key: cord-0772760-q6rpsp8z
authors: Azizmohammadi, Susan; Azizmohammadi, Sima; Dahmardeh, Sarah; Azargashb, Hossein; Shokouh, Seyyed Javad Hosseini; Mohajeri-Iravani, Mojgan; Mobasher, Maziar; Soleiman-Meigooni, Saeed; Zabihi, Mahdi
title: Analysis of 239 ordinary and severe cases of COVID-19: Clinical features and treatment
date: 2021-07-01
journal: Eur J Transl Myol
DOI: 10.4081/ejtm.2021.9579
sha: d41c87a2ac79e98f6a7e488df6d2b030154a0717
doc_id: 772760
cord_uid: q6rpsp8z

This study retrospectively analyzed the clinical characteristics of patients with new coronavirus infection (COVID-19) and summarizes the treatment experience. A total of 239 COVID-19 patients admitted to the Hajar Hospital, Aja University of Medical Science, Tehran, Iran from March 22, 2020 to May 18, 2020 were selected, including 176 cases in the ordinary group and 63 cases in the severe/critical group. We collected and compared the clinical data of the two groups of patients, including general conditions, clinical symptoms, signs, laboratory tests, lung CT imaging and prognosis, and analyzed the treatment plans of the two groups. The mean age of 239 COVID-19 patients was 48.1±17.6 years, including 132 males. Patients in the severe and critically ill groups were older than the normal group, with more males and more underlying diseases. The difference was statistically significant (p < 0.05). The lymphocyte (LYM) counts and albumin (ALB) counts of the severe and critically ill groups were more significantly lower than those of the normal group; while the percentage of neutrophils (NEU), C-reactive protein (CRP), D-dimer, and lactate The increase of lactate dehydrogenase (LDH) and urea nitrogen (BUN) was more significant, and the difference was statistically significant (p < 0.05). Patients in the severe and critically ill groups received more antiviral drugs, glucocorticoids, and nasal catheters than those in the normal group, and the difference was statistically significant (p < 0.05). Also, we observed that the most radiological finding was bilateral ground-glass opacity in both groups, however, the rate of typical abnormalities in both chest CT scan and chest x-ray was significantly higher in sever/critical group except air-bronchogram. Taken together, we showed that combination of oseltamivir and glucocorticosteroid such as dexamethasone was very effective in severe patients.

the main presentations of COVID-19 in Iraninan population have not been published widely. In this regard, we tried to share our experience and clinical manifestation of COVID-19 cases in Iran. Therefore, present study is aimed to evaluate and analyze the clinical characteristics of the COVID-19 patients in Iran, and summarize the treatment experience from them, and provide reference for clinicians on the front line of antiepidemic disease. In reaching this goal, we enrolled 239 admitted patients, including 63 severe cases. 

We divided the COVID-19 patients in three subgoups: 

The relevant data was collected and obtained through the in-hospital electronic medical record system, which was summarized in an electronic format and reviewed by senior physicians. The information collected included demographic data, previous medical history, history of epidemic exposure, clinical symptoms and signs, laboratory tests, chest imaging findings, treatment measures, and prognosis. The laboratory tests at least included: blood routine, CRP, PCT, prothrombin time (PT), D-dimer, creatine kinase (CK), creatine kinase isoform Enzymes (CK-MB), LDH, alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum albumin (ALB), total bilirubin (TB), creatinine (Cr), and BUN. The laboratory examination data of ordinary patients were collected within 48 hours of admission, and the severe and critically ill patients were collected within 48 hours of admission to the intensive care unit. The statistical content of treatment measures included the application of antiviral drugs, antibacterial drugs, glucocorticoids, oxygen therapy and respiratory support.

All statistical analyses were performed by using SPSS 25.0 software, the t-test and chi-square test were used to compare the mean of two groups of samples. The measurement data of normal distribution is represented by mean (x̄) ± SD; p value under 0.05 was consider as a significance level. Table 1 shows the general data of 239 COVID-19 patients collected in this study. The average age of the patients was 48.1±17.6 years. Among them, 132 were male (55.3%) and 107 were female (44.7%). In terms of disease susceptibility, there was no statistically significant difference between men and women (p = 0.42), but men were more likely to develop severe pneumonia (47 cases (75%) vs 16 cases (25%), P=0.032). Compared with the common type, patients with severe and critically ill patients are older [(59.8±14.1) years vs (43.9±14.5) years, p < 0.001], and previously had hypertension [32 cases (50.8%) vs 16 cases ( 9.1%), p < 0.001] and cerebrovascular diseases [9 cases (14.3%) vs 0 cases, p = 0.026], and the number of underlying diseases of previous diseases was higher than that of the ordinary group (p < 0.001). Other indicators such as contact history, onset symptoms, pulse, breathing frequency and other indicators showed no significant differences (all p > 0.05). Table 2 shows the comparison of laboratory examination items between 63 severe /critically ill patients and 176 ordinary patients. In blood tests and 26 patients (11.0%), There was no significant difference in Cr detection value between the two groups ( p = 0.819); BUN increased more significantly in severe and critically ill patients [5.4 (4.3 ~ 6.0) mmol L -1 vs 3.6 (3.0 ~ 4.5) mmol L -1 ] ( p < 0.001), but the mean is still within normal range.

Among 236 patients. 207 patients were undergoing lung CT examination and 88 patients were undergoing chest X-ray upon admission. 207 patients had lung CT imaging on admission, including patients 144 (81.8%) in ordinary patients and 63 patients (100%) in severe patients with CT imaging changes in the lungs. In addition, among 88 patients with chest X-ray evaluation, 57 patients (32.3%) was placed into ordinary group and 31 patients (49.2%) were severe/critically ill patients. Table 3 shows the detailed findings of chest X-ray and chest CT examination in ordinary and severe/critically ill patients. There was no statistically significant difference between the groups. The lung CT signs of the diagnosed cases are summarized as follows: Most patients with lung CT usually show single or multiple ground glass shadows, and consolidations. Our results showed that the most prevalent chest CT feature was ground-glass opacity (43.0%) with bilateral involvement pattern (78.7%) and followed by consolidation and peripheral distribution. Severe/critically ill patients had a significant higher rate of abnormalities, including ground-glass opacity, consolidation, crazy-paving pattern (p < 0.001). Only airbronchogram was not significantly differ among two groups. In addition, the same results were seen in chest X-ray (Table 3) . Table 4 shows that all patients received one or more treatment, including 239 cases of oseltamivir (100%) and 44 cases of lopinavir (18.4%). Patients in the severe and critically ill groups received significantly more antiviral drugs than the general group (p < 0.001). More than 50% of patients in both groups used antibacterial drugs, mainly including azithromycin and levofloxacin. Glucocorticoids in severe and critically ill patients [44 cases (69.8%) vs 34 cases (19.4%), p < 0.001]. The rate of nasal catheters and high flow oxygen inhalation is also higher (p <0.001, 0.026). In this study, five critically ill patients died of acute respiratory distress and other patients were discharged from the hospital.

The initial reports on the SARS-CoV-2 and COVID-19 believed that they were similar to the SARS and MERS coronaviruses that occurred in the early years. Most infected patients showed fever, dry cough, fatigue, and dyspnea. 3, 9, 10 This study also confirmed that fever and dry cough accounted for 84.8% and 57.0% of the patients' onset symptoms, respectively. The other onset symptoms also included fatigue, muscle aches, difficult breathing, dizziness, headache, and diarrhea. However, we observed that fewer patients started with typical upper respiratory symptoms, such as runny nose, sneezing, swollen throat, etc., which is different from the previously reported symptoms related to SARS and MERS. 3 Earlier reports showed that the new coronavirus is more susceptible to men, which may be related to the 99 patients included are mostly male workers in Wuhan South China Seafood Market. 11 The ratio of men to women in this study is 1:0.81, but there is no statistical difference, so there is insufficient evidence to prove that men are more susceptible to COVID-19. However, we found that men account for a higher proportion of severe and critically ill patients, which means that men are more likely to develop severe and critically pneumonia. This study also found that severe and critically ill patients often have more comorbid diseases, which mainly include hypertension and cerebrovascular diseases, suggesting that these past medical histories may be a risk factor for severe and critically ill patients. According to the analysis of the duration of time from onset to admission of the two groups of patients, the time between the onset and admission to hostital of patients in the heavy and critically ill groups is significantly longer than that of ordinary patients, which also provides us with inspiration for disease prevention and control: suspected cases should be diagnosed and detected early, early isolation, early diagnosis, early treatment, to avoid the conversion of some ordinary patients to heavy and critical due to delayed diagnosis and treatment. Laboratory analysis shows that many indicators are significantly different between the patients in the severe and critical group and the normal group. We observed that the absolute value of NEU, NEU%, and CRP were more significantly increased in patients with severe and critically ill patients; and the percentage and absolute value of lymphocytes of LYM% were also more significantly decreased than those of ordinary type. Changes in these indicators indicate that the mechanism of COVID-19 development may be similar to pneumonia caused by SARS and MERS coronavirus, and there may be a process of cellular immune impairment. 4 SARS-CoV-2 infection also has a certain impact on the coagulation system. Some patients have prolonged PT, APTT, and severe and critically ill patients. The D-dimer increase is more obvious than the normal type. At the same time, we also observed that lactate dehydrogenase (LDH) was significantly higher in patients with severe and critically ill patients than in the normal group, which indicates that the virus may directly or indirectly damage cardiomyocytes through cytokine storms. The reduction of ALB levels is particularly obvious in severe and critically ill patients. It is speculated that it may be related to the liver albumin synthesis disorder caused by the direct damage of the virus to liver cells. In addition, increased body consumption due to inflammation, fever, etc. can also lead to low ALB. Although the vast majority of patients did not have obvious renal impairment and their BUN values were within the normal range, the BUN levels of patients in the severe and critical group were still generally higher than those in the normal group, which may be more severe than the former. Fever caused by high metabolism. In conclusion, SARS-CoV-2 infection has adverse effects on multiple organs and systems, including the coagulation system, heart, liver, and kidneys, and the specific damage mechanism requires further pathophysiology for the pathogenicity of the virus the study. Anti-viral drugs is particularly important in the treatment of coronavirus, but there is still no specific drug for coronavirus infection. 12 In this study, all patients received oseltamivir antiviral therapy. We showed that combination of oseltamivir and glucocorticosteroid such as dexamethasone was very effective in severe patients. However, statistuical analysis failed to show the effectiveness of this treatment in criticaly ill patients. In view of previous reports that SARS-CoV, MERS-CoV, and SARS-CoV-2 infections can induce cytokine storms, 3 glucocorticoids are often used to treat severely ill patients and can benefit by reducing lung damage caused by inflammation. However, there are also studies that the application of glucocorticoids does not significantly improve the prognosis. 13 In conclusion, Taken together, our data reported that five critically ill patients died of acute respiratory distress and other patients were discharged from the hospital. Elderly patients with multiple cardiovascular and cerebrovascular diseases are more prone to severe and critical COVID-19, and often have abnormalities in multiple organs or systems.Totally, we showed that combination of oseltamivir and glucocorticosteroid such as dexamethasone was very effective in severe patients. Clinicians should make timely decisions based on clinical symptoms, signs and laboratory examination results judge and adjust the treatment plan.

ALB -albumin ALT -alanine aminotransferase AST -aspartate aminotransferase BUN -urea nitrogen CK -creatine kinase CK-MB -creatine kinase isoform enzymes COVID-19 -new coronavirus infection Cr -creatinine, CRP -C-reactive protein FiO2 -Fraction of inspiration oxygen ICU -intensive care unit LDH -lactate dehydrogenase LYM -lymphocyte NEU -neutrophils PaO2 -partial pressure of oxygen PLT -platelets PT -prothrombin time RT-PC -real-time fluorescence quantitative polymerase chain reaction SARS-CoV-2 -severe acute respiratory syndrome coronavirus 2 TB -total bilirubin

SuZ, SiZ, SD, HA, SJHS, MMI, MM, SSM, and MZ contributed to the research concept and study design, literature review, data collection, statistical analyses, data interpretation, manuscript writing and review.

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Accepted for publication

Funding None

The authors declare no conflicts of interest.

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