Some thoughts on the most likely cause of Acute Hepatitis recently seen in children. TLDR: COVID-induced lymphocyte dysfunction leading some pediatric patients to develop severe infection from circulating Adenovirus leading to Acute & Fulminant Hepatitis. 🧵 1/13 1st disclaimer: The exact cause of the recent spike of acute hepatitis cases in children is still unknown, but connecting some dots points to a more likely theory / explanation. Time will tell 2/

TIMELY study with Treasure trove of insights on BA.2:

Buries ONCE & FOR ALL that viral evolution is ALWAYS associated with milder diseases:
BA.2 (compared to BA.1):

1.4-fold higher Reproduction number

More replicative & Fusogenic

MORE PATHOGENIC🧵 1/ biorxiv.org/content/10.110… How many times have we recently heard: SARS-CoV2’s evolutionary path will always make it milder & less pathogenic, giving Omicron as a clear example. Well, we don’t have to wait for another VOC, since a lineage of Omicron BA.2 already proved them WRONG 2/

https://twitter.com/drnaderkhijazi1/status/1484245150209617927?s=21

Omicron #BA2 is ~1.5 times more transmissible than original BA1.
Study👇 showing same Viral Load!
Cause will almost certainly be:
Even less Cell Tropism with BA2
More efficient Endosomal entry
➡️ Intrinsically more transmissible,
Not Immune escape 1/ medrxiv.org/content/10.110… BA.2 will eventually dominate, but thankfully no significant change compared to BA.1 in:
Severity & Clinical picture
Vaccine Efficacy
Response to Antivirals
Reinfection rate

More on why Omicron is more transmissible than other variants here 👇 2/

https://twitter.com/DrNaderKHijazi1/status/1484245150209617927

MAJOR recent revelations + Connecting the dots:
1. ⬆️ Omicron infectiousness NOT related to Viral Load
2. Different ‘Cell Entry’ mode
3. ‘With’ or ‘For’ Covid conundrum
4.Delayed deaths > 1 month & ⬆️ Excess death.
Why we should call Omicron: COVID-21. Mega🧵 1/ Omicron is a major shift from other VoC in so many ways we are trying to comprehend.
This🧵 tries to connect separate recent revelations representing more pieces of the Omicron jigsaw puzzle 🧩. It also concludes it’s time to Re-classify Omicron-induced Disease as: COVID-21
2/

Some experts are claiming Covid already reached endemicity, like other ‘Seasonal Coronaviruses’, or will in the next few months. Why this is NOT rooted in science or precedent & is just wishful speculation /thinking. We are in uncharted territory. Thread 🧵 1/ How many times have you heard ‘COVID will soon become seasonal & endemic like ALL other Coronaviruses? There are SO many faults in this argument. For 1: Circulating Seasonal Coronaviruses are from a different lineage A (Embicovirus sublineage) 2/

Mounting evidence confirming overall less severity with Omicron than Delta. This is definitely welcome & probably only good news coming out of this respiratory virus with unprecedented transmissibility. Even if same virulence would’ve been catastrophic 1/ medrxiv.org/content/10.110… I expect a truly different phenotype (unique manifestations / symptoms) with predilection to invade upper airways more than lungs 🫁 with subsequent less systemic inflammation ➡️Illness➡️Death. 2/

med.hku.hk/en/news/press/…

When fighting COVID-19: Who’s Immune System do you want to have: Superman Or Batman?
The answer is key 🔑 to understand why Bat’s 🦇 immune system should be an evolutionary model for us. Mega Thread 🧵 1/ The answer is clear: Bat 🦇 man / woman.
Bats harbor many viruses yet they don’t get sick. Reason is 2 fold: 1. An ‘always on’ Innate system 2. An Immune system that doesn’t go on overdrive. Their immune system is just superior to all mammals 2/

If our Immune System had a Mission Statement it would be: ‘To recognize Danger and contain it at ALL cost’
A simplified Mega thread 🧵(for Non-Immunologists w/ references) about how our immune system works & pivoting to it’s crucial role in COVID-19. Nader K. Hijazi, MD, FCCP 1/ Ever thought: How could completely different Viruses end up with similar lung 🫁 pathology? ARDS also occurs with different Bacteria + Fungi! Even Sterile etiology in distant organs: Pancreatitis, Trauma, Blood 🩸transfusion! How? Answer lies within our immune system & lungs🫁 2/

We should start classifying ‘COVID Post Vaccination’ as a distinct phenotype / entity: (COVID-PV). I will list a few characteristics observed during my clinical practice as a Frontline Pulmonary physician 🫁 (Thread 🧵 ): 1/ Pattern of Pulmonary infiltrate: The distribution of patchy infiltration is the same BUT in COVID-PV the Ground Glass Opacities / changes GGOC (surrounding white haziness) represents inflammatory fluids filling alveoli) is distinctly absent / minimal. First image is my patient 2/

BIG news: Study finds ‘Vaccinated + unvaccinated individuals have similar viral loads with delta variant’. What does it mean & Why this is: -Expected ⁃ Likely inconsequential for the patient, but ⁃ Of paramount importance for transmission. Thread 🧵: 1/ medrxiv.org/content/10.110… First we need to understand a major difference between SARS CoV2 and it’s ancestral SARS CoV1:
SARS CoV1 enters the body almost exclusively through the lower airways / alveolar cells of lungs via ACE2 receptors. This means that patients develop symptoms very 🔜 after infection /2

This is the 15 page protocol I used for treating Hospitalized patients with COVID-19 in March and circulated April 7. We had excellent results.I still stand by it. Please note the importance of correlating days since symptom onset on presentation to the expected natural course 1/ E.g. A patient with no shortness of breath or Hypoxemia on day 12 will be much more reassuring than the same patient on day 6 who is expected to deteriorate in the next 1 to 5 days and need close attention and early and proactive treatment 2/

Interesting case: 50 yo m vaccinated w/ Sinopharm vaccine 3 months ago, presented with acute Sx tested + PCR COVID. CT chest CO-RADS score 2-3 (not typical). Most likely a blunted response with no ground glass changes. This is likely very common in vaccinated pts getting COVID 1/ Radiologist described findings as atypical for Covid and suggested ruling out other causes. Knowing that the patient is vaccinated and having seen hundreds of chest CT scans for Covid, most likely explanation: Vaccines are not sterilizing and don’t prevent infection, but 2/

@EricTopol @BallouxFrancois @AdamJKucharski @tomaspueyo @DrEricDing @Covid19Crusher What is the MOST important step needed NOW to control the Pandemic worldwide + reduce mutations that will clearly eventually result in new strains evading vaccines & prior immunity?: 🧵 1/ Have as many companies/countries manufacture vaccines 💉 after getting the know how. It is becoming very obvious that if SARS-CoV2 is left to spread uncontrollably, it won’t be long until some mutating strain will arise making prior immunity & current vaccines weak or useless /2

Dear Earthlings: Thanks to NASA’s ingenuity and cool public outreach, the names of my family will arrive on the red planet Mars tonight.
The Perseverance rover onboard Atlas V-541 rocket 🚀 launched by NASA July 31, 2020 will land on Jezero crater, Mars tonight. Mission:
To search for alien life
Attempt the first flight ever of a helicopter on another planet
It will also carry the names of 10,932,295 people who submitted their names to NASA through the ‘Send your name to Mars’ campaign, stenciled on a chip on a placard on the rover.

@gummibear737 Gummi here is a wild thought and takes weather / climate to a whole new level; Gulf Stream gyres. I really don’t know what to think of it, but the data and graphs fits very well. Notice interior of Spain also strangely affected more. (References + graphs in second tweet) Thought? @gummibear737 qeios.com/read/ME7VKG Here is the article. Again, although bizarre to me, should never discount ideas out of the conventional wisdom thinking box 📦. 2/

@Covid19Crusher @gummibear737 @BallouxFrancois Yes it shows less hospitalized, severe and fatal cases in May-June, and more frequent milder cases. (Look at numbers next to corresponding colors I added) Again pointing to seasonality. It is very clear. What confused many was the continued spread in summer, which is 1/ @Covid19Crusher @gummibear737 @BallouxFrancois Typical in the first wave of a most new pandemic virus (H1N1, Spanish flu) bc most with no immunity. Make no sense to suspect role for Memory Thanks-cells (why show only in the second wave?!), or a sudden mutation. If there are structural / fxnal changes to 🦠 it would be /2

Many are trying to explain the declining mortality rate, esp in the 2nd wave of countries like Spain 🇪🇸 , France 🇫🇷 and Italy 🇮🇹. Some suggested Memory T-cells from prior infections. The most logical explanation is weather / Climate / Summer. Here are some thoughts with ref. 1/ The Drop in COVID-19 deaths must be at least partially related to weather. Early on, many suspected a role for climate contributing to overall impact of COVID-19 pandemic, but continued spread around the world in May & June, even in warmer and humid countries, dampened that hope

@JamesTodaroMD Sorry but have to disagree with this argument. Nothing more important than how many people unnecessarily died from COVID-19:
Sweden: 5770 deaths (571 deaths /million)
Norway: 256 deaths (47 deaths /million)
Finland: 334 deaths (60 deaths /m)
Denmark: 621 deaths (107 deaths /m) @JamesTodaroMD Benefits of delaying spread:
1. Part of flattening the curve and reducing healthcare burden, thus reducing mortality
2. Allows time to understand the disease and figure out what treatments work
3. Buys time to prepare the healthcare system with PPEs, Ventilators, etc