key: cord-1008657-k7k01wax
authors: Tsai, Chun-Chou; Wang, Yung-Chih; Chiang, Tsung-Ta; Chen, I-An; Chiu, Chun-Hsiang; Yang, Ya-Sung; Yeh, Kuo-Ming; Chang, Feng-Yee
title: Successful treatment of 28 patients with coronavirus disease 2019 at a medical center in Taiwan
date: 2020-07-29
journal: J Formos Med Assoc
DOI: 10.1016/j.jfma.2020.07.033
sha: 4c36a88d6172b6089855a518a3adbf565986adbd
doc_id: 1008657
cord_uid: k7k01wax

Abstract Background Coronavirus disease-2019 (COVID-19) is a worldwide pandemic. We present the clinical characteristics and outcomes of 28 COVID-19 patients treated in our hospital in Taiwan. Methods Patients with COVID-19, confirmed by positive real-time reverse-transcriptase polymerase chain reaction results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral nucleic acids from oropharyngeal swab specimens between February 4, 2020 and July 6, 2020, were enrolled. Their clinical characteristics and outcomes were reviewed. Results Seventeen of the 28 patients (60.7%) had pneumonia. The most frequent symptoms were cough (n = 23, 82.1%) and fever (n = 17, 60.7%). The development of pneumonia was associated with age ≥40 years (p <0.024), body mass index (BMI) ≥25 kg/m2 (p = 0.014), fever (p = 0.007), shortness of breath (p = 0.036), chills ((p = 0.047), and lower platelet counts (<200,000/μL) (p = 0.007). Increased quarantine duration was associated with age ≥40 years (p = 0.026), Charlson index ≥1 (p=0.037), lower lymphocyte (<1500/uL; p = 0.028) or platelet counts (<200,000/μL) (p = 0.016), lower serum sodium (<140 mEq/L; p = 0.006), and higher C-reactive protein (CRP) level (≥1mg/dl; p = 0.04). Treatment with hydroxychloroquine or in combination with other medicines did not reduce the quarantine duration. All 28 patients recovered with a median quarantine duration of 27.2 days. Conclusion COVID-19 patients with older age, higher BMI, fever, chills or shortness of breath, lower serum sodium level, lower platelet or lymphocyte count, and higher CRP level may be associated with developing pneumonia or longer quarantine duration.

than that in patients with a lower Charlson comorbidity index (32.2±11.6 days vs. 24±8.1 148 days; p = 0.037). 149

The symptoms of the included COVID-19 patients are listed in Table 2 . The most 151 frequent symptoms were cough (n = 23, 82.1%) and fever (n = 17, 63%). Seven patients 152 (25%) had a distorted sense of taste and 10 patients (35.7%) had a distorted sense of smell. 153

Ten patients (35.7%) had shortness of breath. Other symptoms included headache (14.3%), 154 myalgia (17.9%), rhinorrhea (42.9%), sore throat (28.6%), diarrhea (35.7%), chest pain 155 (17.9%), chills (17.9%), nausea and vomiting (10.7%), and eye illness (3.6%). Patients with 156 fever seemed more prone to develop pneumonia than patients without (82.4% vs. 27.3%; p = 157 0.007). Patients with shortness of breath or chills also had a higher possibility of having 158 pneumonia than did patients without (shortness of breath vs. no shortness of breath; 90% vs. 159 44.4%; p = 0.036) (chills vs. no chills; 100% vs. 52.2%; p = 0.047). 160

The laboratory results of these COVID-19 patients, confirmed within 24 h after 162 admission, are listed in Table 3 . Among these confirmed cases, 16 patients (57.1%) had a 163 relatively lower absolute lymphocyte count (ALC) (<1500/uL). They were more prone to a 164 longer quarantine duration than that in patients with a higher ALC (21.9±9 days vs. 31.2±9.5 165 days; p = 0.028). Eight patients (28.6%) had a relatively lower platelet count (<200,000/uL). 166 10 They were more prone to having pneumonia (45% vs. 100%; p = 0.007) and a longer 167 quarantine duration (24.4±8.6 days vs. 34.3±11 days; p = 0.016) than those in patients with a 168 higher platelet count. Patients with relatively low serum sodium (<140 mmol/L) (71.4%) 169 levels or higher CRP levels (≥1 mg/dL) were prone to longer quarantine durations than 170 patients with higher serum albumin or lower CRP levels (Na ≥140 mmol/L vs. Na < 140 171 mmol/L; 19.1±5.6 days vs. 30.5±10 days; p = 0.006) (CRP ≥1 mg/dl vs. CRP <1 mg/dl; 172 32.5±11.8 days vs 24.3±8.2 days; p = 0.04) 173

The medications prescribed to these confirmed COVID-19 patients are listed in Table 4 . 175

Hydroxychloroquine was administered to 22 (78.6%) of the 28 patients. The combined use of 176 hydroxychloroquine and azithromycin was prescribed to 13 patients (46.4%). The combined 177 use of hydroxychloroquine, azithromycin, ceftriaxone, and teicoplanin was prescribed to 178 three patients (10.7%). Three patients (10.7%) did not receive any antibiotics or 179 hydroxychloroquine. The quarantine durations did not differ significantly between patients 180 treated with different medicine combinations (Table 4) . 89.3%) and had gone abroad for study or tourism. As in a previous study, patients with 204 12 comorbidity showed poorer clinical outcomes than those without. 10 Second, most of our 205 COVID-19 patients had relatively mild illnesses. Among them, only one patient developed 206 acute respiratory distress syndrome (ARDS) (n=1; 3.6%) while other studies reported much 207 higher percentages of patient developing ARDS. 11-12 Third, most of our patients were 208 diagnosed in the early stage of disease. Symptomatic patients who visited our hospital with a 209 travel or contact history were all referred to our emergency room and tested for COVID-19. 210

Timely identification of patients at risk allowed early diagnosis and relatively mild disease 211 severity in our patients. Finally, successful supportive treatment may also play a role. 212

Optimized supportive care remains the mainstay of therapy for COVID-19, and the clinical 213 efficacy for the subsequent agents is still under investigation. 214

In our study, older COVID-19 patients (age ≥40 years) were prone to having pneumonia 215 and a longer quarantine duration compared to younger patients (Table 1) . Older age is 216

reportedly associated with higher mortality in COVID-19 patients. 13 This may be due to 217 the age-dependent differences in activity and expression of pulmonary renin-angiotensin 218 system components under pathophysiologic conditions. 14 An animal study reported increased 219 fluid-soluble angiotensin-converting enzyme activity was in bronchoalveolar lavage of rats 220 exposed to lipopolysaccharide. This increased enzyme activity was significantly higher in 221 elderly rats. 14 This may indicate that the elderly more prone to the development and 222

progression of lung injuries. COVID-19 patients who were overweight (BMI ≥25 kg/m 2 ) 223 13 were more likely to have pneumonia than were non-overweight patients (Table 1 ). This risk 224 factor was also reported in H1N1-infected patients. In previous studies, obesity was found to 225 increase H1N1 vulnerability 15 and may be associated with the need for hospitalization and 226 death in H1N1 patients. 16 Patients with a high Charlson comorbidity index (≥1) in our study 227 had longer quarantine durations (Table 1) . A previous study suggested that the Charlson 228 comorbidity index might serve as an independent determinant for hospital mortality in 229 COVID-19 patients. 17 Our study revealed that it might also serve as a determinant for 230 hospital quarantine durations in COVID-19 patients. 231

The most frequent symptoms in our patients were cough and fever (Table 2 ). This finding 232 was similar to those of other studies. 13 A growing number of papers have reported smell or 233 taste disturbances in COVID-19 patients. 18 In our study, 10 (35.7%) and seven patients (25%) 234 had distorted senses of smell and taste, respectively (Table 2) A previous study reported that lymphopenia might be associated with severe 244 COVID-19. 21 The results of our study showed that it may also be associated with longer 245 hospital quarantine (Table 3) . A meta-analysis of nine studies suggested that 246 thrombocytopenia was significantly associated with COVID-19 severity. 22 A more sizable 247 drop in platelet counts was noted, especially in non-survivors. 22 In our study, a lower platelet 248 count (<200,000/uL) might also be associated with developing pneumonia and longer 249 hospital quarantine duration (Table 3) . Lower serum sodium levels may indicate poor 250 nutrition and health status. In our study, serum sodium (<140 mmol/L) was associated with 251 longer hospital quarantine (Table 3) patients. 25 We prescribed hydroxychloroquine to most of the enrolled patients; however, the 261 15 hospital quarantine duration did not differ significantly between patients who received 262 hydroxychloroquine and those who did not (Table 4 ). This may be due to the small number of 263 cases in our study. Further studies on the efficacy of hydroxychloroquine or azithromycin are 264 needed. However, a previous study reported that hydroxychloroquine may not reduce the 265 need for intubation or mortality in COVID-19 patients. 26 The combination of 266 hydroxychloroquine and different antibiotics in our study did not reduce the duration of 267 hospital quarantine (Table 4 ). Further studies are needed to clarify the efficacy of these 268

Our study has several limitations. First, it was conducted in a single center; thus, the In conclusion, among the patients with COVID-19 enrolled in our study, older age; 280 16 higher BMI; shorter body height; symptoms of fever, chills, or short of breath; and lower 281 platelet count may be associated with developing pneumonia, while older age, higher 282

Charlson comorbidity index, lower lymphocyte count, lower platelet count, lower serum 283 sodium level, and higher CRP level may be associated with a longer quarantine duration. 284

Prescribing hydroxychloroquine alone or combined with other antibiotics may not reduce the 285 duration of hospital quarantine. 286 287

All authors report no potential conflicts. 

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