As ‘the clock starts ticking’ after coronavirus infection, Trump faces an uncertain road ahead

The news that President Trump is showing mild signs of Covid-19 infection after testing positive tell us nothing about what the disease might have in store for the commander-in-chief, physicians who treat patients with the illness warn.

And they suggest people the president’s age — he is 74 — who develop Covid-19 often have more subtle symptoms initially that may give way to pneumonia and severe illness.

One of the common early symptoms among elderly Covid patients is a drop in mental acuity or periods of mild confusion — which would be a disconcerting turn of events, if it were to happen to a sitting president.

This is a disease that can and often does confound, with many people experiencing no or very mild symptoms and others progressing to prolonged, debilitating bouts of illness that, in some cases, can lead to death. It’s also a disease that can take its time: People who appear to be recovering can take a turn for the worse at a point where, with other respiratory infections like influenza or colds, one would be expected to be starting to recover.

The critical time to know whether Trump will remain in the former group or progress to more serious disease is a window of between about eight to 12 days after symptoms begin, experts say.

“For anybody who gets infected, the clock starts ticking,” said Lakshman Swamy, an intensive care physician with Cambridge Health Alliance, in Cambridge, Mass.

“No matter what it is that he feels today, what all of us are going to be watching for is how he’s doing in about a week,” agreed Megan Ranney, an emergency physician at Lifespan Health Systems in Providence, R.I.

It’s believed that the immune systems of people who go on to develop severe Covid-19 infection fail to contain the viral infection, at which point a cascade of inflammatory responses takes off, triggering new and serious symptoms such as blood clots and organ failure.

“The problem is that a lot of the time, very abruptly … they worsen. Their oxygen needs just start to go up really fast,” Swamy said of Covid-19 patients he has seen in the hospital. “That doesn’t mean that that’s going to happen by any means. I think it’s still more likely, hopefully, that it will be a mild course.”

The world may never know how and where Trump became infected. The president has been doing more in-person election campaigning than public health officials believe to be wise in the middle of the worst pandemic of the past century. This week alone he has held rallies and attended private fundraising events in Minnesota and New Jersey.

In particular, an event on the White House lawn announcing Trump’s selection of Amy Coney Barrett as his choice for the Supreme Court is drawing new scrutiny. Wes Ely, a pulmonologist and critical care physician at Vanderbilt University in Nashville, called it “just super frustrating” in an interview after news of Trump’s positive test.

“I was like, oh, my God, what the heck are they doing? No one had masks on. And he could have gotten that virus at that event or any of the rallies,” he said.

Trump, who has downplayed the significance of the pandemic from the start, has resisted wearing masks at public events, even mocking his Democratic rival, former Vice President Joe Biden, during this week’s debate for routinely wearing a mask in public.

Infection can take up to 14 days to become evident, though most people who contract the virus develop symptoms within about five days. They tend to be at their most infectious at that point — even emitting high levels of virus in the day or two before they become symptomatic.

Anyone who was in close proximity to Trump and his wife, Melania — who has also contracted Covid-19 — in the past few of days should be in quarantine.

When someone contracts the virus, it can take a few days for the level of the virus in their systems to reach detectable levels. It was why experts were cautioning that the Bidens’ negative test Friday doesn’t preclude the chance he was infected at the debate, which was just a few days earlier.

“It’s certainly still a possibility,” said Michael Mina, an epidemiologist at Harvard’s T.H. Chan School of Public Health. Mina said the vast majority of people who eventually test positive do so within five to seven days after contracting the virus, so that while it’s a good sign the Bidens tested negative, they should have additional tests in the coming days.

White House chief of staff Mark Meadows confirmed that the president has been displaying mild symptoms. And the New York Times, citing sources, said Trump seemed “lethargic” at a fundraising event on Thursday in Bedminster, N.J., and fell asleep on Air Force One on his return from a rally in Minnesota on Wednesday.

Symptoms vary widely with Covid-19. “They can range from just the sniffles or some mild fatigue to severe muscle aches, severe fatigue, nausea, vomiting, diarrhea, and of course, cough and trouble breathing, which most of us think of as classic Covid,’’ Ranney said.

But in the elderly — and both Ranney and Swamy classified Trump in that category — the disease presentation can be different.

“In elderly patients, you … may not see the fevers. You may not see the sort of classic Covid symptoms. You may just see that someone’s falling asleep more. That could be the start of it,” Swamy said. “But that’s really hard to make sense of because that doesn’t mean that every elderly person who’s falling asleep has Covid.’’

Ranney said she diagnosed Covid-19 in “so many” elderly patients during Rhode Island’s spring crush of cases who didn’t appear to have the disease. For instance, they did not have the shortness of breath many think of as the defining feature of Covid-19 infection. In fact, the infections were only caught because the hospital was testing anyone who came to the emergency room for care.

“They show up being just a little confused or a little off. A little fatigued. A little dizzy,” she said.

Still, that doesn’t mean Trump won’t develop more severe symptoms seen in some Covid-19 cases. A patient might be hospitalized if they experience shortness of breath and other signs of low oxygen — including levels in the low 90s on a home pulse oximeter — or an unrelenting fever. Once in the hospital, patients can be treated with drugs to prevent the serious blood clots common in Covid-19, as well as a new antiviral and an old steroid.

“Our progress in therapeutics has been to this point, exclusively hospital-based,” said Paul Sax, clinical director of Division of Infectious Diseases at Brigham and Women’s Hospital in Boston. “We can’t use remdesivir or dexamethasone in the outpatient setting. That’s something that’s reserved for people who are in the hospital.”

A patient who is getting sicker will likely move from a regular bed in a Covid ward to the intensive care unit, first when pneumonia has developed or later when it worsens to acute respiratory distress syndrome, or ARDS. A later stage called Covid sepsis means that other organs beyond the lungs are at risk of failing.

Given Trump’s age and his weight — whether he would be medically classified as obese is a matter of debate — his chances of developing severe disease are higher than his wife’s. (Men also have a higher rate of severe Covid illness than women.)

Data from the Centers for Disease Control and Prevention suggest a person 65 to 74 has a five times greater chance of being hospitalized with coronavirus infection than a person aged 18 to 29. The risk of death from Covid-19 in the president’s age demographic is 90 times higher than that people in the 18 to 29 age group.

Ranney noted the risk of death from the infection for a person Trump’s age is 8%. While that means most people his age will survive this infection, that fatality rate is very high for a viral respiratory infection.

Wherever Trump is being treated in the days ahead, his medical team will have him under close observation. So will the American people, Ranney said.

“I think as a country we will all be watching closely for the next seven to 14 days and hoping that he’s one of those that escapes the severe consequences — but knowing that we still have no good treatments for this stage of the illness,” she said.

Andrew Joseph contributed reporting.