Michael S. Saag is associate dean for global health and the director of the Center for AIDS Research at the University of Alabama at Birmingham.
Nearly a month ago, on March 12, I was taking the train from Boston to New York City where I was meeting my son, Harry, a physician in Manhattan, for a long drive back to Alabama. On the train, I wrote an op-ed for the Birmingham News warning that the coronavirus was coming to our region and that we were not ready. The piece was published the next day.
When we pulled into our driveway in Birmingham that evening, Harry spiked a fever. We looked at each other and, as physicians, knew what this likely meant: covid-19. By Saturday afternoon, I, too, developed symptoms.
We both tested positive on Monday. Harry’s symptoms were mild and lasted five days, as might be expected for a young, otherwise healthy 34-year old. At 64, I was more concerned. My initial symptoms were mild — fatigue, cough, headache, fuzzy thinking and loss of my sense of smell.
By day six, things took a big turn for the worse. I began a daily cycle of afternoon chills, fever (101 degrees), profound muscle aches, loss of appetite, inability to concentrate and hypesthesia — numbness — on the top of my head. The symptoms would largely dissipate by the morning, leading me to believe I had “turned the corner,” only to cruelly, relentlessly, return the next afternoon. And the next. And the next. It was like “Groundhog Day.”
The cumulative effect over time was draining, both physically and spiritually. My fear of going to the hospital and being placed on a ventilator led to a desperate move: I started hydroxychloroquine plus azithromycin on day seven, based on anecdotal reports of 20 patients who received this treatment in France.I took the medication for five days. I couldn’t tell whether it worked, which is why we need clinical trials to prove its efficacy and safety, as Anthony S. Fauci has stated repeatedly.
After 14 days of battling the Mephistophelean virus, I finally won. The symptoms left completely a week ago.
What did I learn? First, despite all of my knowledge of infectious diseases and how this virus was predicted to behave, I was not prepared for the personal battle and the toll it takes. The horror of going through the symptoms is less about how I felt moment to moment, but rather the fear of the unknown. During those long, Rod Serling-like nights, I wasn’t sure whether I would make it to the next morning without having to be hospitalized, and worse, end up on a ventilator. This fear of what might lie ahead lurks in the nighttime fog of every covid-19 patient.
I also was plagued by my knowledge of what was happening biologically. I knew that my symptoms were caused by my immune system’s overexuberant response to the virus. The immune system coordinates its response to pathogens through the release of what are called cytokines, chemicals released by immune cells that stimulate other cells of the immune system to counterattack. These cytokines cause the symptoms of infection — the fever, muscle aches, fuzzy thinking and fatigue. The overproduction of these chemicals in response to this virus creates a so-called cytokine storm, sometimes of hurricane proportions. The battle with the cytokines is what leads to the intensive care unit and ventilators. It is almost more than the body can take.
Lying in bed, praying for morning to come as quickly as possible, I knew my cytokines were being produced in prodigious amounts to fight the virus.
Fortunately for me, the cytokine storm spared my lungs. I never became short of breath. I monitored my blood oxygen levels hourly; the value never went below the critical level of 90 percent saturation. But during the dark nights I wasn’t sure whether the values would hold.
The illness also taught me we need interventions that can stop the pathogen. SARS-CoV-2, the virus that causes covid-19, has no known treatment. We desperately need one. Like most viruses, SARS-CoV-2 replicates at high rates (as in, billions of viruses a day), and it is the unchecked viral replication that the immune system is at work trying to shut down.
I know from my years as an AIDS researcher that we need antiviral drugs that stop the replication. We have this type of treatment for HIV and hepatitis C. Given early enough after infection, antiviral therapy shuts down viral replication completely, giving the host a chance to clear the virus without requiring a cytokine storm, thereby preventing the worst symptoms and minimizing death.
We won’t have a vaccine for at least 18 months. All we have in our armory to mollify the virus now is our knowledge that social distancing (staying at home and going out only for essential activities) is the only way to control virus transmission and limit the carnage.
This will not be the last time a virus skips from animal to human. It should be the last time we are so unprepared. But even for a doctor like me, the experience has been a humbling lesson that medicine has limits. Mother Nature rules. We can modify and lessen the symptoms, but her power is far greater than ours.