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  • Cytokine storms

    Posted by TM Lutas on April 19th, 2020 (All posts by )

    Covid-19, as a virus, generally does not directly kill. Instead, it fools our own immune system into killing us via the mechanism of a cytokine storm.

    It is not the only disease that can provoke cytokine storms. We don’t know how to reliably stop cytokine storms. If we did, we wouldn’t have to shut down the economy. We could just treat those who are starting to get sick so they wouldn’t develop into a cytokine storm, pay the bills, however, and we would all come out trillions of dollars ahead with a death toll of no national or international significance as the only people who would succumb would be those already on death’s door.

    If nobody else will say it, I will. We don’t need to close down the majority of our economy just to change what’s written on a death certificate that was coming out anyway.

    Diseases will continue to emerge. Any disease that provokes cytokine storms while not killing many itself will be just as scary as Covid-19 and we’ll be back to the question of whether we have another economic shutdown.

    Cytokine storms are not just associated with infectious diseases. The first mention of the term in the literature was about graft vs host disease in a 1993 article. They entered into the general public’s imagination 15 years ago with the H5N1 flu. We don’t really understand why they happen and how to reliably stop them from taking a life. This is a public health issue deeper than how we pay for healthcare. It threatens us all and will continue to do so at irregular intervals as new diseases emerge that cause cytokine storms.

    So as we move past our currently unsustainable shutdown due to Covid-19, we all have to decide whether we’re going to let cytokine storms go until the next time some disease breaks out and kills significant numbers of people via this mechanism or whether we’re going to treat this seriously so that the next time we’ll be ready. It’s our choice.

     

    20 Responses to “Cytokine storms”

    1. John Says:

      Mr. Lutas,

      I really do not disagree with what you are saying at all, but this kind of thing is really becoming a personal frustration for me:

      “We don’t need to close down the majority of our economy”

      No, we don’t and I don’t know of any plans or even suggestions that we do so. You are far from the only person using this kind of terminology and I think it is counter-productive. It is the economic equivalent of the “We’re all going to die!” panic on the virus side.

      The best I can tell, something around 15-20%(plus or minus) of businesses (not even production or revenue) is shut down and as things go on that could well climb, but stating that the majority is shut down, or worse, the implication in your second paragraph that it is all shut down, is irresponsible. It invokes panic or resignation and neither is a useful reaction, furthermore it undermines your actually very reasonable commentary.

      I’m sure someone will correct me if I’m just living in a bubble where 51% plus of the economy is not shutdown.

      FWIW.

    2. MCS Says:

      15% doesn’t sound like much until it’s the end of your nose they’re cutting off.

    3. Grurray Says:

      Speaking of Talebian, the fact that medical staff are now saying they’re only resorting to mechanical ventilation as a last resort reserved for the most critical patients tells me that.. 1) the root problem is located somewhere other than the lungs, and 2) there were iatrogenic effects in early treatment protocols.

      A large part of the problem is that hospitals are not prepared for this type of crisis. Remember bending the curve? That is for saving hospitals, not the public.

      Hospitals are set up for high margin elective procedures where they can pile up peripheral charges tucked away in opaque billing procedures. They don’t want to deal with common good public health initiatives. They’re not the solution for mass screening of people who are not in need of immediate hospitalization, which is surely the best solution. For that we need an entirely different medical infrastructure.

    4. Jonathan Says:

      Hospitals are set up for high margin elective procedures where they can pile up peripheral charges tucked away in opaque billing procedures.

      We have a winner.

    5. MCS Says:

      I’m not sure that hospitals even know what business they are in anymore. At one extreme, politicians can just mandate whatever they feel like and hospitals have to go along. At the other, insurance companies dictate prices with their ability to direct paying patients elsewhere. Left in the middle are everyone too rich to qualify for medicaid and too poor to buy insurance from insurance companies that really don’t want to sell it.

      If EMTLA applied to restaurants, they’d be required to feed anyone that walked in the door that claimed to be hungry without even considering how they would get paid.

      The only sure thing is that no one with money is willing to pay for some hypothetical future need.

    6. The Dark Lord Says:

      isolate the at risk elderly and very few people would die … very few people below 65 run into this problem with covid19 … very few

    7. TM Lutas Says:

      John Says – The “we’re all going to die” people are on the other side of the argument (literally). I do hope you will forgive a bit of hyperbole. I think you are not accurately accounting for all the economic activity that has been shut down.

      When schools, restuarants, and other facilities shut down, we had a massive initial shock to the system and unemployment claims shot up at a tremendously fast rate, totalling about 20M in new claims above what we would have otherwise expected. We went from 159M employed people to somewere short of 140M employed people in a few short weeks. When 20M people give or take are no longer earning a paycheck, that is an even that has second order effects and not just because those people are likely not to be engaging in a lot of discretionary spendiing anytime soon.

      People who are still employed, still earning money, are battening down the hatches. If we wern’t, there would be a new grill on my back deck, the previous one having become dangerously rusted through last fall and tossed as an actual safety hazard. We can pan sear our meat this summer. There are a number of other purchases that we’re not making right now.

      Separately, we have significant amounts of value destruction going on. For instance, cows need to be milked no matter that the restaurants and schools that were the destination of that milk are gone. The farmers dumping milk into sewers are not voluntarily engaging in value destruction. They just don’t have anywhere to put the stuff.

      I would not be surprised if we’re down between a quarter and a third when all secondary and tertiary effects are toted up.

      Grurray – Cytokine storms are an immune response so, yes, the lung isn’t the root problem. This is not even controversial.

      The Dark Lord – Vulnerability to cytokine storms lacks a reliable test. If you’ve got the vulnerability, you’re at greater risk if you are old. Young people get them too though.

    8. Mike K Says:

      insurance companies dictate prices with their ability to direct paying patients elsewhere.

      When I was still running the trauma center, Blue Cross tried this on us. They negotiated a contract, as all insurance companies do, with the hospital and decided to take their subscribers to the competing hospital.
      What they had not anticipated was that trauma victims, a very expensive class of cases, by law still went to our hospital. Now they had no contract and were paying retail. They came back next contract period.

      There is a good podcast here that goes into cytokine storm and the immune response.

      Here is a pre-covid 19 article on cytokine storm.

      Here is an article on cytokine storm in typhus.
      It seems to indict IL-10 but the villain in Covid seems to be IL-6.

    9. Mike K Says:

      Young people get them too though.

      It seems to be more of a problem with the younger cases, especially with diabetes or obesity.

    10. Gavin Longmuir Says:

      “If nobody else will say it, I will. We don’t need to close down the majority of our economy just to change what’s written on a death certificate that was coming out anyway.”

      Well said, Mr. Lutas!

      However, there are two parties who are quite happy to see the economy shut down (or severely constrained, if one prefers that terminology):

      1. China’s leaders, who must be laughing their heads off at those dumb Westerners committing economic suicide. There’s payback for the “Century of Humiliation” that you outsiders imposed on China — suckers!

      2. The Democrat leadership, who care nothing for the people of the United States, only for themselves and their grip on the greasy pole. They will happily impose any burden on US citizens if it increases the probability of getting rid of the Bad Orange Man. Most of their supporters are government employees anyway — their paychecks have not stopped coming; what shut-down?.

      But those two parties (and their media/academic allies) have launched us all into the unknown territory of lockdowns. The only safe prediction is that there will be Unintended (and Unanticipated) Consequences.

    11. MCS Says:

      Then there are the perfectly foreseeable consequences that are being ignored. What are any of the states doing to reduce expenditures to account for reducer revenue? Can you imagine the howling if states and local governments started to lay off employees. They’re going to have to and soon. It’s not going to be pretty.

    12. MCS Says:

      An interesting look at the numbers:
      https://pjmedia.com/trending/heres-how-much-downstate-new-york-is-skewing-the-united-states-coronavirus-numbers/

      If you subtract the metro New York numbers, the U.S. isn’t even in the top ten.

      I’m not sure that the factors of population density and mass transit explain the difference.

    13. Grurray Says:

      At the other, insurance companies dictate prices with their ability to direct paying patients elsewhere.

      My observation has been that it is the hospital charging outrageously exorbitant prices for procedures that the patient usually never checks because the bill is sent directly to the insurance company. Then the insurance company counters, and there are a few rounds of negotiating back and forth until a suitably lower price is agreed upon. This is why Trump mandated last November that hospitals must publicly post their prices.

      My wife and I have this habit of closely examining any of our medical bills even if insurance takes care of most of it. It’s kind of like watching a train wreck.

    14. Mike K Says:

      This is why Trump mandated last November that hospitals must publicly post their prices.

      I am all for that but the retail prices you see on your EOB have very little to do with what is paid. If it is Medicare, you have a “Profile” and you are not allowed to charge a cash patient less than you charge a Medicare patient. If you do, and they catch you, your “profile” will be reset to that price and you will then be paid 15 to 20% of that amount.

      With private insurance, the negotiated price is a “Trade Secret” and you will be dropped as a provider if you disclose what it is. The insurance company (this all predates Obamacare because I was retired) pays a small fraction of that “retail price.”

      Some of Trump’s rule was directed at insurance companies. I know lots of doctors who have dropped all Medicare and insurance and practice for cash only. A couple of years ago, the busiest hip replacement surgeon in Newport Beach was all cash and charged what Medicare paid. His overhead had gone down by 2/3. No back office.

      The top joint replacement guy at St Johns in Santa Monica is also all cash.

    15. Sharon W Says:

      My husband, active, healthy, no comorbidities, no medications, 64 years old ended up being one of the small percentage of people that went into cytokine storm. We didn’t know a single person who had Covid 19 or was exposed to it. On the evening of 3/26 he came down with a cold like turning on a light switch. 2 days later I came down with it in the exact same manner (coughing through the night). We both were running fevers. When his hit 102 on 3/29 I took him to the Urgent Care where he was treated from our car. Negative for flu, called the next evening and told positive for SarsCoV2. His oxygenation was trending down and on 4/5 I dropped him off at the hospital. They stabilized him and applied the cocktail of 3 (hydroxycholorquine/azithromycin/zinc). He didn’t respond and ended up in ICU on 4/9. Our hospital did not have the Remdesivir which was in clinical trial, and if they did there would have been a 50% chance of him receiving a placebo. He was put in the clinical trial for Actemra. On 4/15 he was moved into the Telemetry Unit. The entire time he was on maximum oxygen via Facemask and then Oximizer. Today I was told he will likely be able to come home within 48 hours (please God and thank you God). I asked the doctor on Wednesday if he thought the Actemra turned the tide. He said in his subjective opinion, “no”. He stated that on 4/11 he “did not take the final bend to cytokine storm” and his pre-infection excellent health carried the day. My experience with Covid 19 was the headaches across the eyes, several days of fever, night sweats that required 3 changes of pajamas, appetite suppressed (lost 12 pounds), the taste buds affected greatly (nothing tasted as it normally did). I was never tested because we were told “assume you have it”. So as far as numbers, I had it and recovered but that doesn’t appear in any statistical account here in Los Angeles. The response of our Governor and Mayor is absolutely absurd. The vulnerable should be sheltering and the rest of us should be living our lives with a greater wisdom about germs/infection (something my husband and I already practiced prior to this). The homeless are taking over this city and the public policies being enacted (more money for illegal aliens) that are pure madness.

    16. Anonymous Says:

      Sharon W,
      Thank you for that detailed report. WOW!

      Death6

    17. Dan from Madison Says:

      “…pre-infection excellent health carried the day…” – I would think that gyms and personal trainers will make a killing off of this thing when it’s all said and done and we are somewhat back to normal. I can’t think of one story I have read where a generally healthy person dropped dead from this. I am sure there are some, but probably few and far between.

    18. Mike K Says:

      the taste buds affected greatly

      That’s the anosmia , which is a well known part of it. He might have had a partial response to HCQ which helped avoid the cytokine storm or he may be one of the 32% that don’t respond. At least he got it.

      The OC Register story last week had the alleged Infectious Disease guy at Hoag saying he would not use it on the next case after the 88 and 90 year old couple went home in 5 days. Fortunately, the son prescribed it for his parents.

    19. MCS Says:

      Here’s another data point:
      https://www.theguardian.com/world/2020/apr/21/boy-with-covid-19-did-not-transmit-disease-to-more-than-170-contacts

      Summary: Kid picks up Wuflu from sharing ski chalet with Brit that brought it from Asia, also has flu-flu and a cold. Goes on to contact 170 people, Passes flu and cold to sibs, doesn’t pass Wuflu to anybody. Only one point.

      As this goes on, pretty much every assumption that went into all these “models” has been proven false. At the beginning, nobody knew anything and had to make the best guess they could. Since then there has only most recently been any sort of testing of these guesses. Every time they do, they have proven to be wildly wrong and all that I’ve heard erred in the direction of pessimism. This is science?

      If the infection rate is in double digits as every widespread testing has shown, contact tracing is pointless. It will be impossible to determine where any of the positive contacts actually acquired their infection. In any event, the number of cases will quickly overwhelm any such process.

    20. Phil Ossiferz Stone Says:

      Sharon W: Both Federal funding and political representation are determined by census data. The illegal aliens and homeless are important clients. They get the Democrats more money and more power. I recall reading a story in a Bay Area newspaper a few years ago that said every time a homeless person OD’s and needs an ambulance trip to the hospital, the city of SF makes something like $37,000. It as asinine and brutal and simple as that.

      May God bless and watch over you and yours — and God damn it, get the hell out of there.