key: cord-0855687-3mr42tvo
authors: Zhang, Hongmei; Cao, Xiaocui; Kong, Man; Mao, Xiaoli; Huang, Lifeng; He, Panwen; Pan, Shiyao; Li, Jin; Lu, Zhongxin
title: Clinical and hematological characteristics of 88 patients with COVID‐19
date: 2020-07-23
journal: Int J Lab Hematol
DOI: 10.1111/ijlh.13291
sha: 1c73f5774a80552a22e9c7ef89c554a0ef0706f6
doc_id: 855687
cord_uid: 3mr42tvo

INTRODUCTION: To retrospectively analyze epidemiological, clinical and hematological characteristics of COVID‐19 patients. METHODS: The demographic, symptoms, and physiological parameters of 88 patients were collected and analyzed. The performance of complete blood count (CBC) indexes for monitoring and predicting the severity of COVID‐19 in patients was evaluated by analyzing and comparing CBC results among different COVID‐19 patient groups. RESULTS: White blood cells (WBCs), the neutrophil percentage (Neu%), absolute neutrophil count (Neu#), and neutrophil‐to‐lymphocyte ratio (NLR) were significantly higher in the critical group than in the other three groups (P < .05), while the lymphocyte percentage (Lym%), monocyte percentage (Mon%), lymphocyte count (Lym#), and lymphocyte‐to‐monocyte ratio (LMR) were significantly lower in the critical group than in the other three groups (P < .05). WBCs, the Neu%, Neu#, NLR, and neutrophil‐to‐monocyte ratio (NMR) were significantly higher in the severe group than in the mild and moderate groups (P < .05), while the Lym% was significantly lower in the severe group than in the mild and moderate groups (P < .05). The Mon%, Lym#, and LMR were significantly lower in the severe group than in the moderate group (P < .05). Using receiver operating characteristic (ROC) curve analysis to differentiate severe and nonsevere patients, the areas under the curve (AUCs) for the NLR, Neu%, and Lym% were 0.733, 0.732, and 0.730, respectively. When differentiating critical patients from noncritical patients, the AUCs for the NLR, Neu%, and Lym% were 0.832, 0.831, and 0.831. CONCLUSIONS: The NLR is valuable for differentiating and predicting patients who will become critical within 4 weeks after the onset of COVID‐19.

An outbreak of novel coronavirus (COVID-19) occurred in December 2019, and it was recognized by the World Health Organization (WHO) on January 12, 2020. Patients initially presented with fever, dry cough, fatigue, and other symptoms. Within 1-2 weeks, they could progress to acute respiratory distress syndrome (ARDS), metabolic acidosis, and even shock, multiple organ failure and other fatal complications. 1, 2, 3 There is no specific therapy, and comprehensive support and symptomatic treatment are employed. 4 Patients with mild and moderate disease can recover quickly with appropriate medical interventions, 5 but the death rate of severe or critical patients, especially patients with underlying diseases and elderly patients, is higher. 6, 7, 8 As of May 10, 2020, 3 917 366 cases have been confirmed, and 274 361 patients have died, with a mortality rate of 7%. 9 In different countries, due to differences in pressure on the medical system and in prevention and control measures, the mortality rate is quite different, with rates of 5.91% (80 787/1 367 638), 10 .06% ( States, Spain, the UK, Italy and Russia, respectively. Therefore, indicators that can be used to evaluate the severity of the disease, monitor the treatment process and the clinical outcome and provide a clinical reference could provide information for targeted or preventive medication, which is expected to significantly reduce patient mortality and prevent further worsening of the epidemic.

CBCs are a convenient and effective laboratory examination.

The purpose of this study was to review and analyze differences among CBC results of COVID-19 patients with different disease severity and how CBC results changed after disease onset to identify key indicators of disease progression and stage and to provide a basis for diagnosis and treatment basis for clinicians.

All 88 patients reviewed in this study were hospitalized at the Central Hospital of Wuhan from January 28, 2020 to February 24, 2020.

Most of the patients complained of fever or respiratory symptoms.

Patient epidemiological information, including whether they had contact with suspected or confirmed patients in the 2 weeks before admission, was collected and recorded. Nasopharynx or pharynx swabs were collected from all patients before their admission to detect the virus. This study was approved by the hospital ethics committee. As this was a retrospective study, the Ethics Council gave approval to not obtain written informed consent from patients. All 

Patient epidemiological information was obtained from questionnaires that patients completed when they were admitted to the hospital, and patient symptoms, signs, medical history, and other data were obtained from patient descriptions and clinicians' records from consultations and physical examinations (hospital information system (HIS)).

CBC results (BC-6800plus hematology analyzer, Mindray, Shenzhen, China) were collected from the laboratory information system (LIS). A total of 413 CBC test results were collected from 88 patients hospitalized in our hospital from January 28, 2020 to February 24, 2020, and these test results were classified according to the real-time condition and recovery of patients into 4 groups: 8 tests were collected from the mild group, 243 tests were collected from the moderate group, 113 tests were collected from the severe group and 49 tests were collected from the critical group for subsequent statistical analysis.

Categorical variables are expressed as absolute numbers and percentages, and the R × C chi-square test was used for comparisons among multiple groups. CBC results were considered continuous variables and are expressed as the mean and standard deviation (SD).

Variance analysis was used to compare multiple groups. The least significant difference (LSD) t test was used when the variance was homogeneous, and Tamhane's T2 test was used when the variance was not homogenous. Statistical significance (P < .05) was determined by a two-tailed Student's t test with SPSS statistical software (version 19.0, SPSS Inc, Chicago IL).

A summary of patient information is shown in Table 1 ; there were 45 male patients (26-89 years old) and 43 female patients (22-81 years old). The average age of patients in the severe and critical groups was significantly higher than that in the moderate group (P < .05).

Eleven (12.5%) patients had contacted suspected patients in the past 2 weeks, and 7 (8.0%) had contacted confirmed patients. In regard to clinical symptoms, 71 (80.7%) patients had fever, 43 (48.9%) had asthenia, 32 (36.4%) had dry cough, 28 (31.8%) had expectoration, 21 (23.9%) had shivering and 15 (17.0%) had muscle pain, and there was no significant difference in symptoms in the different groups (P > .05). Among all patients, 33 (37.5%) had underlying diseases, of which hypertension (26.1%) and diabetes (12.5%) were the most common. There was no significant difference between the groups (P > .05).

A comparison of CBC results showed that as the disease progressed, WBCs, the Neu%, Neu#, NLR, NMR, and platelet-to-lymphocyte ratio (PLR) gradually increased, and there were significant differences among the four groups (P < .05). The Lym%, Mon%, Lym#, and LMR gradually decreased, and there were significant differences among the four groups (P < .05). Among these differences, WBCs, the Neu%, Neu#, and NLR were significantly higher in the critical group than the other three groups (P < .05), while the Lym%, Mon%, Note: P < .05 indicates that there were statistically significant differences among the groups.

Lym#, and LMR were significantly lower in the critical group than in the other three groups (P < .05). Additionally, WBCs, the Neu%, Neu#, NLR, and NMR were significantly higher in the severe group than in the mild and moderate groups (P < .05), while the Lym% was significantly lower in the severe group than in the mild and moderate groups (P < .05). The Mon%, Lym#, and LMR were significantly lower in the severe group than in the moderate group (P < .05), and the PLR was significantly higher in the severe group than in the mild group (P < .05) and was not significantly different in the severe and moderate groups (P > .05; Table 2 ). A grouped box plot for the parameters with significant differences in the analysis of variance described above (WBCs, the Neu#, Neu%, Lym#, Lym%, Mon%, NLR, LMR, NMR, and PLR) is shown in Supplement S1. Each parameter gradually increased or decreased as the disease progressed.

Next, CBC results of severe and critical patients (162 tests total, collectively referred to as the severe type) were considered the positive standard, CBC results of mild and moderate patients (251 tests total, collectively referred to as the nonsevere type) were considered the negative standard, and the ROC curve was used to analyze the diagnostic value of each CBC parameter for distinguishing the severe and nonsevere types ( Figure 1A ,B Figure 1C,D) , the results showed that the AUCs of the NLR, Neu%, Autopsy results showed early changes in acute lung injury during infection and diffuse alveolar injury with exudate, in which the inflammation was mainly lymphocytic, which also explains the decrease in lymphocytes. 14 The diagnostic efficacy of blood cell indexes for differentiat- This small sample size study retrospectively analyzed the basic information and CBC results of 88 inpatients at our hospital in a single center. In view of the particular circumstances in our hospital's region, it is unclear whether the information gathered in this study is accurate and representative of other regions; therefore, the applicability of these results in other parts of the world needs to be further verified. A CBC is the most common and easy-toobtain test item. We will further study the role of neutrophils and lymphocytes, as well as T-lymphocyte subsets, in the immune response to SARS-CoV-2 infection. We hope that by studying the characteristics of inpatients in this study, we can provide clinicians in other countries with more information on the characteristics of COVID-19 patients and potentially valuable information for timely and appropriate intervention in the diagnosis and treatment of this disease. This will help to control this epidemic, which endangers all humans.

We thank all patients who participated in this study. Thanks to all healthcare workers in our hospital for their efforts in caring for these patients. Thanks to all people who work so hard to fight against the novel coronavirus pneumonia .

The authors have no competing interests.

Man Kong and Panwen He has access to all data in this study and is responsible for the integrity of the data and the accuracy of the 

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