Objectives: We compared the clinical characteristics, laboratory examinations, computed tomography images, and treatments of patients with COVID-19 from three different cities in China.
Methods: A total of 476 patients were recruited from January 1, 2020, to February 15, 2020, at three hospitals in Wuhan, Shanghai, and Anhui. The patients were divided into four groups according to age and into three groups (moderate, severe, and critical) according to the fifth edition of the Guidelines on the Diagnosis and Treatment of COVID-19 issued by the National Health Commission of China.
Measurements and Main Results: The incidence of comorbidities was higher in the severe (46.3%) and critical (67.1%) groups than in the moderate group (37.8%). More patients were taking angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the moderate group than in the severe and critical groups. More patients had multiple lung lobe involvement and pleural effusion in the critical group than in the moderate group. More patients received antiviral agents within the first 4 days in the moderate group than in the severe group, and more patients received antibiotics and corticosteroids in the critical and severe groups. Patients >75 years old had a significantly lower survival rate than younger patients.
Conclusions: Multiple organ dysfunction and impaired immune function were the typical characteristics of patients with severe or critical illness. There was a significant difference in the use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers among patients with different severities of disease. Involvement of multiple lung lobes and pleural effusion were associated with the severity of COVID-19. Advanced age (≥75 yr) was a risk factor for mortality
This study summarizes the clinical characteristics, laboratory tests, dynamic changes in CT images, treatments, and prognoses of patients with COVID-19 in two eastern China cities and in the city of disease onset, Wuhan. Patients with COVID-19 were divided into three groups (moderate, severe, and critical) according to the criteria set in the fifth edition of the Guidelines on the Diagnosis and Treatment of COVID-19 issued by the National Health Commission of China.
Patients in the severe and critical groups had more comorbidities, especially diabetes and hypertension. ACEIs and ARBs were commonly used antihypertensive drugs. ACE2 (angiotensin-converting enzyme 2) is a component of the renin-angiotensin system that is expressed in the heart and plays an important role in cardiac function. ACE2 is the host receptor of SARS-CoV-2. It was reported that ACE2 is also the receptor of SARS and NL63. COVID-19 has a higher affinity than SARS-CoV for ACE2. Recently, using a single-cell RNA-sequencing technique, Zhao and colleagues showed that ACE2 virus receptor expression was concentrated in a small population of type II alveolar cells. It was reported that ACE inhibitor therapy could increase cardiac ACE2 mRNA expression, and losartan increased cardiac ACE2 activity. Compared with other antihypertensive drugs, whether ACEI/ARB would aggravate COVID-19 is not clear. In this study, the use of antihypertensives in patients with COVID-19 was evaluated for the first time. The proportion of patients taking antihypertensives was higher in the moderate group. There were more patients taking ACEI/ARB in the moderate group. More case studies are needed in the future to further extend our preliminary conclusion. The mechanism and relationship between antihypertensives and the severity of COVID-19 remain to be studied.
In this study, we demonstrated that systemic organ indexes, including levels of T lymphocytes, D-dimer, C-reactive protein, aspartate aminotransferase, myohemoglobin, CD3+, CD4+, and CD8+, were associated with COVID-19 severity. These laboratory findings demonstrated that patients with COVID-19 also had impaired cardiac, liver, hematological, and cellular immune system function, as previously reported. Previous studies showed that CD8+ T cells protect against and depletion of macrophages exacerbates Middle East respiratory syndrome coronavirus–induced pathology and clinical symptoms of disease. SARS-CoV–specific memory CD8+ T cells protect susceptible hosts from lethal SARS-CoV infection. Dramatic losses of CD4+ T (∼90–100% of patients) and CD8+ T cells (∼80–90% of patients) were found in patients with SARS infection compared with healthy control individuals. We also found that CD3+, CD4+, and CD8+ T cells were significantly reduced in patients with severe or critical COVID-19, but immunoglobulins were less affected, as previously reported.
CT scans showed dynamic changes from ground-glass opacification to consolidation, and then absorption of the lesions or change to a linear opacity. In this study, for the first time, CT images of COVID-19 were observed and recorded in real time. We found that more lung lobes were involved in the severe and critical groups than in the moderate group, which was consistent with other research results (7). We also demonstrated for the first time that the percentage of patients with pleural effusion was significantly higher in the severe and critical groups than in the moderate group. Previous studies also showed that pleural effusion was a poor prognostic indicator in H5N1 infection.
Previous reports showed that none of the scoring systems used to assess severity of illness, such as the pneumonia severity index or CURB-65, have a good predictive ability in influenza pneumonia. Our results showed that CURB-65 scores were associated with the severity of COVID-19, but the difference in scores among the three groups was small. The variance in MuLBSTA scores, an early warning model for predicting mortality in viral pneumonia, among the three groups is significant and therefore may have a better predictive value.
A comparison of patients inside and outside of Hubei showed that early isolation, early diagnosis, and early management might contribute to a decrease in the spread and progression of COVID-19. Our study also stratified patients with COVID-19 based on age. Patients >75 years old had more severe disease and a higher risk of death. Age >75 years was also an important index contributing to the mortality risk. These results were consistent with previous studies.
Several limitations need to be addressed in further research. First, given the limited number of cases, some of our conclusions are preliminary, especially regarding the influence of the antihypertensive drugs ACEI/ARB on COVID-19. These results need to be further validated with more patients. Second, although data regarding outcomes of prognosis and treatment have been updated, the effects of antiviral agents and corticosteroids require further validation. Prospective studies should be performed to obtain more accurate results. Third, we only analyzed dynamic changes in CT images of a patient with marked improvement. More cases need to be analyzed to obtain more information.
In conclusion, this multicenter, retrospective study demonstrated that patients with severe or critical disease were older and had more comorbidities. Multiple organ dysfunction and immune dysfunction were characteristic of patients with severe or critical disease. The proportion of patients who were taking antihypertensives was higher in the group with moderate disease, and more patients received ACEI/ARB in the moderate group. Patients with severe or critical disease had more lung lobes involved and pleural effusion. These clinical features are helpful for the diagnosis and treatment of COVID-19.
Reference & Source information: https://www.atsjournals.org/
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