key: cord-0847368-hvuews1e
authors: Zhao, Yi; Zhou, Jie; Pan, Liuhua; Zhang, Yujie; Wang, Honggang; Wu, Wei; He, Jingsong; Chen, Jun; Huang, He
title: Detection and analysis of clinical features of patients with different COVID‐19 types
date: 2020-06-26
journal: J Med Virol
DOI: 10.1002/jmv.26225
sha: f673dc1b40947d0db162e1c9e84b188bba21e33f
doc_id: 847368
cord_uid: hvuews1e

OBJECTIVE: This study was designed to investigate the change of various indexes in patients with different types of coronavirus disease 2019 (COVID‐19). METHODS: 75 COVID‐19 patients were collected from the First Affiliated Hospital, Zhejiang University School of Medicine, and they were classified into moderate, severe and critically severe types according to the disease severity. The basic information, blood routine, pneumonia‐related blood indexes, immune‐related indexes along with liver, kidney and myocardial indexes in patients with different types were analyzed. RESULTS: The analysis of immune‐related indexes showed that the proportions of critically severe patients with abnormal IL‐2 and IL‐4 were higher than those of severe and moderate patients. In addition, the proportion of patients with abnormal total cholesterol increased as the severity of disease increased, and the proportion in critically severe patients was significantly higher than that in moderate patients. CONCLUSIONS: The patients with a more severe COVID‐19 are older and more likely to have a history of hypertension. With the progression of COVID‐19, the abnormal proportion of total white blood cell, neutrophils, lymphocytes, IL‐2, IL‐4 and total cholesterol increased. The change of these indexes in patients with different COVID‐19 types could provide reference for the disease severity identification and diagnosis of COVID‐19. In addition, the change in the total cholesterol level suggested that COVID‐19 would induce some liver function damage in patients. This article is protected by copyright. All rights reserved.

In December 2019, a case of unknown pneumonia occurred in Wuhan, Hubei, China, which was initially named novel coronavirus pneumonia (NCP). patients as soon as possible will help to carry out the treatment and contain the spread of the virus to protect people's health.

Studies have indicated that some important basic information of patients is vital in the diagnosis of many diseases such as COVID-19. For example, Chen et al. found that male patients were more than female patients in an analysis of 99 cases with COVID-19 3 . According to the statistics, male patients were more than female patients among people who got infected with MERS-CoV (middle east This article is protected by copyright. All rights reserved.

The data of 75 COVID-9 patients from January 22 to March 15, 2020 were After nucleic acid samples of all the patients were tested positive, patients were divided into mild (n=4), moderate (n=22), severe (n=39) and critically severe (n=10) cases based on the following criteria. 11 . (1) Mild cases: The clinical symptoms are mild, and no manifestations of pneumonia are found in imaging; (2) Moderate cases: Fever and respiratory symptoms are present in patients, and manifestations of pneumonia can be seen in imaging; (3) Severe cases: Adults who meet any of the following conditions: respiratory rate≥30 breaths/min; This article is protected by copyright. All rights reserved. Accepted Article oxygen saturation≤93% at resting; arterial partial pressure of oxygen (PaO 2 ) /fraction of inspiration (FiO 2 ) ≤300 mmHg; patients with pulmonary imaging showing significant lesion progression >50% within 24-48 h are treated as severe cases; (4) Critically severe cases: Patients who meet any of the following conditions: occurrence of respiratory failure requiring mechanical ventilation; occurrence of shock; other organ failure requiring monitoring and treatment in intensive care unit. As the sample size of mild cases was small with little statistical significance, so the mild cases were studied together with moderate cases and they were collectively called moderate cases. Blood, fecal, urine, and conjunctival secretions were collected from the patient on day 3-5 after disease classification.

(1) Clinical features: the body temperature, gender and underlying diseases (including hypertension and diabetes) of patients at the time of admission were recorded in detail and the patients with missing data were excluded.

(2) Blood routine and other blood indexes: peripheral blood samples were collected for testing the indexes, including total hemoglobin (Hb, g/L), total white blood cell (WBC, 10 9 /L), neutrophil count (10 9 /L), lymphocyte count (10 9 /L), procalcitonin (PCT, ng/mL), C-reactive protein (CRP, mg/L).

(3) Immune-related indexes: serum samples of the patients were collected and the following indexes were examined, including TNF-γ (pg/mL), IL-10 (pg/mL), IL-6 (pg/mL), IL-2 (pg/mL), IL-4 (pg/mL), IGM (mg/dL), IGA (mg/dL), IGG (mg/dL).

(4) Liver, kidney and myocardial-related indexes: peripheral blood samples were collected to test total cholesterol (mmol/L), albumin (g/L), total bilirubin (μmol/L), direct bilirubin (μmol/L), alanine aminotransferase (ALT, U/L), Accepted Article aspartate aminotransferase (AST, U/L), creatine kinase isoenzyme (U/L), creatine phosphate kinase (CPK, U/L), glomerular filtration rate (GFR, mL/min).

All data were statistically analyzed using SPSS 22.0 software. Clinical data of patients with different disease classifications were compared and analyzed using Fisher exact test. Partial measurement data were expressed as mean ± standard deviation (SD) and analyzed using t test. Statistically, P<0.05 was considered to have a significant difference, and P<0.01 represented an extremely significant difference.

Because of different clinical features of patients with different COVID-19 types, we conducted statistical analysis of patients with different disease classifications based on the clinical features, such as age, gender, underlying diseases and body temperature ( Table 1) . It was found that the ages of critically severe and severe patients were generally older than that of moderate patients (P<0.05), and there was no significant difference in the age between critically severe and severe patients (P>0.05). According to the statistics of patients with hypertension, the proportion of patients with hypertension in all critically severe cases was remarkably higher than that in moderate cases (P<0.01). However, no significant difference of the proportion was found between severe cases and moderate cases or critically severe cases (P>0.05). Moreover, it was discovered that there was no significant difference in gender, diabetes and body temperature among the three types of patients (P>0.05). These results indicated that age and hypertension were two important indexes affecting the disease severity, which This article is protected by copyright. All rights reserved.

presented that patients in an advanced age or with hypertension tended to have a more severe disease, while gender, diabetes and body temperature were not significantly different in patients with different COVID-19 types.

Blood routine and disease-related blood indexes are commonly used for disease diagnosis, which are of great significance. In order to study the differences in blood routine and other pneumonia-related blood indexes of patients with different COVID-19 types, we firstly compared and analyzed the blood indexes in patients with different types ( Table 2 ). In terms of total Hb count, there was no significant difference between moderate and critically severe cases, moderate and severe cases, or critically severe and severe cases (P>0.05). For total WBC, the proportions of patients with abnormal WBC in critically severe and severe cases were higher than that in moderate cases (P<0.05). Similar results could be observed concerning abnormal neutrophil count (P<0.05) and lymphocyte count (P<0.01), but there was no significant difference between severe cases and critically severe cases (P>0.05). These results suggested that total WBC, neutrophil count, and lymphocyte count were associated with the severity of COVID-19.

In addition, we measured the levels of PCT and CRP of patients with different classifications. These two indexes are commonly used to reflect inflammation in clinical practice. The elevation of PCT indicates bacterial infection, while the elevation of CRP indicates inflammation in the body 12 . It could be observed from Table 2 that there were no significant differences in the proportions of patients with abnormal PCT and CRP among the three groups This article is protected by copyright. All rights reserved.

(P>0.05). This indicated that PCT and CRP were lowly correlated with the disease severity of COVID-19.

Studies have shown that "cytokine storm" (also known as hypercytokinemia)

is present in severe infections with SARS, MERS, H5N1 and H7N9, and is associated with the severity of disease as a predictor of death 13,14 . We made a comparative analysis on various immune-related indexes of patients with different COVID-19 types to investigate their differences ( Table 3 ). In the statistical analysis of cytokines, it was found that the proportion of patients with abnormal IL-2 and IL-4 in all critically severe cases was higher than that in moderate cases and severe cases. There were no significant differences in the proportions of patients with abnormal TNF-γ, IL-10, IL-6, IGM and IGG among the three groups (P>0.05). These results indicated that IL-2 and IL-4 were the two immune-related indexes associated with the progression of COVID-19, and they would gradually increase with the aggravation of the disease.

Liver, kidney and myocardial indexes are of great value in disease diagnosis.

We compared the liver, kidney and myocardial-related indexes of patients with different COVID-19 types to study their differences ( Table 4 ). The study on total cholesterol found that the proportion of patients with total cholesterol abnormality in critically severe cases was higher than that in moderate patients (P<0.01).

While concerning total bilirubin, albumin, direct bilirubin, ALT, AST, creatine kinase isozyme, CPK and GFR, no significant differences were observed in This article is protected by copyright. All rights reserved.

In addition to the routine clinical features, some blood routine indexes are also important for disease progression in patients. Tissue damage caused by infection or malignant disease can lead to a change in the WBC count. Neutrophils are primarily involved in nonspecific immunity 18 , and lymphocytopenia is a sign of hypoimmunity. A study reported that lymphopenia (56.5%), increased CRP level (73.6%) and elevated PCT level (17.5%) were observed in COVID-19 patients 19 . Our research showed that the total WBC, neutrophil count and lymphocyte count were three blood routine indexes associated with progression of COVID-19. The proportions of patients with these three abnormal indexes in severe and critically severe cases were significantly higher than that in moderate patients, with no significant difference between critical cases and severe cases.

These results revealed that SARS-CoV-2 may act mainly on lymphocytes, especially on T lymphocytes, like SARS-CoV.

A study has shown that cytokines/chemokines (such as IL-2, IL-7, IL-10, GCSF, IP-10, MCP-1, MIP1A, and TNF-α) are significantly higher in ICU patients with COVID-19 than those in non-ICU patients 20 . Study on SARS indicated that IL-1, IL-6, IL-8, IL-12, IFN-γ, IP-10, and MCP-1 are associated with inflammation and extensive lung damage 21 . Besides, elevated levels of IFN-γ, IL-15, IL-17, and TNF-α are also features of MERS-CoV infection 22 .

Therefore, inhibition of excessive inflammatory response in COVID-19 patients is critical to reduce the mortality of severe and critically severe patients. All these studies demonstrate that the change in the levels of cytokines and inflammatory factors in patients is of reference value for guiding pharmacy. Here, we found that IL-2 and IL-4 were highly correlated with the progression of COVID-19, and the proportions of patients with abnormal IL-2 and IL-4 in critically severe cases were higher than that in moderate or severe patients with a significant difference, which is consistent with the study made by Zhang et al. 20 . This suggests that our study This article is protected by copyright. All rights reserved. Since COVID-19 was firstly discovered in Wuhan, it has spread rapidly and shown widespread severity. Early isolation, early diagnosis and early management contribute to better control of disease progression. Our study found that age, hypertension, total WBC count, neutrophil count, lymphocyte count, IL-2, IL-4 and total cholesterol were highly correlated with COVID-19 disease progression, which had certain reference value. Proper monitoring of patients' physiological and biochemical indexes is conducive for effective treatment of patients with different COVID-19 types, thus reducing the complications and mortality of COVID-19. The data in this study can be used to determine the disease progression of COVID-19 patients and to conduct disease classification. Besides, the change in total cholesterol of patients with different classifications suggests that COVID-19 may also have a negative effect on liver function of patients. This article is protected by copyright. All rights reserved. 

Notes: normal reference values: TNF-γ, 0-20.06 pg/mL; IL-10, 0-2.31 pg/mL; IL-6, 0-6.61 pg/mL; IL-2, 0-4.13 pg/mL; IL-4, 0-8.37 pg/mL; LGM, 30-220 mg/dL; IGA, 100-420 mg/dL; LGG, 860-1740 mg/dL.

Beyond or below the normal reference value is considered abnormal. 

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