Leukopenia and leukocytosis as strong predictors of COVID-19 severity: A cross-sectional study of the hematologic abnormalities and COVID-19 severity in hospitalized patients

Background and Aims

Predicting severe disease is important in provocative decision-making for the management of patients with the coronavirus disease 2019 (COVID-19); However, there are still some controversies about the COVID-19's severity predicting factors. This study aimed to investigate the relationships between clinical and laboratory findings regarding COVID-19's severity in patients admitted to a tertiary hospital in Mashhad, Iran.

Methods

A cross-sectional study was conducted on patients with documented COVID-19 infection based on the reverse transcription-polymerase chain reaction test. Clinical symptoms, vital signs, and medical history of the patients were recorded from their medical records. Laboratory findings and computed tomography (CT) study findings were documented. Disease severity was defined based on CT scan findings.

Results

A total of 564 patients (58.8 ± 16.8 years old) were evaluated. The frequency of severe disease was 70.4%. There was a significant difference in heart rate (p = 0.0001), fever (p = 0.002), dyspnea (p = 0.0001), chest pain (p = 0.0001), diarrhea (p = 0.021), arthralgia (p = 0.0001), and chills (p = 0.044) as well as lymphopenia (p = 0.014), white blood cell count (p = 0.001), neutrophil count (p < 0.0001), lymphocyte count (p < 0.0001), and prothrombin time (p = 0.001) between disease severity groups. Predictors of severe COVID-19 were pulse rate (crude odds ratio [cOR] = 1.014, 95% confidence interval [CI] for cOR: 1.001, 1.027) and leukopenia (cOR = 3.910, 95% CI for cOR: 1.294, 11.809). Predictors for critical COVID-19 were pulse rate (cOR = 1.075, 95% CI for cOR: 1.046, 1.104), fever (cOR = 2.516, 95%CI for cOR: 1.020, 6.203), dyspnea (cOR = 4.190, 95% CI for cOR: 1.227, 14.306), and leukocytosis (cOR = 3.866, 95% CI for cOR: 1.815, 8.236).

Conclusions

Leukopenia and leukocytosis have the strongest correlation with the COVID-19 severity. These findings could be a valuable guild for clinicians in COVID-19 patient management in the inpatient setting.

The Outcome of Critical-phase COVID-19 in Liver Transplant Recipients

Background:

Considering the importance of assessing solid organ transplants, infected individuals with coronavirus disease 2019 (COVID-19), and the lack of information in this regard, this descriptive study aimed to investigate the clinical features, immunosuppressive agents, and outcomes of liver transplant recipients in the critical phase of infection with COVID-19.

Methods:

This descriptive cross-sectional study was conducted on 12 critically ill liver transplant recipients referred to Imam Reza and Montaseriyeh hospitals affiliated with Mashhad University of Medical Sciences, Mashhad, Iran, within 2020-21. The required data, including demographic and clinical information, were gathered and recorded in a checklist, and the correlations between variables were assessed in SPSS software (version 24).

Results:

Hypertension, diabetes, and chronic kidney disease were reported in 83.3% (n=10), 58.3% (n=7), and 41.6% (n=5) of patients, respectively. The administration of Mycophenolic acid was correlated with conjunctivitis (r=-0.67; P=0.02), weakness (r=0.77; P=0.006), and sore throat (r=-0.67; P=0.02). Ground glass opacity was reported in all patients, which was along with consolidation in 90.9% of the cases, and acute pulmonary embolism was found in 36.3% of the subjects. Finally, 66.7% (n=8) of patients passed away. Among immunosuppressive agents, only the use of Mycophenolic acid was correlated with the outcome (r=-0.77; P=0.006).

method:

This descriptive cross-sectional study was conducted on 12 critically ill liver transplant recipients referred to Imam Reza and Montaseriyeh hospitals affiliated to Mashhad University of Medical silences, Mashhad, Iran, within 2020-21. This study was extracted from a thesis to obtain a specialist MD degree in infectious diseases (Code: 981818). The required data, including demographic and clinical information, were gathered and recorded in a checklist, and the correlations between variables were assessed in SPSS software (version 24).

Conclusion:

Due to the high rate of mortality among liver transplant recipients in the critical phase of COVID-19, earlier and more aggressive treatment with antiviral and antibacterial agents should be performed in this group of patients.

other:

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Temporal changes of lung computed tomography findings pulmonary COVID-19 infection

OBJECTIVES

COVID-19 infection demonstrates characteristic findings in chest CT. The optimal timing of repeated CT scans still needs to be clarified, and the optimal time to assess imaging clearance in COVID-19 is still unknown. It is crucial to have a roadmap of the imaging course of COVID-19 pneumonia to develop guidelines for prompt diagnosis of pulmonary complications, especially fibrosis, at the earliest stage.

PURPOSE

To assess the temporal changes of chest CT findings in patients with COVID-19 pneumonia and evaluate the rate of a complete resolution and determine the patients are at excessive risk for residual parenchymal abnormalities.

MATERIALS AND METHODS

This retrospective observational study included 48 patients with real-time polymerase chain reaction-confirmed COVID-19 who were admitted to three academic hospitals. These patients underwent at least one initial chest CT before or after admission and at least one follow-up CT scan four weeks or more after the onset of the symptoms. All chest CTs were categorized according to time of performance into four groups, including the first week, second week, third-fourth week, and more than 28 days. Lung involvement was categorized as predominantly alveolar (ground-glass opacity and consolidation), organizing pneumonia, and reticular patterns. The severity of involvement was also evaluated by the reader.

RESULTS

Forty-eight patients and a total of 130 chest CT scans were evaluated. The alveolar pattern showed a gradual decrease in frequency from 91% in the first week to 9% after the fourth week of the disease but the organizing pneumonia pattern gradually increased with disease progression and the frequency of reticular pattern increased significantly after third week. Complete resolution of CT findings was seen in 17 patients (13.1%) and was significantly more prevalent in patients of younger age (p value<0.001) and with lower initial CT severity scores (p value=0.048). CT severity scores in the second week were significantly higher in ICU admitted patients (p value=0.003).

CONCLUSION

There are temporal patterns of lung abnormalities in patients with COVID-19 pneumonia. The predominant CT pattern was alveolar infiltrate in the first and second weeks of the disease, replaced with an organizing pneumonia pattern in the third and fourth weeks. Progression of lung involvement was correlated with ICU admission due to the highest CT severity score in the second and third weeks of presentation but not in the first week in patients who were admitted at ICU. Complete CT resolution was significantly more common in patients of younger age and lower initial CT severity scores.

The effects of high dose vitamin D supplementation as a nutritional intervention strategy on biochemical and inflammatory factors in adults with COVID-19: Study protocol for a randomized controlled trial

Introduction: Low serum vitamin D has been shown to be a risk factor for Coronavirus 2019 (COVID-19). The aim of this study was to assess the effects of high dose vitamin D supplementation on hs-CRP, ESR and clinical outcomes, including duration of hospitalization, quality of life and New York Heart Association (NYHA) Functional Classification, in adults with COVID-19. Methods: This double-blind, randomized control trial will be conducted on patients with RT-PCR and/or chest CT scan diagnosis of COVID-19 admitted in Imam Reza Hospital, Mashhad, Iran. Participants will be randomized into control and intervention groups based on randomization sampling. The intervention group will receive soft gel containing 50,000 IU vitamin D on the first day followed by 10,000 IU/day through a supplement drop daily for 29 days. The control group will receive 1000 IU vitamin D daily through supplement drop and a placebo soft gel. All participants will undergo laboratory assessment including inflammatory markers, serum 25)OH)D, complete blood count (CBC), liver and renal profile, lipid profile and erythrocyte sedimentation rate (ESR) at baseline and at day 30. The mortality rate will be recorded in both groups. Results: Data will be presented using descriptive statistics. Comparison of changes in study parameters over the study period will be performed using analysis of covariance adjusting for possible confounders. Conclusions: The findings of this will provide evidence on the effects of high dose vitamin D supplementation on inflammatory markers in hospitalized COVID-19 patients.

Clinical characteristics of 200 COVID-19 patients in Mashhad, Iran, February and March 2020

Introduction:

Coronavirus disease 2019 (COVID-19) is a pulmonary involvement which was reported for the first time in December 2019 in the city of Wuhan, Hubei province, China. The aim of the study was to describe the demographic, clinical, laboratory, and radiological characteristics of 204 definitive laboratory-confirmed COVID-19 patients hospitalized in Mashhad, Khorasan Razavi province, Iran.

Patients and Methods:

This study was performed on 204 laboratory-confirmed COVID-19 patients. A set of laboratory tests combined with various patient information and results from lung high-resolution computed tomography (HRCT) were gathered in a checklist and analyzed to give us a better view of patients who are hospitalized due to the complications caused by this disease.

Results:

The average age of our patients was 58.83 ± 15.93 years. There were 122 (59.8%) male and 82 (40.2%) female patients, and almost all of our patients had at least one underlying disease. Nine (4.4%) of our patients reported having gone for a trip to COVID-19-epidemic areas in the last 2 weeks. The most common signs shared among all our patients were cough, fever, and decreased O₂ saturation; the average respiratory rate was 25.50 ± 6.74/min, average axillary body temperature was 37.69°C ± 0.69°C, and average O₂ saturation was 88.34% ± 7.34%.

Conclusion:

Based on our results, the most common signs of this disease are fever, cough, and shortness of breath, similar to seasonal influenza. Our data on disease severity showed that 33 (16.2%) patients had moderate disease, 139 (68.1%) had severe disease, and 28 (13.7%) were critical; 22 (10.8%) of our hospitalized patients died due to the complications of this disease.

Cytomegalovirus pneumonia in an immunosuppressed sarcoidosis patient; a rare case of cytomegalovirus infection in a sarcoidosis patient

Background:

Sarcoidosis is a multisystemic granulomatosis disease that is mostly treated with immunosuppressive regimens. Studies demonstrated that these patients are prone to develop various infections. However, some infections including viral severe pneumonia is rare complications in sarcoidosis patients. In the present report, we described for cytomegalovirus (CMV) pneumonia in a female patient with sarcoidosis which has been successfully managed by ganciclovir.

Case Presentation:

Herein, we present a known case of sarcoidosis admitted to the emergency department because of fever, dyspnea, and productive cough. The patient was receiving prednisolone and methotrexate for months. The primary chest x-ray imaging revealed bilateral infiltration, especially in the upper lobes and hilar lymphadenopathy. The lung high resolution computed tomography showed a bilateral diffuse nodular pattern. After 72 hours of antimicrobial treatment, the fever was still present and the patient became a candidate for fiberoptic bronchoscopy. The gram staining of the bronchial fluid, polymerase chain reaction for tuberculosis, and PCP was also unremarkable. However, the PCR-CMV was positive. The quantitative PCR for CMV form blood sample was taken and the result came back as 3.6*10³. With the impression of CMV pneumonia, a daily dose of 5mg of ganciclovir was prescribed. After 3 weeks of receiving 5mg/kg of ganciclovir twice daily (600mg daily), clinical symptoms, and dyspnea improved. Also, the radiological findings improved.

Conclusion:

In the present report, we demonstrated that sarcoidosis patients’ receiving immunosuppressives are prone to develop CMV pneumonia, and fever and dyspnea were the alarm signs of CMV pneumonia is our patient which was successfully managed by ganciclovir.

METHYLENE BLUE FOR TREATMENT OF HOSPITALIZED COVID-19 PATIENTS: A RANDOMIZED, CONTROLLED, OPEN-LABEL CLINICAL TRIAL, PHASE 2

Background

There is no pharmacological intervention on the treatment of hypoxemia and respiratory distress in COVID-19 patients.

Objective

The objective of the study was to study the effect of the reduced form of methylene blue (MB) on the improvement of oxygen saturation (SpO₂) and respiratory rate (RR).

Methods

In an academic medical center, 80 hospitalized patients with severe COVID-19 were randomly assigned to receive either oral MB along with standard of care (SOC) (MB group, n = 40) or SOC only (SOC group, n=40). The primary outcomes were SpO₂ and RR on the 3^rd and 5^th days. The secondary outcomes were hospital stay and mortality within 28 days.

Results

In the MB group, a significant improvement in SpO₂ and RR was observed on the 3^rd day (for both, p < 0.0001) and also the 5^th day (for both, p < 0.0001). In the SOC group, there was no significant improvement in SpO₂ (p = 0.24) and RR (p = 0.20) on the 3^rd day, although there was a significant improvement of SpO₂ (p = 0.002) and RR (p = 0.01) on the 5^th day. In the MB group in comparison to the SOC group, the rate ratio of increased SpO₂ was 13.5 and 2.1 times on the 3^rd and 5^th days, respectively. In the MB group compared with the SOC group, the rate ratio of RR improvement was 10.1 and 3.7 times on the 3^rd and 5^th days, respectively. The hospital stay was significantly shortened in the MB group (p = 0.004), and the mortality was 12.5% and 22.5% in the MB and SOC groups, respectively.

Conclusions

The addition of MB to the treatment protocols significantly improved SpO₂ and respiratory distress in COVID-19 patients, which resulted in decreased hospital stay and mortality. ClinicalTrials.gov: NCT04370288.

Clinical features and disease severity in an Iranian population of inpatients with COVID-19

Coronavirus disease 2019 (COVID-19) can present with a variety of symptoms. Severity of the disease may be associated with several factors. Here, we review clinical features of COVID-19 inpatients with different severities. This cross-sectional study was performed in Imam Reza hospital, Mashhad, Iran, during February-April 2020. COVID-19 patients with typical computed tomography (CT) patterns and/or positive reverse-transcriptase polymerase chain reaction (RT-PCR) were included. The patients were classified into three groups of moderate, severe, and critical based on disease severity. Demographic, clinical, laboratory, and radiologic findings were collected and compared. P < 0.05 was considered statistically significant. Overall, 200 patients with mean age of 69.75 ± 6.39 years, of whom 82 (41%) were female were studied. Disease was severe/critical in the majority of patients (167, 83.5%). Disease severity was significantly associated with age, malignant comorbidities, dyspnea, nausea/vomiting, confusion, respiratory rate, pulse rate, O2 saturation, extent of CT involvement, serum C-reactive protein (CRP), pH, pO2, and aspartate transaminase (P < 0.05). Moreover, complications including shock, coagulopathy, acidosis, sepsis, acute respiratory distress syndrome (ARDS), intensive care unit (ICU) admission, and intubation were significantly higher in patients with higher severities (P < 0.05). O2 saturation, nausea/vomiting, and extent of lung CT involvement were independent predictors of severe/critical COVID-19 (OR 0.342, 45.93, and 25.48, respectively; P < 0.05). Our results indicate O2 saturation, nausea/vomiting, and extent of lung CT involvement as independent predictors of severe COVID-19 conditions. Serum CRP levels and pO2 were also considerably higher patients with higher severity and can be used along with other factors to predict severe disease in COVID-19 patients.

Synchronous presentation of COVID-19 pneumonia and pulmonary embolism

The patients with COVID-19 pneumonia who suffer from worsening of the clinical respiratory symptoms, after the beginning of the treatment, should be evaluated for pulmonary embolism using CT angiography if there are no contraindications.

A Severe Case of Bilateral COVID-19 Pneumonia with Concurrent Ischemic Stroke and Myocardial Infarction

Looking at the recent data provided in literature, we can see an association between cardiovascular and cerebrovascular accidents in COVID-19 thought to be related to severe inflammation and prothrombotic environment caused by the virus. This article reports a patient presenting with typical signs and symptoms of SARS-CoV-2 infection including flu like symptoms and respiratory distress. Initially a chest CT was performed that showed characteristic findings of atypical pneumonia caused by SARS-CoV-2 virus which was later confirmed with a nasopharyngeal PCR positive for COVID-19. During the course of admission patient developed unstable angina. Further testing confirmed an acute ST elevation myocardial infarction. While on anticoagulant treatment, patient showed signs of cerebrovascular accident. An emergency brain CT was ordered which did not yield any significant changes supporting our clinical diagnosis. Further diagnostic workup using magnetic resonance imaging disclosed evidence of cerebral ischemia in medial cerebral artery territory. Our study suggests that prophylactic anticoagulant regiment is not reassuring in COVID-19 patients and close observation and vigilance, can help clinicians to act timely and can improve patient survival.

Efficacy and safety of convalescent plasma therapy in severe COVID-19 patients with acute respiratory distress syndrome

Since SARS-CoV-2 infection is rapidly spreading all around the world, affecting many people and exhausting health care resources, therapeutic options must be quickly investigated in order to develop a safe and effective treatment. The present study was designed to evaluate the safety and efficacy of convalescent plasma (CP) for treating severe cases of COVID-19 who developed acute respiratory distress syndrome (ARDS). Among 64 confirmed cases of severe COVID-19 with ARDS in this study, 32 patients received CP besides first line treatment. Their clinical response and outcome in regard to disease severity and mortality rate were evaluated and compared with the other 32 patients in the control group who were historically matched while randomly chosen from previous patients with the same conditions except for receiving CP therapy. Analysis of the data was performed using SPSS software. Patients with plasma therapy showed improvements in their clinical outcomes including a reduction in disease severity in terms of SOFA and APACHE II scores, the length of ICU stay, need for noninvasive ventilation and intubation and also showed an increase in oxygenation. They also showed reduction in mortality which was statistically significant in less severe cases with mild or moderate ARDS. Early administration of the convalescent plasma could successfully contribute to the treatment of severe COVID-19 patients with mild or moderate ARDS at risk of progressing to critical state.

Investigation of hematological parameters related to the severity of COVID-19 disease in Mashhad, Iran

Introduction:Human coronavirus disease 2019 (COVID-19) is an emerging respiratory disease that has become pandemic worldwide. The patients have a range of mild to severe symptoms, such as pneumonia, acute respiratory distress syndrome, arrhythmia, shock, and other organs involvement. Clinical and hematological evidence can serve as a prognostic factor to detect severe cases of COVID-19. Objectives: The present study aimed to evaluate hematological parameters related to the severity of the disease in COVID-19 patients in Mashhad, Eastern Iran. Patients and Methods: All the individuals with positive real-time reverse transcription-polymerase chain reaction test results and the patients with clinical symptoms whose computed tomography scan results were matched with the diagnosis of viral pneumonia were included in the study. The hematological examinations and complete blood count of the patients were performed by the healthcare personnel through collecting blood samples at the time of admission and discharge from the hospital. Results: In total, 189 COVID-19 patients were included in the study, 47.6% and 58.73% of whom were over 60 years old and male, respectively. Investigation of the hematological parameters revealed that the number of white blood cells, mean value of corpuscular volume, number of platelets, and lymph count had significantly increased at the time of discharge (P<0.01). On the other hand, red blood cells, hemoglobin, hematocrit, mean corpuscular hemoglobin, mean corpuscular hemoglobin, and red cell distribution width values were significantly higher at the time of admission in comparison to discharge (P<0.01). Furthermore, it was found that male gender had a significant relationship with the development of lymphopenia in the patients (P=0.021). Conclusion: It can be concluded that hematological parameters and inflammatory biomarkers in COVID-19 patients could potentially act as the independent factors and affect the prognosis of the disease.

Thrombotic events in COVID-19 patients: A case series and literature review

BACKGROUND

Coronavirus disease 2019 (COVID-19) has rapidly emerged as a threatening pandemic. Clinical features of this pandemic involve a wide range of manifestations and are not completely known. Here, we present six cases of thrombotic events in patients with COVID-19.

CASE PRESENTATION

In this case series, we present six patients with confirmed COVID-19, according to real-time polymerase chain reaction, who were referred to our emergency department and were found to have thrombotic events. Pulmonary thromboembolism was diagnosed in three patients by computed tomography (CT) angiography. One patient was found to have deep vein thrombosis in Doppler ultrasonography. Another patient who presented with loss of consciousness was finally diagnosed with a cerebrovascular accident using brain CT. One of the patients had developed a myocardial infarction evident on the electrocardiogram.

CONCLUSION

It is ostensible that COVID-19 puts the patients at an increased risk for developing thrombotic conditions, possibly through formation of hyper-inflammatory and hyper-coagulative states. However, further prospective studies are recommended to confirm these findings.