key: cord-0834132-zct5b5ad
authors: Cao, Jianlei; Tu, Wen-Jun; Cheng, Wenlin; Yu, Lei; Liu, Ya-Kun; Hu, Xiaoyong; Liu, Qiang
title: Clinical Features and Short-term Outcomes of 102 Patients with Corona Virus Disease 2019 in Wuhan, China
date: 2020-04-02
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa243
sha: 6cf98142930dbcbe7b6815c99a6be9fb851fd41d
doc_id: 834132
cord_uid: zct5b5ad

OBJECTIVE: In December, 2019, a series of pneumonia cases of unknown cause emerged in Wuhan, Hubei, China. In this study, we investigate clinical and laboratory features and short-term outcomes of patients with Corona Virus Disease 2019(COVID-19). METHODS: All patients with COVID-19 admitted to Wuhan University Zhongnan Hospital in Wuhan, China, between January 3 and February 1, 2020 were included. All those patients were with laboratory-confirmed infection. Epidemiological, clinical, radiological characteristics, underlying diseases, laboratory tests treatment, complications and outcomes data were collected. Outcomes were followed up at discharge until Feb 15, 2020. RESULTS: The study cohort included 102 adult patients. The median (IQR) age was 54 years (37-67years) and 48.0% were female. A total of 34 patients (33.3%) were exposed to source of transmission in the hospital setting (as health care workers, patients, or visitors) and 10 patients (9.8%) had a familial cluster. Eighteen patients (17.6%) were admitted to the ICU, and 17 patients died (mortality, 16.7%; 95% confidence interval [CI], 9.4%-23.9%). Among patients who survived, they were younger, more likely were health care workers and less likely suffered from comorbidities. They were also less likely suffered from complications. There was no difference in drug treatment rates between the survival and non-survival groups. Patients who survived less likely required admission to the intensive care unit (14.1% vs. 35.3%). Chest imaging examination showed that death patients more likely had ground-glass opacity (41.2% vs. 12.9%). CONCLUSIONS: The mortality rate was high among the COVID-19 patients described in our cohort who met our criteria for inclusion in this analysis. Patient characteristics seen more frequently in those who died were development of systemic complications following onset of the illness and the severity of disease requiring admission to the ICU. Our data support those described by others that COVID-19 infection results from human-to-human transmission, including familial clustering of cases, and nosocomial transmission. There were no differences in mortality among those who did or did not receive antimicrobial or glucocorticoid drug treatment.

In December 2019, a cluster of patients with pneumonia of undetermined etiology was recognized in Wuhan, Hubei, China [1] ; subsequently, a novel coronavirus (SARC-CoV-2) was identified from lower respiratory tract samples obtained from affected patients [2] . The virus and its associated disease were given the designation COVID-19 in February 2020, distinguishing this syndrome from the acute respiratory syndromes associated with two other betacoronaviruses (severe acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory syndrome coronavirus [MERS-CoV] that caused earlier outbreaks of severe disease in humans [3] [4] . Structural analysis suggests that SARS-CoV-2 might be able to bind to the angiotensin-converting enzyme (ACE) 2 receptor, as SARS-CoV in humans [5] .

Yang et al. [6] declared that the mortality of critically ill patients with SARS-CoV-2 pneumonia was considerable and older patients (>65 years) with comorbidities and ARDS were at increased risk of death, while another study indicated that as of early February 2020, compared with patients initially infected with SARS-Cov-2 in Wuhan, the symptoms of patients in Zhejiang province were relatively mild [7] . We speculated that the virus can also cause great harm to humans. However, the clinical features and short-term outcomes of patients with COVID-19 is still limited. In this study, we investigate clinical and laboratory features and short-term outcomes of patients with COVID-19.

All patients with COVID-19 admitted to Wuhan University Zhongnan Hospital in Wuhan, China, between January 3 and February 1, 2020 were included [8] . All those patients were with laboratory-confirmed SARS-CoV-2 infection [9] . It should be noted that our hospital, located in the center of the epidemic area, is one of the major tertiary university hospitals and is responsible for the treatments for patients with severe COVID-19. The patients admitted to our hospital were SARS-CoV-2 pneumonia and/or those infected cases with chronic illness.

COVID-19 with minimally symptomatic or asymptomatic SARS-CoV-2 infection were admitted to the cabin hospital. The study was approved by Zhongnan Hospital Ethics Committee and oral consent was obtained from patients or relatives. of transmission within 14 days (yes or no), the incubation period (defined as the time from exposure to source of transmission to onset of symptom), familial cluster (yes or no), health care workers (yes or no) and hospitalized patients/outpatients/visitors(yes or no) were collected. Clinical symptoms (fever, dry cough, fatigue, shortness of breath, diarrhea, headache, sore throat, nausea and vomiting) and comorbidities (hypertension, diabetes, cerebrovascular and cardiovascular disease, respiratory diseases, malignancy, chronic kidney disease, and chronic liver disease) were also obtained. Clinical treatment options were collected and assessed. Drug treatment mainly included antiviral treatment, antibiotic treatment, glucocorticoid treatment, intravenous immunoglobulin therapy and Chinese medicine treatment. Other treatment options such as Oxygen inhalation, noninvasive ventilation, invasive mechanical ventilation, extracorporeal membrane oxygenation and continuous renal replacement therapy (CRRT) were also recorded. Clinical complications (lymphopenia, hypoxemia, shock, acute respiratory distress syndrome [ARDS], acute infection, arrhythmia, acute kidney injury, acute liver injury and acute cardiac injury) during hospitalization were recorded and analyzed. The acute infection was defined by the serum level of procalcitonin(≥0.5 ng/ml).

The results were presented as median (IQR) for continuous variables and number (%) for categorical variables. The different characteristics between death and survival groups were tested by Mann-Whitney U test (continuous variables) or Chi-square test (categorical variables). All statistical analyses were tested SPSS 22.0 (IBM). A two-sided a of less than 0·05 was considered statistically significant.

The initial study cohort included 104 adult patients. Two patients were excluded because of transfer during hospitalization, leaving 102 patients for analysis. Demographic details are shown in TABLE 1. The median (IQR) age was 54 years (37-67years) and 48.0% were female.

A total of 34 patients (33.3%) were exposed to SARS-CoV-2 in the hospital setting (health care workers [23.5%], patients and/or visitors [9.8%]) and 10 patients (9.8%) had a familial cluster.

Features of the signs and symptoms most commonly at admission were self-reported fever (81.4%), fatigue (54.9%), and dry cough (49.0%). The timeline of SARS-CoV-2 onset in included patients is shown in Figure 1 .

Chest imaging examination showed that 18 patients (17.6%) had ground-glass opacity. 

The median duration from the onset of symptoms to death and median time from exposure to SARS-CoV2 to death were 15(IQR, [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] showed that death patients more likely had ground-glass opacity (41.2% vs. 12.9%).

The mortality rate was high among the COVID-19 patients described in our cohort. Patient characteristics seen more frequently in those who died were development of systemic complications following onset of the illness and the severity of disease requiring admission to the ICU. Furthermore, more intensive supportive care in the ICU might improve outcomes, however, the mortality rate was higher for those who were transferred to the ICU, likely reflecting their underlying disease severity and comorbidities [8] .

Our findings and previous studies [1] [2] [9] [10] [11] show that lymphopenia is common in cases with SARS-CoV-2 infection, suggesting that SARS-CoV-2 consumes many immune cells and inhibits the body's cellular immune function. In this study, most of the deaths were caused by multiple organ dysfunction syndrome, suggesting that the impaired immune function is an important cause of death. Furthermore, we have reason to believe that the immune system was mobilized and cytokine storm was formed [1, 12] . One study showed that in a SARS-CoV infected mouse model, researchers showed that apart from the respiratory system, the heart was also infected with the coronavirus, with a down-regulated expression of ACE2 [13] . In this study, we confirmed that nearly a quarter of our death patients were caused by cardiac arrest.

Our data support those described by others that COVID-19 infection results from human-to-human transmission, including familial clustering of cases, and nosocomial transmission [2, [9] [10] . We showed that 33.3% of the included patients were exposed to SARS-CoV-2 in the hospital setting. It might be due to the fact that many of our infected staff were admitted to our hospital. It was sad that in the early days of the COVID-19 outbreak, we did not know much about the disease, and hospitals and doctors did not have adequate protection. Beginning Jan. 20, 2020, all medical workers in our hospital started to use protective clothing and goggles. Furthermore, since coronavirus diffusion takes place by droplet transmission, aerosolisation during hospital procedures like intubation or bronchoscopy might represent a big concern, exposing other patients and health-care staff to an increased risk of infection, as during the flu pandemia [14] . However, in our study, some potential confounders such as small sample size, single patient type (mainly hospital staff and moderate to severe patients) and lack of discharge information should not be ignored.

Further studies are warranted to explore natural history of COVID-19.

In this study, the mortality was 16.7%, which was higher than previous studies (range from 4.3% to 11.0%) [1, [9] [10] . It should be noted that a significant number of patients were still in hospital and mortality would continue to rise in previous studies [1, [9] [10] . All the patients in our study had discharged or died. Our results were more likely close to real results. [25] . Second, we only recorded 17 died patients.

Therefore, we did not perform logistic regression analyses to assess risk factors for death.

Thus, continued observations of the natural history of the disease are needed. Third, our study mainly includes adult patients, which might cause selective bias. Pregnant women [26] and children [27] also are equally sensitive to the SARS-CoV-2 virus. Lastly, we only include laboratory confirmed patients. In fact, RT-PCR assay had a considerable percentage of false negatives [28] . Huang et al. [28] suggested that use of chest CT in combination with negative RT-PCR assay for the SARS-CoV-2 but high clinical suspicion.

In conclusion, the mortality rate was high among the COVID-19 patients described in our cohort who met our criteria for inclusion in this analysis. Patient characteristics seen more frequently in those who died were development of systemic complications following onset of the illness and the severity of disease requiring admission to the ICU. Our data support those described by others that COVID-19 infection results from human-to-human transmission, including familial clustering of cases, and nosocomial transmission. There were no differences in mortality among those who did or did not receive antimicrobial or glucocorticoid drug treatment. 

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

A novel coronavirus from patients with pneumonia in China

Epidemiology and cause of severe acute respiratory syndrome

People's Republic of China

Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia

Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine

Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series

Clinical Features and Short-term Outcomes of 18 Patients with Corona Virus Disease 2019 in Intensive Care Unit

Clinical Characteristics of 138 Hospitalized Patients With

SARS-coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS

Minimise nosocomial spread of

Real-time tentative assessment of the epidemiological characteristics of novel coronavirus infections in Wuhan

Transmission dynamics of 2019 novel coronavirus

Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro

Baricitinib as potential treatment for 2019-nCoV acute respiratory disease. The Lancet

Clinical characteristics of 2019 novel coronavirus infection in China

Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement

Use of Chest CT in Combination with Negative RT-PCR Assay for the 2019 Novel Coronavirus but High Clinical Suspicion

Procalcitonin level, ng/ml ≥0.1ng/ml 35/82, 42

mg/l 195

‡ if one patient had several blood samples tested during hospitalization, we would choose the highest one. The threshold of those blood marker is determined by the laboratory of our hospital

Brain natriuretic peptide; NT-proBNP, N-terminal pro brain natriuretic peptide

We thank all patients included in this study. We are really grateful to all the health workers around the world. Their expertise & humanity are fundamental to stop SARS-COV-2 from spreading further. Data available can be obtained from the corresponding author.

The study funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.