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Romeo and Juliet: Revisited (at the time of COVID-19)

  • Giorgio Costantino
    Affiliations
    Department of Clinical Sciences and Community Health, Milan, Italy

    IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 28, 20122 Milan
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  • Flora Peyvandi
    Affiliations
    Department of Pathophysiology and Transplantation, University of Milan, Italy

    IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 28, 20122 Milan
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  • Nicola Montano
    Correspondence
    Corresponding author.
    Affiliations
    Department of Clinical Sciences and Community Health, Milan, Italy

    IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 28, 20122 Milan
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  • Carlo Agostoni
    Affiliations
    Department of Clinical Sciences and Community Health, Milan, Italy

    IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 28, 20122 Milan
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      Keywords

      Once upon a time, EM, a 27-years old female resident in Internal Medicine, fell in love with JP, a 27-yrs male, a resident as well. It happens, in the pre-COVID-19 Milan, Lombardy, Italy.
      One day at the beginning of March, JP got unfortunately infected with COVID-19. His-nasal swab resulted positive and he was confined at home in quarantine. After 3 days of fever he was definitely fine. Fifteen days later, two consecutive nasal swabs in 24 h were found negative, and he was allowed to come back to work in the Hospital. His-lover EM became sick 4 days after him. She was placed in turn into quarantine without being tested and after 3 days of fever, she was fully recovered. After fifteen days in turn, according to the rules, she was tested twice with swabs and resulted negative, and then allowed to come back at work, following JP.
      And they lived happy together…. No!
      When the serologic tests became available, and all physicians and residents of the Hospital were screened, EM resulted positive. But, as a consequence, since she had never had a formal diagnosis of COVID-19 infection, according to the current public health procedures, she underwent a mandatory swab test. This was still unexpectedly positive - 6 weeks after her symptoms disappeared - thus imposing a further quarantine and other fifteen days away from JP (he could just go to see her under her famous balcony….).
      What are we doing? We are using naso-pharingeal swabs, whose sensitivity is reported as low as 70% to screen patients for infection (when we would need a very sensitive test!), sometimes forgetting the pre-test probability of patients [
      • Wang W.
      • Xu Y.
      • Gao R.
      • et al.
      Detection of SARS-CoV-2 in different types of clinical specimens.
      ]. On the contrary, we still need a negative confirmation from a swab to stop quarantine. In this context, a naso-pharyngeal swab has a very low specificity since prolonged RNA detection for weeks after clinical recovery may not reflect the patients’ real infectivity status. Recently, the Korean center for Disease Control published a report about the follow up of 287 patients with positive serologic and nasal swab tests, weeks after they got the infection. None of their contact was infected and cell cultures for virus isolation were all negative []. Finally, we use serologic assays to be either reassuring and, maybe above all, reassured, ready to perform a new swab at the occurrence [
      • Nuccetelli M.
      • Pieri M.
      • Grelli S.
      • Ciotti M.
      • Miano M.
      • Andreoni M.
      • Bernardin S
      SARS-CoV-2 infection serology: a useful tool to overcome lockdown?.
      ]. We are relying upon tests to decide the logistic clinical fate of patients to just follow the new scientific (romantic? historicist?) mirage aimed at separating infected from non-infected people through the use of rigid protocols without taking into account any clinical history. This approach to conducting and applying clinical medicine undoubtedly suggests that it could be more useful to doctors, and maybe to raise public and political visibility, than to patients. On the contrary, instead of searching for a false sense of safety fulfilling the requirements of the vast majority of stakeholders – except patients, we should accept the uncertainty of this situation and follow the preventive recommendations at community level in the most appropriate way.
      At the end of the story, the Covid-19 era is reminding all of us that medicine in neither black nor white, and that the grey area is the dimension of life. Juliet was in the grey area of death - still alive while appearing dead -, nevertheless Romeo, blinded by his instinctive approach, did not get it, precipitating himself – and, immediately after, Juliet too - in the black shadow of death.
      EM and JP could now stay safe together in their lives, within a grey area, simply accepting the limits of medicine [
      • Simpkin A.L.
      • Schwartzstein R.M.
      Tolerating Uncertainty The next medical revolution?.
      ].

      References

        • Wang W.
        • Xu Y.
        • Gao R.
        • et al.
        Detection of SARS-CoV-2 in different types of clinical specimens.
        JAMA. 2020; (10.1001/jama.2020.3786)32159775
      1. XXX https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030(accessed May 20th, 2020)</bib.

        • Nuccetelli M.
        • Pieri M.
        • Grelli S.
        • Ciotti M.
        • Miano M.
        • Andreoni M.
        • Bernardin S
        SARS-CoV-2 infection serology: a useful tool to overcome lockdown?.
        Cell Death Discov. 2020; 6: 38
        • Simpkin A.L.
        • Schwartzstein R.M.
        Tolerating Uncertainty The next medical revolution?.
        NEJM. 2016; 375: 1713-1715