 1 week after onset of symptoms.
Patient remains stable at home 1 week after positive testing with resolution of most symptoms. Her anosmia persists.

Lessons Learned:
As illustrated in the preceding cases, anosmia and dysgeusia are emerging as early, key clinical signs of COVID-19. In fact, the American Academy of Otolaryngology has proposed anosmia, hyposmia, and dysgeusia be added to screening tools for COVID-19. Patients in this case series were diagnosed in the outpatient setting and have remained clinically stable since presentation. Close follow up is planned to track symptom resolution. The mechanism for anosmia has yet to be defined. Preliminary studies show SARS-CoV-2 utilizes ACE2 and the cell surface protease TMPRSS2 on host cells to gain entry. RNA precursors for both proteins have been found within human olfactory mucosa, suggesting a portal of entry and a mechanism for anosmia. Others studies have shown treatment of hypertension with ACE inhibitors and ARBs cause upregulation of ACE2. Further analysis is required to fully elucidate the cause of anosmia and the correlation between RAAS blockade with vulnerability to COVID-19. In the meantime, clinicians should consider adding anosmia and dysgeusia to their review of systems for suspected cases.

References:
Brann D, Tsukahara T, Weinreb C, Logan D, Datta S. Non-neural expression of SARS-CoV-2 entry genes in the olfactory epithelium suggests mechanisms underlying anosmia in COVID-19 patients. bioRXiv, preprint. doi: doi.org/10.1101/2020.03.25.009...
Ferrario CM et al. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation. 2005 May 24;111(20):2605-10. Epub 2005 May 16.