key: cord-0891736-nu1msnui
authors: Kadiane-Oussou, N’dri Juliette; Klopfenstein, Timothee; Royer, Pierre-Yves; Toko, Lynda; Gendrin, Vincent; Zayet, Souheil
title: COVID-19: comparative clinical features and outcome in 114 patients with or without pneumonia (Nord Franche-Comte Hospital, France)
date: 2020-10-10
journal: Microbes Infect
DOI: 10.1016/j.micinf.2020.10.002
sha: ba3a210ddf5585e4ea7f09a33abf9faab8a7ba5f
doc_id: 891736
cord_uid: nu1msnui

COVID-19 patients (n=114) were included (55 patients with pneumonia (group P) and 59 without pneumonia (group NP). Patients in group P were older (69 (±17) years vs 46 (±16); p<0.001) with a male predominance (58.2% vs 27.1%; p<0.001). The symptoms which were statistically more frequents in patients with pneumonia were fever ≥ 38°C (93% vs 70%; p=0.002) and dyspnea (73% vs 22%; p<0.001). Symptoms such as facial headache (42% vs 15%; p=0.001), sore throat (39% vs 16%; p=0.007), dysgeusia (61% vs 33%; p=0.003), anosmia (63% vs 31%; p=0.001) were statistically more frequents in patients without pneumonia.

An outbreak of pneumonia began in December 2019 in Wuhan (China), a novel coronavirus was 33 identified as causal agent, named later the severe acute respiratory syndrome coronavirus 2 (SARS-34

CoV-2). Clinical description from coronavirus disease 2019 (COVID-19) outbreak reveals that most of 35 the patients have minor disease (minimal symptoms to influenza like illness) or pneumonia (1). 36 COVID-19 pneumonia is mainly moderate-mild, but can be severe, up to acute respiratory distress 37 syndrome (ARDS). The aim of this study was to compare the clinical characteristics and outcome of 38 COVID-19 patients with pneumonia and without pneumonia (i.e. parenchymal pulmonary lesions). 39

We conducted a retrospective study in NFC (Nord Franche-Comté) Hospital as a major French cluster 41 of COVID-19 began on March, 1 st in Nord Franche-Comté. Between March, 1 st and March, 17 th 2020, 42 we enrolled all adult patients (≥ 18 years) with confirmed COVID-19 who consulted or were 43 hospitalized in our hospital. Pregnant women, children (< 18 years) and patients with dementia 44 (unable to report functional symptoms) were excluded. Each patient (including outpatients) had 45 physical examination (including pulmonary auscultation). 46

We collected demographic characteristics, comorbidities, and characteristics of the current COVID-48 19: clinical features, evolution of the symptoms and outcome. Due to the beginning of the outbreak 49 of COVID-19, we prepared a standardized questionnaire for each patient suspect of COVID-19 to help 50 J o u r n a l P r e -p r o o f us screen their functional symptoms and the onset and duration of their symptoms. A home follow-51 up was recommended in our national guidelines, for patients who were not hospitalized, until they 52 are asymptomatic for more than 48h. Consequently, outpatients and patients who were discharged 53 after their hospitalization were called 14 days +/-7 days after the beginning of the symptoms; in case 54 of persistent symptoms, we contacted them again 7 days later, until they were asymptomatic to 55 ascertain epidemiological and clinical data. For each patient, we followed the clinical evolution and 56 outcomes at least until recovery plus 48 hours. 

Cconcerning the statistical analysis, continuous variables were expressed as mean and standard 70 deviation (SD) and compared with ANOVA test. Categorical variables were expressed as number (%) 71 and compared by χ 2 test or Fisher's exact test between the two groups (patients with pneumonia and 72 patients without pneumonia). A p-value <0.05 was considered significant. We used the SPSS v24.0 ® 73 software (IBM, Armonk, NY, USA).

Due to the retrospective nature of the study, the Ethics & Scientific Committee of Nord Franche-76

Comté Hospital determined that patient consent was required. Informed consent about study 77 participation was officially announced verbally and noted in writing in the patient's medical record, 78 according to national regulations for retrospective study. All patient data were anonymized prior to 79 the analysis. 

two groups (Table 1 ) 91

Patients in group P were older (the mean age was 69 (±17) years versus (vs) 46 (±16); p<0.001) with a 92 male predominance (58.2% vs 27.1%; p<0.001) and a higher Charlson comorbidity index (3.2 (±2.8) vs 93 0.7 (±1.6); p<0.001) than group NP. Forty patients in group P (72%) had underlying comorbidities. 94

Main comorbidities were: cardiovascular disease (84%, n=46), diabetes mellitus (26%, n=14), chronic 95 obstructive pulmonary disease (COPD) or asthma (16%, n=9) and malignancy (13%, n=7). More than 96 two thirds of the patients in group NP (70%, n=41) had no comorbidities. We noted also more health 97 care worker in group NP (57.6% vs 14.5%; p<0.001). 98 Table 2 summarizes all functional signs (general, respiratory, neurologic, otorhinolaryngological, 100 ocular and gastro-intestinal -GI-symptoms), physical examination and duration of symptoms in both 101 groups. 102

The symptoms which were statistically more frequents in patients with pneumonia than in patients 103 without pneumonia were fever ≥ ≥ ≥ ≥ 38°C (93% vs 70%; p=0.002) or feeling of fever (98% vs 88%; 104 p=0.038) and dyspnea (73% vs 22%; p<0.001). In the other hand, the symptoms which were 105 statistically more frequents in patients without pneumonia than in patients with pneumonia were 106 facial headache (42% vs 15%; p=0.001) defined by frontal and/or retro-orbital pain, neurologic 107 symptoms such as dysgeusia (61% vs 33%; p=0.003) and anosmia (63% vs 31%; p=0.001) and 108 otorhinolaryngological symptoms such as sore throat (39% vs 16%; p=0.007), rhinorrhea (51% vs 109 31%; p=0.031) and nasal obstruction (37% vs 6%; p<0.001). No significant differences were found 110 between the two groups with regard to any other symptom. 111

About physical examination, in the group P, 47 patients (86%) had crackling sounds heard on 112 pulmonary auscultation, 2 patients had sibilant and only one had rhonchi (patient with an underlying 113 COPD). As expected, oxygen saturation levels were lower in group P than group NP (92% (±5) vs 96% 114 (±3); p=0.001). The mean duration of all symptoms was longer in group P than in group NP (17 (±9) 115 days vs 11 (±5); p<0.001); especially for fever and cough (p<0.001). 116 (Table 1 ) 117

Concerning the outcome of patients with pneumonia, 52 patients (95%) were hospitalized (vs 9 118 patients without pneumonia [15%], p<0.001), for a mean duration of 11 days (±10). Among them, 119 twelve patients (22%) were admitted in Intensive Care Unit (ICU) for acute respiratory failure and 9 120 patients (16%) were mechanically ventiled. Thirty five (59%) patients in group P had been discharged 121 from hospital at the end of our study and 20 (36%) patients died. In contrast, only one patient died in 122 group NP (p<0.001). 123

This report, to our knowledge, is one of the largest case series of patients with COVID-19 in France. 125

We described a population of 114 symptomatic adults (54% inpatient [61 hospitalized patients] and 126 46% outpatients), infected with SARS-CoV-2. 127

In the literature, the mean age of patients with COVID-19 was 46 years without predominance for 128 male (4), such as our NP group. Chen et al. showed that patients with COVID-19 pneumonia and 129 severe presentations were older, with a mean age about 68 years, with a male dominance (5). 130

Seventy-two percent of patients with pneumonia had comorbidities, including cardiovascular 131 disease, diabetes mellitus, COPD and malignancy. These comorbidities had a prevalence ≥ 10% in our 132 study as in other studies (4,6,7). Not surprisingly, patient without pneumonia were younger with a 133 lower Charlson comorbidity index (8). 134

The most common symptoms at onset of illness in the group of patients with pneumonia were fever 135 or feeling of fever and dyspnea with a significant difference when compared to the group NP. These 136 signs were reported as the main symptoms in most cohorts with clinical description of COVID-19, 137 especially in patients with pneumonia and severely ill patients (5,9). However, compared with this 138 group, patients without COVID-19 pneumonia were more likely to report symptoms such as facial 139 headache, dysgeusia, anosmia, sore throat, rhinorrhea and nasal obstruction. In a recent published 140 article, we suggested that neurologic symptoms in COVID-19 were more frequently described in Patients with COVID-19 pneumonia are usually hospitalized for observation and supportive care (13) 154 (in our study, 95% of patients in group P were hospitalized). In the group of patient without 155 pneumonia, only 9 patients were hospitalized, mainly for extra-respiratory symptoms. Patients with 156 COVID-19 pneumonia may become critically ill; more than a fifth of patients in group P were 157 transferred to ICU for ARDS with a mean duration of hospitalization in ICU of 12 days and a high 158 lethality as compared to the mortality described in China (7). 159

One of the limitations of our study is the limited number of patients; a bigger study would be 160 interesting to confirm and support our results. In addition, CT-scan was not performed in all patients 161 and the elevated number of health care workers in the group without COVID-19 pneumonia can 162 explained the female predominance, which will not be common in general population. 

Conjunctival hyperemia (Number, (%)) 2 (3.6) 3 (5.1) 1

Tearing (Number, (%)) 3 (5.5) 4 (6.8) 1

Dry eyes (Number, (%)) 3 (5.5) 1(1.7) 0.351

Blurred vision (Number, (%)) 2 (3.6) 2 (3.4) 1 In group NP (patients without pneumonia); only one patient complained of temporal headache

Characteristics of and important lessons from the coronavirus disease 179 2019 (COVID-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for 180 disease control and prevention

Detection of 2019 182 novel coronavirus (2019-nCoV) by real-time RT-PCR

First cases of 184 coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures

Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis

Clinical course and risk factors for mortality of 192 adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Clinical features of patients infected with 195 2019 novel coronavirus in Wuhan

Clinical features of COVID-19 in elderly patients: A comparison 197 with young and middle-aged patients

2019 novel 199 coronavirus (2019-nCoV) outbreak: A new challenge

Features of 201 anosmia in COVID-19

Tissue distribution of 203 ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS 204 pathogenesis

High expression of ACE2 receptor of 2019-206 nCoV on the epithelial cells of oral mucosa

Mild or moderate covid-19

170 171 All authors declare no competing interests. 172