Infectious disease experts and doctors who have treated Covid-19 patients questioned on Sunday whether President Trump’s illness might be more severe than his medical team and the White House have let on, pointing to at least three warning signs that came to light during a briefing from the president’s doctors on Sunday.

The main concern: Trump started receiving the steroid dexamethasone, which is recommended only for hospitalized Covid-19 patients who are on ventilators or require oxygen. Trump’s medical team said Sunday they planned to continue giving him dexamethasone even as they touted that Trump was not on supplemental oxygen at that point and not having difficulty breathing.

“I think today’s news means he’s sicker than I thought he was on Friday and Saturday,” said Nahid Bhadelia, the medical director of Boston Medical Center’s Special Pathogens Unit.

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Outside experts also raised other reasons for skepticism.

For one, Trump has experienced at least two drops in his oxygen levels, his doctors confirmed Sunday. One, on Friday, led to doctors giving the president oxygen at the White House. During the Sunday briefing, the president’s lead physician, Sean Conley, said Trump’s oxygen levels had dropped again Saturday but he wasn’t clear whether oxygen had been provided again. It was that second episode that led the team to start him on dexamethasone, the doctors said. To the outside experts, two periods of low oxygen levels indicated this wasn’t a mild illness.

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The medical team’s remarks about what they had seen on the president’s lung imaging also raised questions. Conley said “there are some expected findings” without offering further details, but experts noted that he did not say Trump’s lungs appeared healthy. The imaging can show signs of pneumonia and inflammation.

“There are the things we know, and there are the things we can deduce between the lines. It feels like a whole lot of Kremlinology and I’d just be happier if they’d tell us the truth,” said Robert Wachter, the chair of the University of California, San Francisco’s department of medicine. Talking about the lung imaging, Wachter said: “What they’re really looking for is, are the lungs normal? Or is there haziness that indicates that his lungs are involved?”

Bhadelia noted that some studies have indicated that even people with mild and asymptomatic Covid-19 can have signs of illness on their lung imaging, so it would be useful to know if there were any changes in the images of the president’s lungs over time.

The outside experts acknowledged that they’re in a difficult situation trying to assess the condition of a patient they’re not treating themselves. They were also missing crucial data points that could help them get a better sense of Trump’s progression overall. Trump’s doctors haven’t said, for example, just how low his oxygen levels got. And while they have said he hasn’t had a fever since Friday, they haven’t disclosed how high his fever was when he had one.

The outside doctors said the descriptions of Trump’s treatment regimen conflict with the medical team’s rosy depictions of the president’s demeanor and energy.

“At least what they’re doing, it makes it seem like he’s pretty sick,” said Krutika Kuppalli, an infectious disease physician at the Medical University of South Carolina. “There’s a disconnect there.”

On Sunday, even as they announced that Trump was taking dexamethasone, his doctors suggested he might be discharged as soon as Monday back to the White House, where he could continue with his treatments, including his course of the intravenous antiviral remdesivir. But that left experts scratching their heads: If the president’s condition is worrying enough to start dexamethasone, surely he should stay in the hospital for longer, particularly given that people with Covid-19 can have manageable symptoms for several days before taking a quick turn for the worse.

“When I heard they’re thinking about discharging him tomorrow, my BS detector went wild,” Wachter said.

Trump’s medical team has indicated that because of who their patient is, they’re throwing every possible treatment at the problem. But the doctors have not always helped their case that they’re being transparent. Conley on Saturday had to issue a statement correcting several pieces of information provided during that day’s briefing, and on Sunday, he acknowledged he had previously been trying “to reflect the upbeat attitude” of the president when he danced around questions about what interventions the president had received.

Dexamethasone is typically reserved for the sickest Covid-19 patients because it suppresses the immune system broadly. While that can be helpful when people have severe illness — which at that point is usually driven by the body’s ramped up immune system, not the virus itself — it could hinder the useful immune attack going after the virus itself if given too early.

The steroid works differently than the other therapies Trump has received: remdesivir and an experimental monoclonal antibody cocktail that is still in clinical trials. Experts think those latter two therapies are more likely to be effective if given early in the course of an illness, because they work to halt the actual infection.

In a clinical trial, dexamethasone reduced deaths by a third in patients hospitalized with Covid-19, but the benefit depended on how sick the patients were. In patients not receiving supplemental oxygen, the study showed no benefit and potential harm.

David Juurlink, an internist and the head of the division of clinical pharmacology at the University of Toronto, raised other concerns about the use of dexamethasone: its side effects.

“The main ones I would worry about in this case are the acute neuropsychiatric side effects. These are not rare,” he said. Those can include trouble sleeping and irritability, Juurlink said, but “more concerning, although rarer, are mania and psychosis.”

“The reason we don’t give it to people who are less sick is because in those people the risk of the side effects outweighs the potential benefits,” he said.

On Sunday evening, Trump left Walter Reed National Military Medical Center, where he has been hospitalized since Friday evening, for a brief excursion to wave to supporters from inside a car. Still, the outside doctors said that, based on what they knew, they didn’t see how Trump could be discharged from Walter Reed Monday, even though the White House has a hospital unit. People who develop severe illness typically do so about a week after they start to show mild symptoms. Trump first started feeling sick on Thursday, his doctor’s have said.

Plus, Trump, a 74-year-old overweight man, is in several categories that make him at higher risk for more serious complications.

“The days ahead are going to be quite critical,” Juurlink said. “When people crash with Covid, they really can crash quite quickly.”

Still, some physicians were heartened by Trump’s medical team’s reports that the president seemed to be improving Sunday.

“He seems to be better today, which is good. He seems to be improving, which is good,” said Carlos del Rio, an infectious disease expert at Emory University. del Rio suggested perhaps that the therapies Trump has received are working for him.

But he also noted that some percentage of people, regardless of the severity of their symptoms, can have a host of other challenges even after they recover from their acute illness. These “long haulers” report experiencing fatigue, brain fog, and other issues, sometimes for months.

“The question is if he can recover rapidly,” del Rio said. “We know many people take a long time to recover and to feel well.”

  • Dexamethasone has received a lot of attention as a marker for the severity of Trump’s illness. This is overstated, in my opinion, because it may reflect aggressive treatment rather than severe disease. Meanwhile the side-effects of Dexamethasone, mania and psychosis, have not received enough attention from commentators. Trump’s already wafer-thin barrier between fact and fiction, his poor impulse control and his sense of grandeur make him close to manic without this push over the edge.

  • “These “long haulers” report experiencing fatigue, brain fog, and other issues, sometimes for months.”

    “Brain Fog?” How would we detect the change?

  • I agree with you. It is all a bunch of BS. If he has the virus he would be in bed not out in an SUV waving at his supporters. And his condition in the video is not that of someone with a lung ailment! I think it is a way to get voters to have sympathy and vote for him or he will have something to blame his loss on when he looses the election!

    • I agree, too. I think it’s more likely a ploy to give himself an excuse for losing. He doesn’t seem to know anything about getting or giving sympathy.

  • I am very concerned about Trumps mental health, especially with episodes of hypoxia and on dexamethasone which yes, can, cause mania! Why has there not been a transfer of power of Pence? Why does Trump still carry the nuclear codes with him? This is utterly ridiculous. I am more than a little worried. I have been an RN for 32 years and I am deeply concerned for the saftey of our nation right now! Trumps is an impulsive man by nature…. I hope that people are watching his behavior right now very closely and doing something to remove him from power!

    • I suffer from RA and have taken the steroid medication currently being given to the President. Why is no one mentioning a fake feeling of well being once the drug is in the system. Aside from reducing inflammation it also gives you a serious boost of energy and the feeling that you can do almost anything. But when you stop the treatment you crash and most of the time your sick state returns. The President says he feels as though he is “20 years younger”..those Doctors need to tell him that feeling is only temporary and due to the drugs, not him beating this virus!

  • Absurd theater, using those in the SUV as cardboard props.
    The cards are falling, the Emperor has no clothes.

  • I’m a lay reader, and I really appreciate this analysis and opinion. Two questions: Does the fact that his second hypoxic event was after he got the monoclonal antibodies tell you anything about the severity or course that his illness will take? Also, do the antibodies — meant to boost immune response — and the dexamethasone — which can suppress immune response, have a mutually canceling effect? Thanks! Nancy

    • They may be intended to target different aspects of the immune response. Dexamethasone regulates some cells involved in the innate inflammatory response, like macrophages. The antibody therapy may help to activate the adaptive immune response and b cell development.

  • Is he sicker than we thought or is this whole thing a put on for a start to finish TV reality show? We’ve seen no actual evidence that he’s ill. He has not sounded short of breath, nor has he looked like he has an oxygen level below normal. It is so sad that he lies so much no one knows.

    • I agree with you. It is all a bunch of BS. If he has the virus he would be in bed not out in an SUV waving at his supporters. And his condition in the video is not that of someone with a lung ailment! I think it is a way to get voters to have sympathy and vote for him or he will have something to blame his loss on when he looses the election!

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