key: cord-0886371-kwj8boi3 authors: Hejazi, Mohammad Esmaeil; Malek Mahdavi, Aida; Navarbaf, Zahra; Tarzamni, Mohammad Kazem; Moradi, Rozhin; Sadeghi, Armin; Valizadeh, Hamed; Namvar, Leila title: Relationship between chest CT scan findings with SOFA score, CRP, comorbidity, and mortality in ICU patients with COVID‐19 date: 2021-09-22 journal: Int J Clin Pract DOI: 10.1111/ijcp.14869 sha: fbca1d9754a2b18c57573640d2457752cf46cb36 doc_id: 886371 cord_uid: kwj8boi3 OBJECTIVE: This study aimed to investigate the relationship between chest computed tomography (CT) scan findings with sequential organ failure assessment (SOFA) score, C‐reactive protein (CRP), comorbidity, and mortality in intensive care unit (ICU) patients with coronavirus disease 19 (COVID‐19). METHOD: Adult patients (≥18 years old) with COVID‐19 who were consecutively admitted to the Imam‐Reza Hospital, Tabriz, East‐Azerbaijan Province, North‐West of Iran between March 2020 and August 2020 were screened and total of 168 patients were included. Demographic, clinical, and mortality data were gathered. Severity of disease was evaluated using the SOFA score system. CRP levels were measured and chest CT scans were performed. RESULTS: Most of patients had multifocal and bilateral ground glass opacity (GGO) pattern in chest CT scan. There were significant correlations between SOFA score on admission with multifocal and bilateral GGO (P = .010 and P = .011, respectively). Significant relationships were observed between unilateral and bilateral GGO patterns with CRP (P = .049 and P = .046, respectively). There was significant relationship between GGO patterns with comorbidities including overweight/obesity, heart failure, cardiovascular diseases, and malignancy (P < .05). No significant relationships were observed between chest CT scan results with mortality (P > .05). CONCLUSION: Multifocal bilateral GGO was the most common pattern. Although chest CT scan characteristics were significantly related with SOFA score, CRP, and comorbidity in ICU patients with COVID‐19, a relationship with mortality was not significant. mortality. [6] [7] [8] [9] [10] Furthermore, underlying diseases such as obesity, diabetes mellitus, chronic respiratory disease, cardiovascular disease, hypertension and cancer have an association with higher risk of mortality. 11, 12 Most patients with COVID-19 present pneumonia thus computed tomography (CT) scanning of the thorax can be a useful tool in screening and diagnosis. 13 Chest CT scan is able to present typical radiological findings of COVID-19 even before the appearance of clinical symptoms. [14] [15] [16] Moreover, chest CT scan is a sensitive method in comparison with reverse transcription polymerase chain reaction (RT-PCR) and assists physicians to identify COVID-19 patients who initially had negative RT-PCR results. 14, 17 The typical chest CT scan indicates numerous ground glass opacity (GGO) and/or consolidations in a peripheral distribution, which also presents the severity of pulmonary inflammation. [18] [19] [20] It has been reported that consolidation and GGO on chest CT scans are more common in non-survivors than survivors. 8, 21 In addition, majority of the patients with COVID-19 have bilateral infiltrates on chest CT scans. 11 Due to its availability, chest CT scan may help first-line triage of patients admitting to the hospital. 22 Chest CT scan is also helpful in assessing the severity and progression of disease, monitoring the clinical course as well as assessing the treatment. 23, 24 Elevation in consolidative opacities and GGO as well as interstitial septal thickening on chest CT scan is associated with exacerbating pneumonia. 15, 25 Chest CT features of COVID-19 pneumonia have been studied mostly in Chinese individuals; however, radiological manifestations should be clarified in other populations and areas around the world that have a quickly increasing number of confirmed cases. SARS-CoV-2 infection is a multifaceted disease; therefore a reliable and appropriate biomarker is required to show changes in pattern of lung involvement and predict the severity of COVID-19 pneumonia. C-reactive protein (CRP) can be useful in the early diagnosis of pneumonia, 26 and patients with severe pneumonia had high CRP concentrations. Recently, studies have indicated that CRP has a positive association with severe dengue infection. 27, 28 Changes in CRP have been demonstrated in COVID-19 patients, but little is known about its correlation with disease severity. 29, 30 According to the research in COVID-19 patients, CRP concentration increased as the disease progressed and positive correlation was observed between CRP concentration with lung lesion and disease severity. 31 Furthermore, serum high-sensitivity CRP concentration and CT scores have a good consistency, and their combination can effectively evaluate disease progression and therapeutic effects. 32 Since Iran has the largest number of approved COVID-19 cases in Asia after China and to the best of our knowledge, there is no study investigating the relationship between chest CT scan characteristics with SOFA score, CRP, comorbidity, and mortality in Iranian COVID-19 patients, current study designed to assess the chest CT scan features in ICU patients with COVID-19 and to find whether there is a relationship between the chest CT scan features with SOFA score, CRP, comorbidity, and mortality. Demographic and clinical characteristics were gathered using a data collection form. The demographic data including age, sex, and smoking; comorbidities including hypertension, diabetes, chronic respiratory disease, coronary artery disease, heart failure, cardiovascular disease, chronic renal failure, malignancy, rheumatologic disease, and chronic liver disease; clinical symptoms including cough, fever, dyspnea, myalgia, fatigue, hemoptysis, chill, headache, sore throat, Chest CT scan can be a useful tool in screening and diagnosis and is able to present typical radiological findings of COVID-19 even before the appearance of clinical symptoms. Chest CT scan is also helpful in assessing the severity and progression of disease, monitoring the clinical course as well as assessing the treatment. Multifocal bilateral GGO was the most common pattern in chest CT scan. There were significant correlations between SOFA score on admission with multifocal and bilateral GGO. Significant relationships were observed between unilateral and bilateral GGO patterns with CRP. There was significant relationship between GGO patterns with comorbidities including overweight/obesity, heart failure, cardiovascular diseases, and malignancy. No significant relationships were observed between chest CT scan results with mortality. anorexia, nausea/vomiting, anosmia, taste loss, and diarrhea; vital signs including blood pressure, respiratory rate, heart rate, blood O 2 saturation, and body temperature as well as mortality (survived or died) were gathered. The SOFA score system was used to determine severity of disease with higher scores reflecting more severe illness. 34 Blood samples were also collected on admission and CRP levels were measured by immunoturbidimetry method. Due to wide variation in CRP level, we classified it into three categories: 1+: <10 mg/dL, 2+: 10-50 mg/dL, and 3+: >50 mg/dL. 35 The date of disease onset was ascertained as the day when the first symptom was appeared. Chest CT scans were conducted by a multi-detector CT scanner 16 slice (Siemens, Munich, Germany) with detailed parameters as below: tube voltage, 120 kV; tube current, standard (60-120 mAs); slice thickness, 1-1.5 mm; reconstruction interval, 1-1.5 mm. The Statistical analysis was carried out by SPSS 16.0 software (SPSS, Chicago, IL). The normal distribution of variables was assessed using the Kolmogorov-Smirnov test. Categorical variables were presented as number with percentage. Continuous variables were expressed as mean ±SD or median (interquartile range), as appropriate. Comparisons between groups were made by Chi-square test, Independent sample t-test, or Mann-Whitney U test, as appropriate. Correlations between variables were determined by Spearman correlation analysis. P <.05 was defined statistically significant. Total of 168 ICU patients with COVID-19 were studied. Baseline characteristics of patients are presented in Table 1 . As presented in Table 2 , most of patients who had multifocal and bilateral GGO pattern on chest CT scans had SOFA scores <5 on admission (day 1). Significant relationships were only observed between the SOFA score classification on admission (day 1) with multifocal and bilateral GGO (P = .016 and P = .044, respectively). (14) Chronic respiratory disease 20 (12) Chronic renal failure 17 (11) Heart failure 15 ( Table 3 presents correlations between chest CT scan with SOFA scores on admission (day 1) and on day 5 in study patients. According to Table 3 , there were only significant correlations between SOFA score on admission (day 1) with multifocal and bilateral GGO (P = .010 and P = .011, respectively). In addition, there were significant correlations between SOFA scores on admission (day 1) and on day 5 with multifocal bilateral GGO (P = .035 and P = .044, respectively). Table 4 shows relationship between chest CT scan and mortality with CRP in study patients. According to Table 4 , most patients with GGO patterns on chest CT scans had CRP 1+. Significant relationships were observed between unilateral and bilateral GGO patterns on chest CT scans with CRP (P = .049 and P = .046, respectively). As demonstrated in Table 5 , significant relationships were observed between unifocal, unilateral, and bilateral GGO patterns on chest CT scans with overweight/obesity (P = .006, P = .045, and P = .034, respectively). Furthermore, significant relationships were observed between multifocal and bilateral GGO patterns on chest CT scans with heart failure (P = .001 and P = .001, respectively). In addition, there were significant relationships between unifocal, multifocal, unilateral, and bilateral GGO patterns on chest CT scans with cardiovascular diseases (P = .041, P = .005, P = .027 and P = .003, respectively). Significant relationships were also observed between unifocal and unilateral GGO patterns on chest CT scans with malignancy (P = .012 and P = .006, respectively). Significant relationship was also observed between multifocal bilateral GGO pattern with cardiovascular diseases (P = .041). According to Table 6 , no significant relationships were observed between chest CT scan results with mortality (P >.05). To the best of our knowledge, this is the first study to assess the relationship between chest CT scan findings with SOFA score, CRP, comorbidity, and mortality in ICU patients with COVID-19 in East-Azerbaijan Province, which is one of the high-risk regions in the North-West of Iran. Consistent with previous studies, 18-20,36-44 our research indicated that multifocal and bilateral GGO were the most common patterns on chest CT scans. Furthermore, multifocal and bilateral consolidation were more prevalent than unifocal and unilateral consolidation patterns. A GGO pattern has been suggested to be a very common feature in COVID-19 pneumonia as 100% of individuals whose diagnosis was affirmed by RT-PCR had this feature. 38 Also, there was no significant difference in the CT scan features between subjects with confirmed COVID-19 who needed admission and subjects who were discharged. 38 Since a GGO pattern can be present in different phases of the disease, 45 warranted to completely understand the prognostic power of this finding in patients with COVID-19. Our study preliminarily demonstrated a significant correlation between chest CT scan features including multifocal and bilateral GGO patterns with SOFA score on admission (day 1). In addition, significant correlations were noticed between multifocal bilateral GGO with SOFA scores on admission (day 1) and on day 5. These findings indicate that in more severe disease, more abnormalities can be observed on chest CT scan. The SOFA score is an important index to reflect the state and degree of multiple organ dysfunctions 11 and can predict the severity and outcome of the disease. 53, 54 In a study by Francone et al, 55 CT score was significantly higher in critical and severe patients than in mild stage subjects which was consistent with our research. In addition, Shen et al 56 found that CT imaging was helpful in classifying disease severity as a larger proportion of scans from critically ill patients presented bilateral lung involvement compared with mild cases. In another study on COVID-19 patients, higher CT scores had a significant relationship with more severe disease. 57 Wu et al 40 also suggested that chest CT scan could be used to assess the severity of the disease and had a considerable function in clinical practice. Therefore, it seems that CT is the main procedure to determine the severity of the disease and can be used to identify disease progression. The main benefit of the CT scan is that the test is available immediately and results are accessible directly after scanning. This benefit depends on the accessibility of a CT scan, personnel and a well-designed approach to perform these scans. Increased inflammatory parameters, such as CRP were reported in COVID-19. 31 Note: Data were expressed as frequency (percentage). Abbreviations: CT, Computed tomography; GGO, ground glass opacity. P < .05 was considered significant. *P values indicate comparison between groups (Chi-square). CT scan and C-reactive protein in study patients (n = 168) Chest CT scan This study had some limitations including a single-center study and having small sample size. Thus, additional large-scale multicenter studies would be helpful. Furthermore, we did not follow-up these patients who survived and correlated their chest CT or clinical findings with outcomes. Lastly, no autopsy was conducted in the deceased patients. In conclusion, multifocal bilateral GGO was the most common pattern on chest CT scans. Furthermore, multifocal bilateral consolidation was more prevalent than unifocal unilateral consolidation pattern. Although chest CT scan characteristics were significantly related with SOFA score, CRP, and comorbidity in ICU patients with COVID-19, a relationship with mortality was not significant. The authors declared that they have no conflicts of interests. Data available on request from the authors. 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