Updated April, 13 2020 2:32pm
I ran across this question posed by Cameron Kyle-Sidelle, MD, he presents a mystery in why we are seeing Hypoxia in patients that do not present with normal ARDS symptoms. He is asking for the medical and scientific community to come together to solve this mystery.
I was not aware that there was an alternate reason for the Hypoxia besides ARDS in COVID19 patients, before a few hours ago, and it has my mind looking for clues. I will go over my thoughts on this so far. I came across this tweet by C. Michael Gibson, MD. In this link he shares a paper that discusses this very issue.
My next thought is perhaps this is why China is using Vitamin C. I then found a few different articles that were of interest. This one specifically talks about this very subject. It tells of the benefits of helping restore oxygen levels, as well as the effects on the cytokine storms.
Could it be that the cytokine response is causing high ferritin levels, and those ferritins are robbing the blood of it’s iron, resulting in hypoxia? It is found in stage two of infection that a person will present with mild inflammation, and moderately elevated ferritin levels. Could it be that this has a two fold punch resulting in hypoxia by robbing iron, as well as inducing a cytokine storm?
Here is an excerpt from an open access article, Rosário, C., Zandman-Goddard, G., Meyron-Holtz, E.G. “et al”. “The Hyperferritinemic Syndrome: macrophage activation syndrome, Still’s disease, septic shock and catastrophic antiphospholipid syndrome”. BMC Med 11, 185 (2013). https://doi.org/10.1186/1741-7015-11-185.
This is a great description of what may be happening. This can also explain the severity of cytokine storms as well as the hypoxia mystery.
As described above, pro-inflammatory cytokines can induce ferritin expression; in turn, ferritin may induce the expression of pro-inflammatory cytokines. Moreover, ferritin induction of anti-inflammatory cytokines (IL-10) is an important mechanism underlying the immunosuppressive effects of ferritin. There seems, therefore, to be a complex interaction between ferritin and cytokines in the control of pro-inflammatory and anti-inflammatory mediators (Figure 2). So, ferritin can be either an immunosuppressive or a pro-inflammatory molecule. These opposing effects are probably dependent on the activation of different pathways, through different receptors, possibly employing different effectors (that is, L- versus H-ferritin), and maybe different contexts.
There are other takes on this as you will see in this article by Hana Levi julian. “Scientists study Coronavirus attack on hemoglobin, Iron & test new treatments with old standby’s” Jewish Press.com April, 10 2020. Chinese researchers belive this is what is happening.
Chinese researchers Dr. Liu Wenzhong, PhD from Sichuan University of Science & Engineering and associate professor Hualan Li from Yibin University found the RNA of the virus codes for a number of non-structural proteins which then hijack the red blood cells and attack the hemoglobin, removing the iron ions from the “heme groups” (HBB) within the hemoglobin and replacing themselves in their stead.
This makes the hemoglobin less and less able to carry oxygen and carbon dioxide. The lung cells sustain “extremely intense poisoning and inflammation due to the inability to exchange carbon dioxide and oxygen frequently, which eventually results in ground-glass-like lung images,” the researchers write.
As a result the lungs are stressed out and inflamed while the rest of the organs are also being affected. The so-called ARDS and subsequent organ failure could be attributed to this. The high levels of iron, suspected to no longer be in the hemoglobin, are being absorbed by the ferritin, which could explain why the ferritin levels might be higher.
I do know that Intravenous Vitamin C is already being given to patients in New York, but I am not aware of the outcomes. Here is an article, By Lorena Mongelli, and Bruce Golding, “New York hospitals treating Coronavirus patients with Vitmain C”. (New York Post March, 24 2020)
About 700 patients are being treated for coronavirus across the hospital network, Molinet said, but it’s unclear how many are getting the vitamin C treatment.
The vitamin C is administered in addition to such medicines as the anti-malaria drug hydroxychloroquine, the antibiotic azithromycin, various biologics and blood thinners, Weber said.
As of Tuesday, New York hospitals have federal permission to give a cocktail of hydroxychloroquine and azithromycin to desperately ill patients on a “compassionate care” basis.
President Trump has tweeted that the unproven combination therapy has “a real chance to be one of the biggest game changers in the history of medicine.”
Weber, 34, said vitamin C levels in coronavirus patients drop dramatically when they suffer sepsis, an inflammatory response that occurs when their bodies overreact to the infection.
“It makes all the sense in the world to try and maintain this level of vitamin C,” he said.
It seems strange that we are just now starting the trials on the use of Vitamin C, and will not be concluded until September 30th. By then it’s too late. Rather we should get the data from China, and use that, they began their trials on February 14th. Protocols and trials should be slightly different when we have 2,000 people dying per day, and those are just national death tolls, not global. These people can’t wait for a trial. If there are medications that other nations have used with success or things they have learned, we need to share information with them and find out what worked for them. This is not the time for nationalism, we are all in this together. People’s lives depend on it.
Many are held in ridged ways, and are afraid to step outside of the box they are in. What we are faced with right now is completely outside of that box, and if we don’t move with the flow, and think in new ways people will pay with their lives.
I myself am not a medical expert, but my take was slightly different than the Chinese scientists. I will look deeper into this in the days to follow. I am appreciative to have stumbled across this question, and to have a chance to deep look on this issue.