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COVID-19: Implications in gastroenterology
What is coronavirus disease 2019 (COVID-19)?
COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.1 The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.2 The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.
What are the most vulnerable patient populations within a typical gastroenterology practice?
While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.3 In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.4 There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.5 As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
Can COVID-19 present with gastrointestinal symptoms?
While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.7 There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.8 More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
What kind of personal protective equipment (PPE) should I wear while performing endoscopy?
An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.
Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.10
If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?
First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.11 This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
As a trainee, how can I minimize my risk while continuing medical education?
Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.
To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.
To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.
Lastly, the Joint GI Society message on COVID-19 can be found here.
References
1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.
2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.
3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.
4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.
5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.
6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.
7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.
8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.
9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.
10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.
11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.
Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.
What is coronavirus disease 2019 (COVID-19)?
COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.1 The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.2 The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.
What are the most vulnerable patient populations within a typical gastroenterology practice?
While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.3 In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.4 There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.5 As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
Can COVID-19 present with gastrointestinal symptoms?
While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.7 There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.8 More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
What kind of personal protective equipment (PPE) should I wear while performing endoscopy?
An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.
Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.10
If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?
First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.11 This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
As a trainee, how can I minimize my risk while continuing medical education?
Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.
To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.
To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.
Lastly, the Joint GI Society message on COVID-19 can be found here.
References
1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.
2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.
3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.
4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.
5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.
6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.
7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.
8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.
9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.
10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.
11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.
Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.
What is coronavirus disease 2019 (COVID-19)?
COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.1 The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.2 The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.
What are the most vulnerable patient populations within a typical gastroenterology practice?
While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.3 In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.4 There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.5 As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
Can COVID-19 present with gastrointestinal symptoms?
While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.7 There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.8 More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
What kind of personal protective equipment (PPE) should I wear while performing endoscopy?
An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.
Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.10
If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?
First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.11 This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
As a trainee, how can I minimize my risk while continuing medical education?
Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.
To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.
To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.
Lastly, the Joint GI Society message on COVID-19 can be found here.
References
1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.
2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.
3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.
4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.
5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.
6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.
7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.
8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.
9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.
10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.
11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.
Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.
