New in second wave: lasting symptoms, eye infection, black fungus

Some symptoms were similar in both waves, such as dry cough and breathing difficulty. Some additional symptoms were observed more frequently during the second wave, such as eye infection, hearing problems, and loose motion.

The second wave of coronavirus infections in India has been notably different from the first in infectiousness, severity and symptoms. Experts have expressed concern about long Covid syndrome, or the persistence of Covid-19 for a long time after the initial illness.

Covid-19 symptoms, then & now

Some symptoms were similar in both waves, such as dry cough and breathing difficulty. Some additional symptoms were observed more frequently during the second wave, such as eye infection, hearing problems, and loose motion.

“More cases of secondary infection and fungal infection (black fungus) were reported during the second wave,” said Dr Abha Mangal, specialist, Community Health Department, St Stephen’s Hospital, New Delhi.

“Symptoms in the first wave were more flu-like, but there were symptoms that did not fit into any criteria in the second wave, like involvement of the gastrointestinal tract,” said Dr Subhash Salunkhe, technical advisor to the Maharashtra government on Covid-19.

In a correspondence published on Wednesday in The Lancet Respiratory Medicine on the implications of the second wave in India, experts have written that the second wave had severe consequences in the form of spiralling cases, reduced supplies of essential treatments and increased deaths particularly in the young population. “Understanding why the second wave has been more dangerous than the first could help to identify the potential areas of diagnostics to target with future control strategies,” they have written.

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More younger patients

According to experts such as Dr Mangal, by and large, the demographic profile of cases in both waves has been similar, with some differences. While mortality remained higher among the elderly and people with co-morbidities, young adults suffered higher mortality during the second wave than during the first. More younger people were affected and faced earlier manifestation of hypoxia , said Pune-based infectious diseases specialist Dr Parikshit Prayag.

According to an ICMR report, the average age of cases was 50 years in the first wave and 49 in the second. Wave two had more asymptomatic patients, but mortality rate between the two waves is not different.

Higher severity

A large new study from North India, posted on a preprint, has found overall higher disease severity at admission and higher mortality rates in the second wave, especially in younger patients, said Dr Sandeep Budhiraja, Senior Director, Institute of Internal Medicine, Max Super Speciality Hospital, New Delhi.

The study assessed records of over 14,000 and 5,000 cases (first and second waves respectively) admitted to a network of ten hospitals. Severe cases accounted for 39.4% of the patients in the second wave, compared to 32.7% in the first. The number of patients with comorbidities such as diabetes, hypertension and chronic kidney disease, too, was higher in the second wave (59.7% vs. 54.8%). A higher severity of disease was observed at the time of admission, which necessitated a greater requirement for oxygen.

Long Covid syndrome

The second wave saw protracted long Covid, features of which were mainly fatigue, brain fog and neuromuscular complications, said Dr Shashank Joshi, expert in Maharashtra’s Covid task force. “We continue to see lung and heart complications but the main symptoms like brain fog and fatigue have been observed in a large number of people who have recovered in the second wave.”

The need for post-Covid vigilance is up to 100 days in the second wave, Dr Joshi said. In the first wave, it was predominantly 2 weeks.

Dr Kirti Sabnis, infectious diseases specialist at Fortis Hospital, Mumbai, said a lot of patients have post-Covid syndrome even with mild to moderate infection. This includes fatigue, anxiety and occasional breathlessness. “Especially those who were sick and in the ICU suffer profound weakness and can need long-term oxygen care at home due to lung damage,” Dr Sabnis said.

Bacterial & fungal infections

There have been unusual bacterial, viral and fungal infections, and even a spurt of mucormycosis (black fungus), independent of diabetes and steroid therapy, Dr Joshi said.

“We are seeing anecdotal cases of arterial thrombosis leading to infarction of the legs and amputation. Bleeding is also seen in some Covid patients as people are put on anticoagulation medicines after discharge,” said Dr Sanjay Pujari, expert with the National Covid Task Force. “This needs to be monitored… Treating aggressively with anti-coagulants without monitoring can put one at higher risk of bleeding,” he said. “… Also, there is a need to identify the subset of patients after recovery who can be put on blood thinners.”

Nature of the spread

In the first wave, about 100 districts reported around 75 % of all disease cases, while in wave 2 about 40 districts reported a similar proportion. This pattern suggests that the second wave was due to a more infectious variant.

The first wave was caused by the SARS Cov-2 virus with no local mutant, while the second wave was largely due to the more infectious Delta variant. While many factors may have contributed to the second wave that peaked in April-May this year, experts said it was likely to have been triggered by the variant B.1.617 and its sub-lineage B.1.617.2 (Delta). Evidence suggests these are more transmissible and perhaps more lethal than Alpha, which was a dominant variant in the Indian population before the second wave.

Dr Kapil Zirpe, former president, Indian Society of Critical Care Medicine, said that during the first wave, there was a lethargy at every level to understand the pattern of waves and preventive measures. “In the future there is likely to be more waves till a minimum of 70% of the population is fully vaccinated and there is herd immunity . The issue is how we can prevent the surge in a short period of time.”

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