Dear Editor,
We read with great interest the article published in this journal entitled “Clinical features of critically ill patients with confirmed COVID-19″ by Yanan Chu and colleagues.1 The authors comprehensively described the epidemiological and clinical characteristics of confirmed COVID-19 patients admitted to the intensive care unit at Zhejiang hospital in China. Here we present a comparative analysis of clinical and laboratory features associated with recovered and deceased COVID-19 patients in Pakistan.
The first case of SARS-CoV-2 emerged in Wuhan, China and later became a serious public health threat with rapid spread to 213 countries across the world. The World Health Organization declared this pandemic as a public Health Emergency of International concern on 30 January 2020. As of 6 September 2020, over 49 million confirmed cases and over 12 million deaths have been reported across the globe.2
First case of COVID-19 in Pakistan, was detected on February 26, 2020; the toll then reached at 3,40,251 confirmed cases including 6923 deaths as of September 6, 2020.2
It is important to know the difference among the demographic, clinical and laboratory characteristics of recovered and deceased COVID-19 patients for the proper case management, which will be helpful to reduce the rate of mortality.
For this retrospective single center study, we included 100 critical COVID-19 confirmed patients admitted to the intensive care unit at a tertiary care hospital in Islamabad Pakistan, from June 12 to July 4, 2020. Laboratory confirmation of SARS-CoV-2 was done at the department of Virology, National Institute of Health (NIH) Islamabad through real-time reverse-transcriptase polymerase chain reaction (PCR) assay using nasopharyngeal swab specimens. We obtained demographic features, clinical symptoms, laboratory test and outcome data from patient's electronic medical records. Clinical outcomes were followed up to 17 July 2020. The SPSS Statistics 23.0 software (SPSS Inc., Chicago, IL, USA) was used to perform statistical analysis of the data. A value of P < 0.05 was considered to be statistically significant. The study was approved by the internal review board of NIH and written informed consent was obtained from the patients (or their caretakers) enrolled for the study.
A total of 100 confirmed COVID-19 patients were enrolled in the study, including 82 of whom were fully recovered later and 18 who died at the hospital. The mean age of recovered patients was 45.32±16.47 years, while that of the deceased group was 60.83± 11.08 years (p< 0.003). In the recovered group, 78% subjects were male and 29.9% were female whereas in deceased group, 61% subjects were male and 38.9% were female. There was no significant difference found in the socioeconomic status of both groups. Comaprison of clinical features between recovered/deceased individuals indicated that majority of the patients exhibited fever (95/100%), fatigue (74/94%), cough (57/72%), loss of taste and smell (62/83%) breathing difficulties (47/88%), headache (54/77%), chest pain (12/77%) and diarrhea (28/61%) respectively. The shortness of breath and chest pain were significantly different and more severe in deceased patients comapred to the survived patients (p< 0.001).
Most of the laboratory parameters, including white blood cell (WBC) count, neutrophil, lymphocytes, prothrombin time (PT), partial thromboplastin time (APTT, bilirubin, Alanine Aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), urea and creatinine were significantly different between the recovered and deceased group (p< 0.001). The decreased level of electrolytes such as sodium, potassium and chloride was found in both groups without any significant difference. The level of cardiac enzyme, creatine phosphokinase (CPK) and creatine kinase (CK-MB) were significantly different between the recovered and deceased group (p< 0.001). High percentage (44%) of deceased patients belonged to the blood group AB− followed 22% who had AB+ whereas the high percentage (39%) in the recovered group matched to blood group A− followed by 20% with O+ blood group. Presence of common comorbidities such as diabetes, sepsis and chronic pulmonary disorder were significantly different between the both group (p < 0.001). The mean duration from the onset to recovery was 18.14 ± 4.22 days whereas the deceased patients survived for 26.75 ± 2.6 days after confirmed diagnosis. Up to 17 July 2020, 82% patients were fully recovered and discharged from the hospital while 18% patients had died at the hospital. Details of demographic, clinical and laboratory features are summarized in Table 1 .
Table 1.
Demographic, clinical and laboratory characteristics of recovered and deceased COVID-19 patients.
| Patient characteristics | COVID-19 |
P-Value | |
|---|---|---|---|
| Recovered; n = 82(%) | Expired; n = 18(%) | ||
| A. Demographic Parameters | |||
| Age in years; Mean + SD | 45.32±16.47 | 60.83± 11.08 | 0.003 |
| Age Groups | |||
| 20–40 | 37 (45.1) | 0 | 0.0003 |
| 41–60 | 22 (26.8) | 08 (44.4) | 0.138 |
| >60 | 23 (28.1) | 10 (55.6) | 0.024 |
| Recovery/Death Days (Mean ± SD) | 18.14 ± 4.22 | 26.75 ± 2.6 | <0.0001 |
| Gender | |||
| Male | 64 (78.1) | 11 (61.1) | 0.133 |
| Female | 18 (29.9) | 07 (38.9) | 0.133 |
| Socioeconomic status | |||
| High | 28 (34.1) | 07 (38.9) | 0.703 |
| Middle | 41 (50.0) | 08 (44.4) | 0.667 |
| Low | 13 (15.9) | 03 (16.7) | 0.928 |
| B. Signs and Symptoms | |||
| Fever | 78 (95.1) | 18 (100) | 0.337 |
| Fatigue | 63 (76.8) | 17 (94.4) | 0.091 |
| Cough | 47 (57.3) | 13 (72.2) | 0.242 |
| Rash | 05 (6.10) | 08 (44.4) | <0.0001 |
| Runny Nose | 13 (15.8) | 07 (38.8) | 0.027 |
| Sore throat | 21 (25.6) | 08 (44.4) | 0.111 |
| Shortness of breath | 39 (47.5) | 16 (88.9) | 0.001 |
| Loss of smell and taste | 51 (62.1) | 15 (83.3) | 0.087 |
| Conjunctivitis | 11 (13.4) | 06 (33.3) | 0.041 |
| Headache | 45 (54.8) | 14 (77.7) | 0.073 |
| Chest Pain | 11 (13.4) | 14 (77.7) | <0.0001 |
| Nausea & Vomiting | 21 (25.6) | 10 (55.5) | 0.012 |
| Diarrhea | 23 (28.1) | 11 (61.1) | 0.007 |
| C. Hematological markers | |||
| WBC (4–10 × 109/L) | |||
| Increased | 11 (13.4) | 07 (38.8) | 0.010 |
| Decreased | 37 (45.1) | 03 (16.2) | 0.025 |
| Neutrophils (2–7 × 109/L) | |||
| Increased | 13 (15.8) | 09 (50.0) | 0.0004 |
| Decreased | 34 (41.4) | 4 (22.2) | 0.128 |
| Lymphocyte (1–3 × 109/L) | |||
| Decreased | 56 (68.2) | 15 (83.3) | 0.204 |
| Platelets (150–400 × 103/µL) | |||
| Decreased | 63 (76.8) | 17 (94.4) | 0.091 |
| Hemoglobin (g/dL; M: 13.0–18.0, F: 11.5 to 16.5) | |||
| Decreased | 09 (10.9) | 04 (22.2) | 0.201 |
| Coagulation Markers | |||
| PT (≤13 s) | |||
| Increased | 66 (80.4) | 18 (100) | 0.04 |
| APTT (≤36 s) | |||
| Increased | 61 (74.3) | 18 (100) | 0.015 |
| D. Biochemical Markers | |||
| i. LFTs | |||
| Total Bilirubin (Normal Range= 0.2–1.0 mg/dL) | |||
| Increased | 27 (32.9) | 12 (66.7) | 0.007 |
| ALT (<50 U/L) | |||
| Increased | 42 (51.2) | 18 (100) | 0.0001 |
| AST (<40 U/L) | |||
| Increased | 48 (58.5) | 18 (100) | 0.0007 |
| ALP (65–306 U/L) | |||
| Increased | 38 (73.1) | 15 (83.3) | 0.004 |
| ii. RFTs | |||
| Urea (10–52 mg/dl) | |||
| Increased | 17 (20.7) | 12 (66.7) | 0.0001 |
| Creatinine (upto 1.2 mg/dl) | |||
| Increased | 24 (29.2) | 16 (88.9) | <0.0001 |
| iii. Electrolytes | |||
| Sodium (135–150 mmol/L) | |||
| Decreased | 59 (71.9) | 15 (83.3) | 0.317 |
| Potassium (3.5–5.0 mmol/L) | |||
| Decreased | 53 (64.6) | 13 (72.2) | 0.535 |
| Chlorides (98–108 mmol/L) | |||
| Decreased | 43 (52.4) | 12 (66.7) | 0.271 |
| iv. Cardiac Enzymes | |||
| CPK (upto 190 U/L) | |||
| Increased | 35 (42.6) | 13 (72.2) | 0.023 |
| CK-MB (upto 25 U/L) | |||
| Increased | 37 (45.1) | 15 (83.3) | 0.003 |
| v. LDH (150–250 U/L) | |||
| Increased | 47 (57.3) | 14 (77.7) | 0.107 |
| vi. Glucose Random (90–160 mg/dl) | |||
| Increased | 43 (52.4) | 13 (72.2) | 0.126 |
| vii. Serum Albumin (3.5–5 g/dL) | |||
| Decreased | 27 (32.9) | 14 (77.7) | 0.0004 |
| viii. CRP (0–6 mg/dL) | |||
| Increased | 73 (89) | 18 (100) | 0.141 |
| E. ABO-Blood Grouping | |||
| A- | 32 (39.0) | 02 (11.1) | 0.023 |
| A+ | 02 (2.40) | 01 (5.50) | 0.483 |
| B- | 08 (9.70) | 02 (11.1) | 0.865 |
| B+ | 04 (4.90) | 0 | 0.333 |
| AB- | 11 (13.4) | 08 (44.4) | 0.002 |
| AB+ | 05 (6.1) | 04 (22.2) | 0.03 |
| O- | 03 (3.60) | 0 | 0.412 |
| O+ | 17 (20.7) | 01 (5.50) | 0.128 |
| F. Comorbidities | |||
| Diabetes | 11 (13.4) | 08 (44.4) | 0.002 |
| Chronic Renal Disease | 04 (4.80) | 03 (16.6) | 0.075 |
| Sepsis | 07 (8.50) | 08 (44.4) | 0.0001 |
| CVD | 19 (23.1) | 05 (27.7) | 0.681 |
| Pulmonary diseases | 13 (15.8) | 09 (50.0) | 0.001 |
| Cancer | 0 | 01 (5.50) | 0.031 |
WBC= White blood cells, PR= Prothrombin time, APTT= Activated partial prothrombin time, LFTs= Liver function tests, ALT= Alanine amino transferase, AST= Aspartate amino transferase, ALP= Alkaline phosphatase, RFTs= Renal function tests, CPK= Creatine phosphokinase, CK-MB= Creatine kinase-MB, LDH= Lactate Dehydrogenase, CRP= C-Reactive Protein, CVD= Cardiovascular Disease, SD= Standard deviation.
In the present study, the mean age of patients expred due to COVID-19 was significantly higher than that of the recovered patients as reported a in the previous study.3 We observed a greater number of male patients compared to females in our reported cases infected by SARS-CoV-2 as already observed during SARS-CoV-2 pandemic.4 In term of laboratory tests, lymphocytopenia, thrombocytopenia, low WBC count, reduced hemoglobin and elevated coagulation markers were observed in most of the COVID-19 infected patients. The elevated level of biochemical markers such as cardiac enzymes, LDH, glucose, CRP and decreased level of electrolytes were noted in study patients coinciding with the results of previous study.5 Majority (39%) of COVID-19 patients who recovered belonged to A− blood group whereas 44% of deceased group belonged to AB− blood group however the blood group related impact of COVID-19 has not been reported extensively. Results of present study suggest that SARS-CoV-2 more likely infect older men suffering from chronic comorbidities such as diabetes, sepsis, pulmonary diseases and with AB blood group that may result in severe and even fatal outcome. The median time from the disease onset to recovery and deaths was 18.14 ± 4.22 and 26.75 ± 2.6 days respectively and similar findings have been reported from China.6 Older age, male sex, comorbidities and AB blood group are believed to be the major risk factors for critical illness and deaths from COVID-19 infection.
This study has several limitations such as small number of cases, single center study, lack of radiological findings and treatment details. The preliminary data derived from the present study permits an early assessment of demographic, clinical and laboratory features of recovered and deceased COVID-19 patients in Islamabad Pakistan.
The actual picture of recovered and deceased COVID-19 patients in Pakistan warrants further investigation at the country level.
Declaration of Competing Interest
All contributing authors stated that there are no conflicts of interest to declare.
Acknowledgments
Funding
NA.
Author contribution
MSR, MU, MMA, AK, SSZZ and MS design the study MSR, MU and MMA search literature, collected data, MU, MSR analyzed data, MSR, MU and MMA wrote paper. All authors approved the final draft.
References
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