Archive for Nicholas Veliotes

Coronaviruses and Acute Respiratory Syndromes (COVID-19, MERS, and SARS)

Coronaviruses are enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia. 

Numerous coronaviruses, first discovered in domestic poultry in the 1930s, cause respiratory, gastrointestinal, liver, and neurologic diseases in animals. Only 7 coronaviruses are known to cause disease in humans. 

Four of the 7 coronaviruses most frequently cause symptoms of the common cold

Coronaviruses 229E and OC43 cause the common cold; the serotypes NL63 and HUK1 have also been associated with the common cold. 

Rarely, severe lower respiratory tract infections, including pneumonia, can occur, primarily in infants, older people, and the immunocompromised.

Three of the 7 coronaviruses cause much more severe, and sometimes fatal, respiratory infections in humans than other coronaviruses and have caused major outbreaks of deadly pneumonia in the 21st century:

  • SARS-CoV2 is a novel coronavirus identified as the cause of coronavirus disease 2019 (COVID-19) that began in Wuhan, China in late 2019 and spread worldwide.

  • MERS-CoV was identified in 2012 as the cause of Middle East respiratory syndrome (MERS).

  • SARS-CoV was identified in 2002 as the cause of an outbreak of severe acute respiratory syndrome (SARS).

These coronaviruses that cause severe respiratory infections are zoonotic pathogens, which begin in infected animals and are transmitted from animals to people.

COVID-19 is an acute, sometimes severe, respiratory illness caused by a novel coronavirus SARS-CoV2.

COVID-19 was first reported in late 2019 in Wuhan, China and has since spread extensively in China and worldwide. 

Transmission of COVID-19

Early COVID-19 cases were linked to a live animal market in Wuhan, China, suggesting that the virus was initially transmitted from animals to humans. 

Person-to-person spread occurs through contact with infected secretions, mainly via contact with large respiratory droplets, but it could also occur via contact with a surface contaminated by respiratory droplets. 

Researchers are still learning how readily this virus spreads from person to person or how sustainable infection will be in a population, although it appears more transmissible than SARS and spread is probably more similar to that of influenza.

Super-spreaders played an extraordinary role in driving the 2003 SARS outbreak and may also play a significant role in the current COVID-19 outbreak. 

A super-spreader is an individual who transmits an infection to a significantly greater number of other people than the average infected person. 

Quarantine and isolation measures are being applied in an attempt to limit the local, regional, and global spread of this outbreak.

Symptoms and Signs

People with COVID-19 may have few to no symptoms, although some become severely ill and die. Symptoms can include fever, cough, and shortness of breath. 

Those with more severe disease may have lymphopenia and chest imaging findings consistent with pneumonia. 

The exact incubation time is not certain; estimates range from 1 to 14 days. The risk of serious disease and death in COVID-19 cases increases with age.

Symptoms and signs reference

1. Centers for Disease Control and Prevention: Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep 69:343-346, 2020. doi: 10.15585/mmwr.mm6912e2external icon.


Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) testing of upper and lower respiratory secretions.

Diagnostic testing for COVID-19 is being made available to select laboratories authorized by the Federal Drug Administration under an Emergency Use Authorization (EUA). 

Clinicians can also access laboratory testing through public health laboratories in their jurisdictions.

For initial diagnostic testing for COVID-19, the CDC recommends collecting and testing a single upper respiratory nasopharyngeal swab. 

Collection of only oropharyngeal swabs is acceptable if other swabs are not available. 

The CDC also recommends testing lower respiratory tract specimens, if available. 

For patients for whom it is clinically indicated (eg, those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen. 

Collection of oropharyngeal swabs is a lower priority and if collected should be combined in the same tube as the nasopharyngeal swab. 

Collection of sputum should be done only for those patients with productive coughs. Induction of sputum is not recommended. 

Specimens should be collected as soon as possible, regardless of the time of symptom onset. 

Maintain proper infection control when collecting specimens. 

For biosafety reasons, the CDC recommends local institutions do not attempt to isolate the virus in cell culture or do initial characterization of viral agents in patients suspected of having COVID-19 infection.

Because of the increasing availability of test kits in the US, previous restrictions on patient selection for testing are being relaxed, and testing is expanded to a wider group of symptomatic patients. 

Clinicians should use their judgment as to whether a patient’s symptoms and signs are compatible with COVID-19 and whether they should be tested. 

Decision to test should also take into account the local epidemiology of COVID-19, the course of illness, and the patient’s epidemiologic factors such as close contact with a confirmed COVID-19 case within 14 days of symptom onset or history of travel to an affected geographic area within 14 days of symptom onset. 

Clinicians are also strongly encouraged to test for other causes of similar respiratory illness (eg, influenza). 

Areas of sustained transmission will vary as the outbreak proceeds. For areas inside the US, clinicians should consult state or local health departments. 

For countries outside the US, affected areas as of March 5, 2020 include China, Iran, Italy, Japan, and South Korea.

If any of these criteria are present, infection control personnel at the healthcare facility and the local or state health department should be notified immediately.


Supportive Treatment of COVID-19 is supportive. No vaccine, antiviral drug, or other specific treatment is available.

To help prevent spread from suspected cases, health care practitioners should use standard, contact, and airborne precautions with eye protection.

Why Greece Succeeded as Italy, Spain Failed to Tackle Coronavirus

When the covid-19 pandemic broke out in Europe, no government had any experience of how to face it and each tried to weather the storm in its own ways. Some governments fared better, some less so.

By and large, there are three major factors that have determined, and still do, how governments cope with the virus.

These are, first, the resoluteness and efficiency of their leadership; second, the capacity of states and public health systems in particular to deal with such an extraordinary health crisis situation; and, third, the cooperation of national publics in following emergency rules.

At a more specific level, as shown by an even cursory comparison of the Spanish and Greek experiences with the pandemic, it seems that a well-integrated and liberal government performs significantly better than one which is disunited and, moreover, diluted with populists. Let’s have a closer look at the two cases.

At the time of this writing (5 April 2020), Spain has close to 130,000 confirmed cases of coronavirus victims and about 12,000 deaths. At the same time, Greece has about 1,700 confirmed cases and 68 deaths.

So, the question is: Why these two Mediterranean countries, whose people are equally sun-loving, bar-hopping, and intensely social, and which should have drawn the same lessons from Italy’s preceding experience, have had such different fates during the early phase of the coronavirus crisis? The answer is simple, almost mundane: Different governments!

The little comparison table below shows the reaction of Italy, Spain, and Greece to the coronavirus outbreak. It reveals three things.

First of all, Italy, the first country in Europe to be hit by the virus with catastrophic results, offered valuable lessons that shouldn’t be missed by other governments.

Secondly, Spain’s government failed to learn and, in fact, performed even worse than Italy.

And, finally, among these countries, Greece is by far the best performer in confronting the pandemic, at least so far.

It certainly helped, of course, that Greece has a centralized state administration system which, unlike in Spain or Italy, facilitates the fast implementation at regional and local levels of decisions taken at top state level. But this explains only part of the different reactions to the pandemic in Spain and Greece. Let’s have a closer look beginning with the case of Italy, which served as a backdrop against which the Spanish and Greek governments made their decisions.


Italy, indeed, offered early valuable lessons to any government that was willing to learn. Coronavirus was confirmed there on 31 January, when a traveling Chinese couple, originally from Wuhan, China, tested positive in Rome. In the next three weeks, more cases of infection were confirmed in the northern regions of Lombardy and Veneto and, on 22 February, the first death from the coronavirus was reported.

From there on, the number of deaths in Italy went into an upward spiral. By 5 March, as the number of the deceased had reached one hundred, the government shut down all schools and universities nationwide.

On 8 March, with confirmed cases approaching 6,000, Prime Minister Giuseppe Conte extended the quarantine lockout to all of Lombardy and other northern provinces, which, at the time, was the most radical measure to combat the virus taken anywhere outside China. On 10 March, the government expanded the quarantine to all of Italy and ordered Italians to stay at home.

From the first confirmed case, it took the Italian government 38 days (and 16 days since the first death) before it imposed a first nationwide lockdown. It was, unfortunately, too late. A few days later, on 19 March, Italy became the country with the highest number of confirmed deaths in the world.

Clearly, then, the chief lesson from Italy was that governments elsewhere would need to react early and take most aggressive measures in order to check the pandemic. But the reactions of the governments in Spain and Greece couldn’t differ more than they actually did. And that had very different consequences in each of these two countries.

Spain, first, was reluctant to learn from Italy. “We are going to have only a handful of cases,” asserted on 9 February Dr. Fernando Simón, an epidemiologist serving as the head of medical emergencies in Madrid. Even as the number of confirmed cases of coronavirus continued to increase, the Spanish government still resisted to take mitigating steps so as to combat the virus spread; in fact, it initially defended the decision to let mass gatherings go on.

On 8 March, about 120,000 people were allowed to march through the center of Madrid to celebrate the international Women’s Day and some 60,000 soccer fans filled one of the city’s stadiums. During that same weekend, 9,000 supporters of Vox, an upcoming right-wing party, gathered inside a former bullring.

By Friday, 13 March , Spain already had the second highest number of coronavirus infections of any European country after Italy, now facing the fastest spreading contagion on the continent and an already overwhelmed health care system. Two ministers of Sánchez’s cabinet, including Irene Montero, the partner of Deputy Premier Pablo Iglesias and one who had participated in the women’s march, tested positive. Another prominent victim of the virus was Santiago Abascal, the leader of Vox.

It was only then, on 13 March, one full month after the first death from the virus was reported (13 February) and with the tally of deaths at 189, that the government decided to close all schools and declare a state of emergency across the country. Why all this was let to happen?

For one thing, it didn’t help that Prime Minister Pedro Sánchez leads a leftist minority government that only formed with difficulty after the inconclusive elections in November 2019.

In the aftermath of that contest, Sánchez, leader of the center-left PSOE, and Pablo Iglesias, leader of left populist Unidas Podemos, formed an alliance which subsequently produced Spain’s first coalition government since its transition to democracy. The new government, consisting of the prime minister, four deputy prime ministers and 22 ministers, formed on 13 January 2020.

Nor did it help that Podemos as a populist party has thrived on political polarization, often militated against the legality of Spain’s institutions for allegedly failing to serve the people’s interests, and typically opposes technocracy and the expert knowledge stemming from it. All that played at the level of micro-politics with disastrous consequences.

Friday, 13 March, was a critical moment. Sánchez announced his intention to enact emergency measures and decree a state of alarm across all the country on the following day. But things went awfully wrong.

The coalition government’s Council of Ministers, which was meant to include only ministers considered essential for responding to the crisis, was marred by intense infighting . Pablo Iglesias, who was supposed to be in quarantine after his partner had tested positive for the virus, appeared unexpectedly to the Council objecting the concentration of powers under the ministries of interior, defense, transport, and health, all headed by PSOE politicians, and demanding that his party be given prominent roles in the national emergency situation.

He also insisted that the government takes social measures for helping poor families, such as paying rents and mortgages. According to El País , the minister of finance rejected the proposal for the high cost it involved amid a developing economic crisis.

The Council of Ministers meeting lasted eight hours and ended with acrimony on both sides with dire consequences for the country. It first of all delayed the implementation of lockdown and other emergency measures, and also led to cancelling a teleconference planned for the same day between Sánchez and the leaders of Spain’s regional governments.

Even worse, since all that happened on a sunny Saturday, several people from Madrid and other big cities left for the regions, bringing the virus with them. One such case was José María Aznar, Spain’s former conservative prime minister, who moved to his holiday villa in the rich resort of Marbella, fueling public anger against him and the government alike.

Meantime, as the death toll keeps rising, Spain’s fissured coalition government utterly failed to rally the opposition parties on its side for creating a unified front against the pandemic. Pablo Casado, the leader of the center-right People’s Party, accused prime minister Sánchez for spreading lies and misinformation, while ultra-right Vox called for Sánchez’s resignation and replacement by a government of national unity.

To make things even worse, most of the regional governments, especially in separatist Catalonia, miss no chance to show their displeasure with the incompetence of, and health crisis mismanagement by, the central state administration.

How different from Spain was the reaction to the coronavirus pandemic in the other Mediterranean country, Greece!

For starters, the effect of the virus in Greece was a particularly big setback since the country was just coming out of years of recession and recent projections for its economic future were quite optimistic.

But Greece’s government was quick to learn from Italy and Spain, and act decisively and swiftly, despite having to simultaneously face additional difficulties.

In February, Turkey ignited a refugee crisis by opening its border with Greece to Europe and aiding thousands of displaced persons to cross it. Greece responded by strengthening the border with soldiers and armed police, soliciting the support of her EU partners, and by refusing to accept asylum applications for a period of one month. The situation at the border remained tense during most of March, which diverted part of the Greek government’s attention to that crucial front.

Another problem was the cramped living conditions in refugee camps in both Greece’s islands and the mainland. And yet, the government’s response to the coronavirus outbreak was nearly outstanding as it determined to reduce the spread of the virus within the country and flatten the curve as early as possible in the hope that the long-term effects on both the society and the economy could be minimized. Here’s what happened in Greece, in brief.

The first case in Greece of a person to test positive – a woman who had recently traveled to Milan – was reported on 26 February and, on the following day, two more cases were confirmed.

That same day, Greece’s minister of health cancelled all planned carnival events throughout the country and the government banned all educational trips abroad.

Only thirteen days later, on 10 March, with the number of confirmed cases totaling 89 and no deaths, the government closed all daycare centers, schools, and universities nationwide.

On 11 March, Prime Minister Kyriakos Mitsotakis, in a nationally televised address, urged the public to follow the instructions of doctors and other experts, and admonished the Church to refrain from delivering the “holy communion” and instead cooperate with the state authorities in enforcing the public health regulations.

On 12 March, the first death from coronavirus was reported in Greece. In the few days to follow, the government shut down theaters, cinemas, restaurants, bars, shopping centers, playgrounds, museums, courthouses, parks, recreational areas, marinas, organized beaches and ski resorts; it only excluded supermarkets, pharmacies and food outlets.

Eventually, the government suspended all religious services, including the Sunday masses of the Greek Orthodox church, and also announced the closure of most hotels in the country and subjected all Greek citizens returning from abroad to mandatory 14-day quarantine.

During March, the Geek prime minister gave five nationally televised addresses (on 11, 17, 19, 22 and 25 March), every time explaining to the Greek people the development of the situation and asking them to comply to the new rules.

The government’s infectious disease spokesman, epidemiologist Sotiris Tsiodras, goes on TV every afternoon to both brief journalists and offer advise to the citizens. As of Greece’s significant opposition parties, they all showed an admirable sense of social responsibility, political moderation, and even readiness to support the government in its difficult decisions during crisis.

The major moral from the different stories of pandemic prevention in Spain and Greece is that governments matter a lot.

More specifically, they need to set aside their political compulsion and listen to experts and other technocrats; they must act early and swiftly; and they should be efficient in making working trade-offs with the society at large, various economic interest groups, and, perhaps more importantly, the political opposition.

So far, Spain’s government has unfortunately failed in all these areas with enormous cost for the Spanish society. And the Greek government gets all credit due for its success in preventing the wild spread of the virus and minimizing the suffering Greek society would otherwise have to endure.

Coronavirus Test For World Leaders

We often learn the most about leadership by observing our leaders in times of crisis. As world leaders attempt to contain the rapid spread of COVID-19, they must simultaneously perform two opposing and difficult tasks—prepare their countries for significant risk and avoid inciting panic.

What we’re seeing as a result is multiple test cases in crisis leadership, as several different countries face similar versions of the same problem and react with noticeably different approaches and results. 

Focusing on the COVID-19 response in three continents—specifically examining China, Italy and the United States—there are clear takeaways and learnings on different aspects of the response to and management of the outbreak. These lessons are not only helpful to other countries as they manage their COVID-19 responses, but they also provide valuable examples for leaders in any field.

China shows limits of command and control and benefits of decisive action 

Even before the COVID-19 outbreak, the Chinese government has been widely reported to have significant capacity for control, using vast state authority and a significant surveillance program. As the origin point of COVID-19, the Chinese government’s effort to control the virus has been watched by the entire world.

China responded with what the World Health Organization called “perhaps the most ambitious, agile and aggressive disease containment effort in history,” including closing down manufacturing sectors, sharing information widely, executing mass testing and quarantining millions of people. The Chinese government made the decision to absorb a significant short-term economic cost to contain COVID-19 rather than potentially lose control. It seems to be working as the number of new cases has steadily decreased in recent weeks and people are getting back to work and factories are ramping up.

This is an example of the benefit of command and control leadership and decisive action to immediately consolidate efforts into an aggressive response.

However, it’s worth considering the erosion of trust this type of system creates. The Atlantic documented the ways in which local Chinese officials underreported the spread of COVID-19 to the federal government, as the Wuhan province failed to report the outbreak until weeks after it began and downplayed the likelihood of human transmission until whistleblowers stepped forward—and were subsequently punished. This delay cost China valuable time in containing the initial outbreak.

When people are afraid to come forward to tell the truth and are discouraged from speaking up, critical information often does not reach leadership until the problem has intensified. While it cannot be known for sure, the COVID-19 outbreak may have been contained earlier had early warnings been escalated.

Italy demonstrates peril of slow response and lack of coordination 

The epicenter of COVID-19 in Europe has been Italy, which saw a rapid increase of cases over the past two weeks—the number of cases even jumped by 50 percent in a single day on March 1.

In part because the outbreak in Italy intensified so quickly, there was a lack of consistency in the Italian government’s response. CNN reported that Italian Prime Minister Giuseppe Conte acknowledged a “not entirely proper,” management of a North Italy hospital helped contribute to the outbreak. Even as the virus spread, the Italian government and tourism heads tried to convey that everything was under control and that it was business as usual, encouraging tourists not to cancel their visits.

Just two days later, Italy drastically scaled up their response, shutting down schools, sporting events and tourism sites, following China’s example. Then, this week, Italy took quarantine measures nationally, effectively placing the entire country in lockdown. These rapidly different and changing messages coming from the Italian government have created confusion and frustration for both citizens and tourists.

The lesson is clear—in a crisis, leaders can create panic and distrust when they rapidly change their messaging. It seems the country’s officials underestimated the potential spread of the virus and various groups and stakeholders were not acting in coordination. When significant problems arise, leaders must be careful to avoid saying something they will end up contradicting later.

The United States tries to control the narrative

The United States’ exposure to COVID-19 has been comparatively limited, but the threat is increasing by the day and the country is on high alert and preparing for the worst. The Center for Disease Control (CDC) has been cautioning Americans to prepare for a potential outbreak since February 25, and Vice President Mike Pence has been tasked with leading the government’s coordinated response.

Even President Donald Trump’s allies would likely admit that this challenge is out of step with his leadership tendencies. President Trump likes to control the narrative surrounding his administration and tries to avoid unfavorable press coverage. This causes him to downplay issues to win the PR battle, as he did in late February in response to a sudden stock market downturn.

Trump has shown a tendency during difficult situations to rely heavily on his inner circle, including his son in law, rather than subject matter experts and to state opinions as facts. This has created several situations where he has contradicted experts on his own task force attempting to educate the public, most notably by consistently overstating the scientifically acknowledged timeline to create a vaccine.

Trump has also questioned the reported fatality rate of the virus, saying in an interview “I think the 3.4 percent [number] is really a false number,” without providing a factual basis for his own assessment or “hunch”. This does not inspire trust and confidence with the masses.

In business, attempting to control the narrative is a common way to respond to public adversity, and it can work when there is not a large divergence from the underlying facts. Just as a leader of a struggling startup might do, the American government has attempted to alleviate concerns and assure Americans COVID-19 has already been contained, when it’s becoming clearer by the day that is not the case. 

However, the virus does not respond to public perception. While the future of COVID-19 in America is unclear, if the virus follows the same pattern of escalation as in China and Italy, there will likely be a lot of criticism of the President’s initial response.

Crisis management is perhaps the most difficult test for leaders. This is especially true for a case like COVID-19, which does not have a comparable historical precedent or solution and where the threat is evolving constantly.

Leaders in all fields can learn from countries’ responses: problems are best preempted in environments of trust and transparency, challenges are best faced with cohesive, decisive and consistent action. They should also realize that winning the short-term news cycle isn’t a long-term solution. Only time will tell exactly how effective the world’s leaders have been and which strategies produced the best outcome.

Coronavirus Vaccine Is Ready

For Human Testing, And It Will Help Save Lives

With each passing day, the Wuhan Coronavirus continues to spread like wildfire not just in China, but also several parts of the globe. Today it has infected over 78,000 people and has killed over 2700.

The fear for contracting the COVID-19 has resulted in major global events like the Mobile World Congress to get cancelled with various participants hesitant to step out of the country. And this fear also surrounds the upcoming 2020 Tokyo Olympics.

Need for a vaccine to stop this novel coronavirus is needed today more than ever. And it looks like we might not have to wait for long after all.

Scientists since the news of the outbreak have been working on a vaccine to combat and prevent people from the novel coronavirus and now a company called Moderna has announced that it has finally developed a coronavirus vaccine that will soon be ready for human testing.

Coronavirus Death Toll Reaches 2,835 In China With Close To 80,000 People Infected

First reported by the Wall Street Journal, the vaccine has already been provided to the US governments at the National Institute of Allergy and Infectious Diseases in Bethesda. It reveals that there are two doses to the vaccine, and the twin doses are designed for an adult to save him/her against infection.

Looking at the pace in which the research is moving a final product for human trial could be ready as early as July this year. While it sure feels like a lot of time, you need to understand that the rate at which the research for the vaccine is moving at, is unprecedented, to say the least.

Researchers need to make sure a number of things before they decide to inject the vaccine into a human. Not only should it work as we intend it to, but it should also protect the person from contracting the virus for a considerable amount of time. 

Moreover, it shouldn’t come with any adverse side effects or cause severe harm to a person’s body. Researchers will also have to look at how it pairs with existing common medication that people consume.


Clinical Presentation

Coronaviruses cause acute, mild upper respiratory infection (common cold).


Spherical or pleomorphic enveloped particles containing single-stranded (positive-sense) RNA associated with a nucleoprotein within a capsid comprised of matrix protein. The envelope bears club-shaped glycoprotein projections.


Coronaviruses (and toroviruses) are classified together on the basis of the crown or halo-like appearance of the envelope glycoproteins, and on characteristic features of chemistry and replication. Most human coronaviruses fall into one of two serotypes: OC43-like and 229E-like.


The virus enters the host cell, and the uncoated genome is transcribed and translated. The mRNAs form a unique “nested set” sharing a common 3′ end. New virions form by budding from host cell membranes.


Transmission is usually via airborne droplets to the nasal mucosa. Virus replicates locally in cells of the ciliated epithelium, causing cell damage and inflammation.

Host Defenses

The appearance of antibody in serum and nasal secretions is followed by resolution of the infection. Immunity wanes within a year or two.


Incidence peaks in the winter, taking the form of local epidemics lasting a few weeks or months. The same serotype may return to an area after several years.


Colds caused by coronaviruses cannot be distinguished clinically from other colds in any one individual. Laboratory diagnosis may be made on the basis of antibody titers in paired sera. The virus is difficult to isolate. Nucleic acid hybridization tests (including PCR) are now being introduced.


Treatment of common colds is symptomatic; no vaccines or specific drugs are available. Hygiene measures reduce the rate of transmission.


Coronaviruses are found in avian and mammalian species. They resemble each other in morphology and chemical structure: for example, the coronaviruses of humans and cattle are antigenically related. There is no evidence, however, that human coronaviruses can be transmitted by animals. In animals, various coronaviruses invade many different tissues and cause a variety of diseases, but in humans they are only proved to cause mild upper respiratory infections, i.e. common colds. On rare occasions, gastrointestinal coronavirus infection has been associated with outbreaks of diarrhoea in children, but these enteric viruses are not well characterized and are not discussed in this chapter.

Clinical Manifestations

Coronaviruses invade the respiratory tract via the nose. After an incubation period of about 3 days, they cause the symptoms of a common cold, including nasal obstruction, sneezing, runny nose, and occasionally cough (Figs. 60-1 and 60-2). The disease resolves in a few days, during which virus is shed in nasal secretions. There is some evidence that the respiratory coronaviruses can cause disease of the lower airways but it is unlikely that this is due to direct invasion. Other manifestations of disease such as multiple sclerosis have been attributed to these viruses but the evidence is not clear-cut.

Figure 60-1. Clinical manifestations and pathogenesis of coronavirus infections.

Figure 60-1

Clinical manifestations and pathogenesis of coronavirus infections. 

Figure 60-2. Immunopathogenesis of coronavirus infections.

Figure 60-2

Immunopathogenesis of coronavirus infections. 


Coronavirus virions are spherical to pleomorphic enveloped particles (Fig. 60-3). The envelope is studded with projecting glycoproteins, and surrounds a core consisting of matrix protein enclosed within which is a single strand of positive-sense RNA (Mr 6 × 106) associated with nucleoprotein. The envelope glycoproteins are responsible for attachment to the host cell and also carry the main antigenic epitopes, particularly the epitopes recognized by neutralizing antibodies. OC43 also possesses a haemagglutin.

Figure 60-3. Electron micrograph showing human coronavirus 229E.

Figure 60-3

Electron micrograph showing human coronavirus 229E. Bar, 100 mn (Courtesy S.Sikotra, Leicester Royal Infirmary, Leicester, England.) 

Classification and Antigenic Types

The coronaviruses were originally grouped into the family Coronaviridae on the basis of the crown or halo-like appearance given by the glycoprotein-studded envelope on electron microscopy. This classification has since been confirmed by unique features of the chemistry and replication of these viruses. Most human coronaviruses fall into one of two groups: 229E-like and OC43-like. These differ in both antigenic determinants and culturing requirements: 229E-like coronaviruses can usually be isolated in human embryonic fibroblast cultures; OC43-like viruses can be isolated, or adapted to growth, in suckling mouse brain. There is little antigenic cross-reaction between these two types. They cause independent epidemics of indistinguishable disease.


It is thought that human coronaviruses enter cells, predominantly, by specific receptors. Aminopeptidase-N and a sialic acid-containing receptor have been identified to act in such a role for 229E and OC43 respectively. After the virus enters the host cell and uncoats, the genome is transcribed and then translated. A unique feature of replication is that all the mRNAs form a “nested set” with common 3′ ends; only the unique portions of the 5′ ends are translated. There are 7 mRNAs produced. The shortest mRNA codes for the nucleoprotein, and the others each direct the synthesis of a further segment of the genome. The proteins are assembled at the cell membrane and genomic RNA is incorporated as the mature particle forms by budding from internal cell membranes.


Studies in both organ cultures and human volunteers show that coronaviruses are extremely fastidious and grow only in differentiated respiratory epithelial cells. Infected cells become vacuolated, show damaged cilia, and may form syncytia. Cell damage triggers the production of inflammatory mediators, which increase nasal secretion and cause local inflammation and swelling. These responses in turn stimulate sneezing, obstruct the airway, and raise the temperature of the mucosa.

Host Defenses

Although mucociliary activity is designed to clear the airways of particulate material, coronaviruses can successfully infect the superficial cells of the ciliated epithelium. Only about one-third to one-half of infected individuals develop symptoms, however. Interferon can protect against infection, but its importance is not known. Because coronavirus infections are common, many individuals have specific antibodies in their nasal secretions, and these antibodies can protect against infection. Most of these antibodies are directed against the surface projections and neutralize the infectivity of the virus. Cell-mediated immunity and allergy have been little studied, but may play a role.

Figure 60-4. Seasonal incidence of coronavirus infections.

Figure 60-4

Seasonal incidence of coronavirus infections.


The epidemiology of coronavirus colds has been little studied. Waves of infection pass through communities during the winter months, and often cause small outbreaks in families, schools, etc. (Fig. 60-2). Immunity does not persist, and subjects may be re-infected, sometimes within a year. The pattern thus differs from that of rhinovirus infections, which peak in the fall and spring and generally elicit long-lasting immunity. About one in five colds is due to coronaviruses.

The rate of transmission of coronavirus infections has not been studied in detail. The virus is usually transmitted via inhalation of contaminated droplets, but it may also be transmitted by the hands to the mucosa of the nose or eyes.


There is no reliable clinical method to distinguish coronavirus colds from colds caused by rhinoviruses or less common agents. For research purposes, virus can be cultured from nasal swabs or washings by inoculating organ cultures of human fetal or nasal tracheal epithelium. The virus in these cultures is detected by electron microscopy or other methods. The most useful method for laboratory diagnosis is to collect paired sera (from the acute and convalescent phases of the disease) and to test by ELISA for a rise in antibodies against OC43 and 229E. Complement fixation tests are insensitive; other tests are inconvenient and can be used only for one serotype. Direct hybridization and polymerase chain reaction tests for viral nucleic acid have been developed and, particularly with the latter, are the most sensitive assays currently available for detecting virus .


Although antiviral therapy has been attempted, the treatment of coronavirus colds remains symptomatic. The likelihood of transmission can be reduced by practising hygienic measures. Vaccines are not currently available.


Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV)A novel coronavirus (nCoV) is a new strain that has not been previously identified in humans.  

Coronaviruses are zoonotic, meaning they are transmitted between animals and people.  Detailed investigations found that SARS-CoV was transmitted from civet cats to humans and MERS-CoV from dromedary camels to humans. Several known coronaviruses are circulating in animals that have not yet infected humans. 

Common signs of infection include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death. 

Standard recommendations to prevent infection spread include regular hand washing, covering mouth and nose when coughing and sneezing, thoroughly cooking meat and eggs. Avoid close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing.



The Mediterranean diet is a way of eating based on the traditional cuisine of countries bordering the Mediterranean Sea. Many studies have shown that people who lived in the Mediterranean area (especially around the year 1960) were healthier and lived longer than the average.

This simply means that if someone wants to improve his health and his overall quality of life he should eat the same things that those people ate during that time.Ahe health benefits linked to the Mediterranean diet are supported by scientific evidence. It is associated with lower all-cause mortality and morbidity (disease occurrence), and has been linked to numerous health benefits, including a lower risk of cancer, cognitive disease and cardiovascular disease as well as metabolic syndrome, obesity, and type 2 diabetes”.

According to “the Mediterranean diet is based on the traditional foods that people used to eat in countries like Italy and Greece back in 1960. Researchers noted that these people were exceptionally healthy compared to Americans and had a low risk of many lifestyle diseases”.

According to the Mayo Clinic “it is recognized by the World Health Organization as a healthy and sustainable dietary pattern and as an intangible cultural asset by the United National Educational, Scientific and Cultural Organization”.

In Greece we have two similar words but with a different meaning. The word “dieta” which means an eating schedule focused on weight loss and the word “diatrofi” from the words “dia” (through) and “trofi” (food) which means way of eating.

The Mediterranean diet is a complete, healthy way of eating focused on your well-being and not just on weight loss (though it can certainly help you lose weight).


It is mostly a way of life and not a restriction of calories. The Mediterranean diet won’t make you weight your chicken or count how many almonds you’ll eat. It will train you to choose fresh, whole foods packed with nutrients and flavor, foods that will satiate your hunger and make you feel full. Foods that won’t make you feel guilty after eating them.

The goal here is not to feel deprived, but to enjoy the taste and the aroma of each bite you take. And remember: foods taste better when they’re local, on season and fresh.


I know that exercise is not considered to be part of a diet, but one of the reasons the Mediterranean people were so healthy is because they did a lot of exercise. They worked in the fields most of the day and also walked long distances to get from one place to another.

I know that exercise is not always easy, especially for those of us who live in the city. But we have to start from somewhere and the progress will come with time.

Maybe you can get a bike or get off the bus one bus stop earlier and walk the rest of the way home. Maybe you can start going to the gym or download one of those free apps for working out at home. Maybe you can walk your friend’s dog or stop using the elevator. Anything is better than nothing.


The last thing I really don’t want to neglect mentioning is being in contact with nature. I honestly feel that our modern way of life has driven us away from nature, and this comes at a great cost.

I still remember my shock one day when I realized that I hadn’t stepped on soil for over a month. Was that the reason I was feeling disconnected and not fulfilled? Probably it wasn’t the sole factor, but it certainly played its part.

Being in close contact with nature makes us value the natural, unprocessed foods more. It also reduces our everyday stress and our anxiety levels, calms our spirit, helps our body to detoxify and gives us the right perspective of things.


  • Eat whole foods, fresh and seasonal.
  • Incorporate beans and legumes in your diet as often as you can. They ‘re the best source of plant-based protein.
  • Try to incorporate vegetables and greens in all of your dishes. Also, have a salad with every meal!
  • Eat fish and seafood twice a week (be mindful that today we have to be careful of the fish we eat because of the heavy metals they may contain).
  • Eat white meat once a week.
  • Eat red meat once a week or once every other week.
  • Eat fruit for dessert. Limit desserts containing sugar to once a week (maybe on Sundays).
  • Eat dairy (yogurt, feta cheese, milk) and eggs in moderation.
  • Eat products made with whole grains and whole-grain sourdough bread.
  • Wherever you can add herbs and spices do it!
  • Drink lots of water and herbal teas without sugar or sweeteners (maybe add a bit of honey).
  • Drink one glass of red wine 3 – 4 times per week (ask your doctor first).
  • Walk as much as you can and exercise 3-4 times a week.
  • Try to reduce your everyday stress by being close to nature (hug a tree!)


Olive oil is the primary source of added fat in the Mediterranean diet. Olive oil provides monounsaturated fat, which has been found to lower total cholesterol and LDL (bad) cholesterol levels.

If you live in a place where olive oil is too expensive and you don’t want to spend a lot of money, I suggest buying extra virgin olive oil and use half of it and half of another vegetable oil (like sunflower or corn oil) rather than buying a refined, lower quality olive oil. In this article you can find more information about the types of olive oil.

If you can incorporate other healthy sources of fat in your eating plan like nuts, tahini, avocado, feel free to do it.



  • Added sugar: soda, candies, table sugar and many others.
  • Refined grains.
  • Trans fats (a.k.a. hydrogenated fat) like margarine.
  • Refined oils.
  • Processed meat and processed foods in general.
  • Buying bottled lemon juice and bagged salad (of course it’s better to buy a packaged salad than not buying any at all).


Incorporating all those whole foods, vegetables and fresh fruit to your diet will increase your fiber intake something that can help you feel satiated with less food. Eating nutrient dense and unprocessed foods will also help you decrease the amount of calories you eat every day.

That’s why the Mediterranean diet has been linked to increased weight loss, decreased inflammation, and a lower risk of chronic disease. But keep in mind that as with every other diet, in order to lose weight you must be in a caloric deficit.


Yes you can! As long as you make a whole wheat pizza dough and use many vegetables and some feta cheese.


One glass of red wine 3 – 4 times a week is okay! But don’t forget to drink lots of water too!


One or two cups of black coffee per day are okay. Try to also drink some cups of herbal tea throughout the weak.

FODMAPs diet for irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects 1 out of 10 people in the United States each year.

With symptoms like cramping, diarrhea, gas and bloating, it’s no surprise that living with IBS can have a significant effect on a person’s quality of life.

Diet is one way people manage the symptoms of IBS. A common treatment approach is to avoid the foods that trigger symptoms. A new diet for IBS, developed in Australia, is showing promise in managing IBS symptoms. It’s called the low FODMAP diet.

What Is the Low FODMAP Diet?

FODMAP stands for:





And olyols.

These fermentable short-chain carbohydrates are prevalent in the diet.

  • Oligosaccharides: fructans and galactooligosaccharides (GOS)
  • Disaccharides: lactose
  • Monosaccharides: fructose
  • Polyols: sorbitol and mannitol

Researchers suggest that the small intestine does not absorb FODMAPs very well. They increase the amount of fluid in the bowel. They also create more gas. That’s because bacteria in the colon they are easily fermented by colonic bacteria. The increased fluid and gas in the bowel leads to bloating and changes in the speed with which food is digested. This results in gas, pain and diarrhea. Eating less of these types of carbohydrates should decrease these symptoms.

So far, studies have shown that a low FODMAP diet improves IBS symptoms. One study even found that 76% of IBS patients following the diet reported improvement with their symptoms.

Eat Less Of These Foods

  • Lactose
    • Cow’s milk, yogurt, pudding, custard, ice cream, cottage cheese, ricotta cheese and mascarpone
  • Fructose
    • Fruits, such as apples, pears, peaches, cherries, mangoes, pears and watermelon
    • Sweeteners, such as honey and agave nectar
    • Products with high fructose corn syrup
  • Fructans
    • Vegetables, such as artichokes, asparagus, Brussels sprouts, broccoli, beetroot, garlic and onions
    • Grains such as wheat and rye
    • Added fiber, such as inulin
  • GOS
    • Chickpeas, lentils, kidney beans and soy products
    • Vegetables, such as broccoli
  • Polyols
    • Fruits, such as apples, apricots, blackberries, cherries, nectarines, pears, peaches, plums and watermelon
    • Vegetables, such as cauliflower, mushrooms and snow peas
    • Sweeteners, such as sorbitol, mannitol, xylitol, maltitol and isomalt found in sugar-free gum and mints, and cough medicines and drops

Eat More Of These Foods

  • Dairy: Lactose-free milk, rice milk, almond milk, coconut milk, lactose-free yogurt; hard cheeses such as feta and brie
  • Fruit: Bananas, blueberries, cantaloupe, grapefruit, honeydew, kiwi, lemon, lime, oranges and strawberries
  • Vegetables: Bamboo shoots, bean sprouts, bok choy, carrots, chives, cucumbers, eggplant, ginger, lettuce, olives, parsnips, potatoes, spring onions and turnips
  • Protein: Beef, pork, chicken, fish, eggs and tofu
  • Nuts/seeds (limit to 10-15 each): Almonds, macadamia, peanuts, pine nuts and walnuts
  • Grain: Oat, oat bran, rice bran, gluten-free pasta, such as rice, corn, quinoa, white rice, corn flour and quinoa

The idea behind the low FODMAPs diet is to only limit the problematic foods in a category — not all of them. (After all, they do have health benefits.) You may tolerate some foods better than others.

Meet with a registered dietician if you are considering this diet. It’s important to make sure your eating plan is safe and healthy. He or she will have you eliminate FODMAPs from your diet. Then you gradually add the carbohydrates back in one at a time and monitor your symptoms. A food diary and symptom chart may be helpful tools.

The Bottom Line

The low FODMAP diet has shown potential in helping people with IBS. Some health professionals believe it’s too restrictive. Proponents of the diet report that people stick with it because of how it improves their quality of life.

Inguinal hernia

An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object.

An inguinal hernia isn’t necessarily dangerous. It doesn’t improve on its own, however, and can lead to life-threatening complications. Your doctor is likely to recommend surgery to fix an inguinal hernia that’s painful or enlarging. Inguinal hernia repair is a common surgical procedure.


Inguinal hernia signs and symptoms include:

  • A bulge in the area on either side of your pubic bone, which becomes more obvious when you’re upright, especially if you cough or strain
  • A burning or aching sensation at the bulge
  • Pain or discomfort in your groin, especially when bending over, coughing or lifting
  • A heavy or dragging sensation in your groin
  • Weakness or pressure in your groin
  • Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

Signs and symptoms in children

Inguinal hernias in newborns and children result from a weakness in the abdominal wall that’s present at birth. Sometimes the hernia will be visible only when an infant is crying, coughing or straining during a bowel movement. He or she might be irritable and have less appetite than usual.

In an older child, a hernia is likely to be more apparent when the child coughs, strains during a bowel movement or stands for a long period.

Signs of trouble

If you aren’t able to push the hernia in, the contents of the hernia may be trapped (incarcerated) in the abdominal wall. An incarcerated hernia can become strangulated, which cuts off the blood flow to the tissue that’s trapped. A strangulated hernia can be life-threatening if it isn’t treated.

Signs and symptoms of a strangulated hernia include:

  • Nausea, vomiting or both
  • Fever
  • Sudden pain that quickly intensifies
  • A hernia bulge that turns red, purple or dark
  • Inability to move your bowels or pass gas

When to see a doctor

Seek immediate care if a hernia bulge turns red, purple or dark or if you notice any other signs or symptoms of a strangulated hernia.

See your doctor if you have a painful or noticeable bulge in your groin on either side of your pubic bone. The bulge is likely to be more noticeable when you’re standing, and you usually can feel it if you put your hand directly over the affected area.


Some inguinal hernias have no apparent cause. Others might occur as a result of:

  • Increased pressure within the abdomen
  • A pre-existing weak spot in the abdominal wall
  • Straining during bowel movements or urination
  • Strenuous activity
  • Pregnancy
  • Chronic coughing or sneezing

In many people, the abdominal wall weakness that leads to an inguinal hernia occurs at birth when the abdominal lining (peritoneum) doesn’t close properly. Other inguinal hernias develop later in life when muscles weaken or deteriorate due to aging, strenuous physical activity or coughing that accompanies smoking.

Weaknesses can also occur in the abdominal wall later in life, especially after an injury or abdominal surgery.

In men, the weak spot usually occurs in the inguinal canal, where the spermatic cord enters the scrotum. In women, the inguinal canal carries a ligament that helps hold the uterus in place, and hernias sometimes occur where connective tissue from the uterus attaches to tissue surrounding the pubic bone.

Risk factors

Factors that contribute to developing an inguinal hernia include:

  • Being male. Men are eight times more likely to develop an inguinal hernia than are women.
  • Being older. Muscles weaken as you age.
  • Being white.
  • Family history. You have a close relative, such as a parent or sibling, who has the condition.
  • Chronic cough, such as from smoking.
  • Chronic constipation. Constipation causes straining during bowel movements.
  • Pregnancy. Being pregnant can weaken the abdominal muscles and cause increased pressure inside your abdomen.
  • Premature birth and low birth weight.
  • Previous inguinal hernia or hernia repair. Even if your previous hernia occurred in childhood, you’re at higher risk of developing another inguinal hernia.


Complications of an inguinal hernia include:

  • Pressure on surrounding tissues. Most inguinal hernias enlarge over time if not repaired surgically. In men, large hernias can extend into the scrotum, causing pain and swelling.
  • Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas.
  • Strangulation. An incarcerated hernia can cut off blood flow to part of your intestine. Strangulation can lead to the death of the affected bowel tissue. A strangulated hernia is life-threatening and requires immediate surgery.


You can’t prevent the congenital defect that makes you susceptible to an inguinal hernia. You can, however, reduce strain on your abdominal muscles and tissues. For example:

  • Maintain a healthy weight. Talk to your doctor about the best exercise and diet plan for you.
  • Emphasize high-fiber foods. Fruits, vegetables and whole grains contain fiber that can help prevent constipation and straining.
  • Lift heavy objects carefully or avoid heavy lifting. If you must lift something heavy, always bend from your knees — not your waist.
  • Stop smoking. Besides its role in many serious diseases, smoking often causes a chronic cough that can lead to or aggravate an inguinal hernia.

Foods reducing Arthritis Pain

Remember, there’s no magic food,” stresses Frechman.  But growing evidence suggests that following a healthy diet and adding in specific foods and spices could help fight inflammation and joint pain.

  • Broccoli, Brussels sprouts and cabbage. These veggies are part of the cruciferous family, and they are full of a compound called sulforaphane, which helps slow cartilage damage in joints due to osteoarthritis, according to a 2013 study involving mice. Admittedly, it’s an early study. But veggies are always a healthy choice. Try adding broccoli, Brussels sprouts, cabbage, kale or cauliflower to your salad or stir-fry.
  • Fatty fish. Fatty fish like salmon, tuna, trout and mackerel are rich in omega-3 fatty acids, which help fight inflammation. Try adding fish to your diet a couple of times a week. If you’re not a big fan of fish, ask your doctor about taking an omega-3 supplement.
  • Garlic. Garlic is a member of the allium family—which also includes onions and leeks. These items contain a compound called diallyl disulfide that may help with a number of diseases—including arthritis. “This compound may have some effect in limiting cartilage-damaging enzymes,” says rheumatologist Scott Zashin, MD, clinical professor at the University of Texas Southwestern Medical School in Dallas.
  • Tart cherries. Some people with arthritis have found relief from products made from tart cherries. The ingredient in cherries that helps with joint symptoms is the same one that gives this fruit its red color—anthocyanin. A 2013 study published in Osteoarthritis and Cartilage found that subjects who drank tart cherry juice had improvements in the pain and stiffness of OA.
  • Turmeric. One of the best-researched inflammation fighters isn’t a food at all, but a spice. Tumeric contains a compound called curcumin. A 2012 review published in the International Journal of Molecular Sciences said that “curcumin could be beneficial in the management of chronic inflammatory-related joint disease,” but authors warned that there is a considerable lack of data regarding side effects and safety. The compound has, however, been used for centuries in India to ward off inflammatory diseases. You’ll find this yellow spice in Indian cuisines—particularly curries.
  • Vitamin CAntioxidants in vitamin C may slow the progression of OA, research finds. A 2011 study from the University of South Florida reported that people who took vitamin C supplements were 11 percent less likely to develop knee OA than those who didn’t take the supplements. You can get vitamin C from strawberries, kiwi, pineapple, or cantaloupe. However, Frechman warns against taking supplements with much higher doses than 65 to 85 milligrams, because in large doses vitamin C can increase the risk of kidney stones.