|Year : 2021 | Volume
| Issue : 1 | Page : 14-20
Clinical, serological, and radiological characteristics of COVID-19 patients in Makkah, Saudi Arabia
Imran Nazir1, Mohammed Al Shareef2, Sayed Shakeel Ur Rahman3, Iffat Imran4, Hanan Mohamed Moalim Abdullah5, Hossam El-din Shaaban6, Khalid Khalil7, Anas Mohammad M Al Hazmi5, Waleed Amasaib Mohammed Ahmed5, Amna Al Kalkami3
1 Department of Internal Medicine, Security Forces Hospital, Makkah, KSA
2 Director General, Security Forces Hospital, Makkah, KSA
3 Department of Nephrology, Security Forces Hospital, Makkah, KSA
4 Department of Obstetrics and Gynecology, College of Medicine, Taif University, Taif, KSA
5 Department of ID, Security Forces Hospital, Makkah, KSA
6 Department of Gastroenterology, Security Forces Hospital, Makkah, KSA
7 Department of Hematology, Security Forces Hospital, Makkah, KSA
|Date of Submission||20-Oct-2020|
|Date of Decision||13-Jan-2021|
|Date of Acceptance||18-Jan-2021|
|Date of Web Publication||26-Mar-2021|
Security Forces Hospital, Makkah, Saudi Arabia
Source of Support: None, Conflict of Interest: None
Background: The COVID-19 pandemic is spreading across the globe at an alarming rate. The number of COVID-19 cases in Saudi Arabia is increasing daily. Saudi Arabia is a hot zone for outbreaks of infectious diseases like COVID-19, especially the Makkah area. Hence, determining the clinical characteristics along with serological, hematological, and radiological abnormalities in COVID-19 patients is important for epidemiological decision-making, such as control and surveillance strategies. Materials and Methods: This was a retrospective descriptive study done in a single health-care hospital, Makkah, Saudi Arabia, for 4-month period. We include admitted COVID-19 patients (confirmed with qualitative real-time polymerase chain reaction test) of any gender with age >14 years. The complete data of COVID-19 patients were extracted from electronic medical records. Data were analyzed by the Statistical Package for the Social Sciences version 23. Categorical variables were presented as counts and percentages, where means and standard deviations (SDs) were extracted for continuous variables. Fisher's exact test was applied to assess association with mortality. Results: Total enrolled cases were 226. The mean age of the patients was 58 years with SD (±0.4458) and 95% confidence interval (2.688–2.810). The common clinical presentations were fever (77.4%), cough (77%), shortness of breath (53.5%), and myalgia (37.2%). Lymphopenia was observed in 54.4%, anemia in 8.4%, leukopenia in 16.4%, and thrombocytopenia in 9.3% of the patients. The fatality rate was 8.4% (n = 19) over this 4-month period. Conclusion: Advanced age and comorbidity plays a pivotal role in disease mortality. Elderly people's constant evaluation and management is of fundamental importance to decrease mortality.
Keywords: COVID-19, hematological markers, radiological features, serological markers
|How to cite this article:|
Nazir I, Al Shareef M, Rahman SS, Imran I, Abdullah HM, Shaaban HE, Khalil K, Al Hazmi AM, Mohammed Ahmed WA, Al Kalkami A. Clinical, serological, and radiological characteristics of COVID-19 patients in Makkah, Saudi Arabia. Saudi J Health Sci 2021;10:14-20
|How to cite this URL:|
Nazir I, Al Shareef M, Rahman SS, Imran I, Abdullah HM, Shaaban HE, Khalil K, Al Hazmi AM, Mohammed Ahmed WA, Al Kalkami A. Clinical, serological, and radiological characteristics of COVID-19 patients in Makkah, Saudi Arabia. Saudi J Health Sci [serial online] 2021 [cited 2021 Jul 23];10:14-20. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/1/14/311957
| Introduction|| |
Viral infections are constantly emerging around the world. More recently, the Middle East respiratory syndrome coronavirus was first identified in Saudi Arabia in 2012. Now, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), previously called the 2019 novel coronavirus, is a newly diagnosed zoonotic virus. This virus was detected for the first time in Wuhan, China, in December 2019. The World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern on January 30, 2020. The COVID-19 pandemic is spreading across the globe at an alarming rate. The number of COVID-19 cases in Saudi Arabia is increasing daily. As of August 12, 2020, the WHO reported that a total of 20.3 million cases of laboratory-confirmed COVID-19 infection had been detected around the world and 291,468 cases with death rate 1.8% in Saudi Arabia. In general, expert estimation suggests that this virus is responsible for about 5%–10% of acute respiratory infections. The pathogenic mechanism of pneumonia caused by SARS-CoV-2 seems to be complex. Coronaviruses primarily infect the upper respiratory and gastrointestinal tract of human being. It invades host human cells by binding to angiotensin-converting enzyme 2 receptors. It is well documented that COVID-19 is considered a systemic disease involving multiple systems, including respiratory, cardiovascular, gastrointestinal, neurological, hematopoietic, and immune. COVID-19 is confirmed through qualitative real-time polymerase chain reaction (RT-PCR) testing via nasal and throat swabs. It is speculated that this viral infection produces an excessive immune reaction in the host that leads to extensive tissue damage. This state is labeled a “cytokine storm.” The spectrum of clinical presentation ranges from asymptomatic to a critical condition that commonly leads to respiratory failure, followed by sepsis, septic shock, and multiple organ dysfunction syndrome. In one of the first reports on the disease, most patients suffered from fever, malaise, dry cough, and dyspnea. COVID-19 is associated with significant mortality, especially in patients with chronic medical conditions. COVID-19 has an impact on hematological markers in addition to acute inflammatory and serological markers and their cell counts correlate with the severity of disease.
Acute inflammatory markers such as C-reactive protein (CRP) and procalcitonin have been linked to unfavorable outcomes in COVID-19, such as acute respiratory distress syndrome and death., Coagulation disorders are also frequently seen in critical risk and intensive care COVID-19 patients., In fact, tissue hypoxia can be one of the consequences of systemic inflammation and is associated with adverse outcomes as well. Hypoxia also has a role of directly activating the coagulation system and is associated with an increased risk of thrombotic events. Chest X-ray findings in COVID-19 patients frequently exhibit bilateral lower lung peripheral air space opacities/consolidation (it represents replacement of alveolar air by fluid, blood, pus, cells, or other substances), and radiologically, it presents in different patterns. Ground-glass appearance on chest radiograph is refer to a diffuse hazy opacity that does not obscure the underlying bronchial structures.
Saudi Arabia is a hot zone for outbreaks of infectious diseases like COVID-19, especially in the Makkah area, where pilgrims and visitors come from around the world as well as inside the kingdom. Hence, it is important to conduct this study for epidemiological decision-making, such as control and surveillance strategies, and for clinicians to better understand the clinical evaluation of COVID-19 patients.
| Materials and Methods|| |
It was a retrospective descriptive study carried out in a single hospital of Makkah, Saudi Arabia, from March 10, 2020 to July 10, 2020 (4-month period). It was conducted after institutional ethical committee approval. We include admitted confirmed COVID-19 patients of any gender with age >14 years. Our aim was to find the clinical characteristics, along with the serological, hematological, and radiological abnormalities, in SARS-CoV-2-infected patients and find their correlation with mortality. Nasal and throat swab specimens were collected for the SARS-CoV-2. Patients were declared confirmed COVID-19 cases through positive qualitative RT-PCR. Each included patient's demographic data, comorbidities, and history of contact with COVID-19 patients was reviewed by simple random method. Laboratory parameters (complete blood count, CRP, ferritin, lactate dehydrogenase [LDH], D-dimer, prothrombin time [PT]/activated partial thromboplastin time, renal profile, and liver profile) on the 3rd day of admission and chest X-ray radiological findings at the time of admission were documented by a medical doctor. Fever was defined as an oral temperature of 38.0°C or higher. Oxygen saturation was measured by pulse oximeter. Anemia is defined by hemoglobin level <12.5 g/dl. Lymphocytopenia was defined as a lymphocyte count of <20%, neutrophilia >70%, monocytosis >8%, and eosinopenia <0.7% of total leukocytes, respectively. Thrombocytopenia was defined as a platelet count of <150,000 per cubic millimeter. Data were documented and analyzed using a Microsoft Excel sheet and SPSS for Windows, version 23.0 software (SPSS, Chicago, IL). Categorical variables are presented as counts and percentages, where means and standard deviations (SDs) are extracted for continuous variables. No imputation was made for missing data. Then, Fisher's exact test was applied to assess association between independent variables and patient mortality. P < 0.05 was considered statistically significant.
| Results|| |
There were a total of 226 admitted cases enrolled in the study. Males constituted 54% (n = 122), and females accounted for 46.0% (n = 104) of the patients. The mean age of the patients was 58 years with SD (±0.4458) and 95% confidence interval (2.688–2.810). The predominant (76.6%) age group was older than 40 years of age, and only 23.5% were in the 21–40-year-old age group. The following underlying chronic diseases were observed: hypertension 14.2% (n = 32), diabetes 15.9% (n = 36), chronic kidney diseases 3.1% (n = 7), ischemic heart diseases 3.1% (n = 7), chronic lung diseases 3.1% (n = 7), and stroke 1.8% (n = 4). The common presenting symptoms on admission were fever, cough, and shortness of breath. Detailed demographic data and presenting symptoms with number, percentage, and P value are shown in [Table 1].
Hematological abnormalities, including anemia 8.4% (n = 19), leukopenia 16.4% (n = 37), neutrophilia 85.4% (n = 193), lymphocytopenia 54.4% (n = 123), monocytosis 4.4% (n = 10), eosinopenia 59.7% (n = 135), and thrombocytopenia (platelets count <150 × 103/cu mm) 9.3% (n = 21), are observed in this study. Their detail and correlation with mortality are documented in [Table 2]. Serological marker frequencies and their mortality correlation are documented in [Table 3]. Radiological features on chest X-ray included peripheral lung infiltrations 72.1% (n = 163), consolidation 9.7% (n = 22), and ground-glass appearance 18.1% (n = 41). The detail of radiological involvement along with their mortality correlation is documented in [Table 4].
|Table 2: Hematological features of COVID-19 patients on the 3rd day of admission|
Click here to view
|Table 3: Serological features of COVID-19 patients on the 3rd day of admission|
Click here to view
Infection with COVID-19 is associated with significant mortality, and 13.3% (n = 30) of the cases required intensive care unit admission. Almost 84.5% (n = 191) of the patients needed supplementary oxygen, 28.3% (n = 64) needed temporary noninvasive ventilation, and 9.7% (n = 22) required invasive ventilation. Cardiac injury was documented in 8.4% (n = 19), septic shock in 1.7% (n = 4), and disseminated intravascular coagulation in 1.3% (n = 3) of the cases. The mortality rate during this 4-month period was 8.4% (n = 19). Mostly 94.7% (n = 18) of the patients died due to respiratory arrest. A different variable association with mortality with their P value is mentioned in respective variable tables.
| Discussion|| |
COVID-19 is a newly emerging disease that is spreading at an unpredicted rate around the world. The global incidence of this pandemic is changing daily. Clinical, laboratory, and imaging findings should be carefully evaluated in comparison to national and global literature. The total number of COVID-19 cases worldwide reached 20.3 million as of August 12, 2020 while there were 291,468 cases in Saudi Arabia. The total number of documented COVID-19 cases in the Makkah region was 75,910, with a death rate of 1.8% on August 12, 2020. An initial observational study conducted in China by Zhou et al. found a median age of 56 years, with males accounting for 62% of the patients. The frequency of fever was 94%, cough 79%, dyspnea 29%, fatigue 23%, and myalgia 15%. Nearly half (48%) of the patients had comorbidities. They document anemia 15.0%, lymphocytopenia 40.0%, and thrombocytopenia 7.0%. Abnormal serological markers included alanine aminotransferase in 31%, LDH 67%, D-dimer 68.0%, ferritin 80.0%, procalcitonin 31.0%, creatinine 4.0%, and PT 6.0% in COVID-19 patients.
Rodriguez-Morales et al. did a systematic review of 621 international studies. The median age was 47.9 years with male predominance (69.0%), and the frequency of fever was 88.7%, cough 57.6%, dyspnea 45.6%, and myalgia 31.0%. Comorbidity mean was 36.8%. They document laboratory abnormalities such as lymphocytopenia 43.1%, CRP 58.3%, LDH 57.0%, erythrocyte sedimentation rate (ESR) 43.1%, and abnormal renal function 7.9%.
Al Sofayan et al. did a national study across the Saudi Arabia. The median age was 36 years with a male predominance of 54.3%. The frequency of fever was 85.6%, cough 89.4%, sore throat 81.6%, myalgia 28.6%, and headache 27.3%. Comorbidities were observed 25.1%. They observed leukopenia 10.6%, lymphocytopenia 37.5%, and thrombocytopenia 6.9%.
The mean age in our study was almost the same as in Zhou et al. while Al Sofayan et al. documented lesser age group. This age difference from a national study can be explained by our inclusion criteria of age >14 years. The male predominance is observed in our study as seen in all previous literature because of more outdoor activities and social gathering by males. Our study patient's cumulative comorbidities were 40.1%, almost comparable as seen in Rodriguez-Morales et al. These were lesser than Fei Zhou et al. study but more than a national study. The higher mean age in our study can account for the higher prevalence of comorbidities as compared to a national study. Some variation from a Chinese study can be influenced by different populations.
Clinical presentation features of our study were almost comparable with national and international literature, although there are some variations that can be interpreted according to different age, time of presentation, and population.
Regarding clinical features, our study data correspond with previous studies (Fei Zhou et al. and Al Sofayan et al.) statistically, except for the low frequency of elevated respiratory rate in the Al Sofayan et al. study. This phenomenon can be explained by their patient selection (including admitted and emergency room cases, younger age groups, and less comorbidity).
Frequencies of abnormal hematological finding observed in our study are more as compared to Fei Zhou et al. study. This difference can be explained by more age and comorbidities in our study.
Serological data with some variations in CRP, ESR, and ferritin are almost comparable with Fei Zhou et al. and Al Sofayan et al. studies. These differences can be explained by different time (early/late) of sampling from onset of disease, comorbidities, and population. PT/international normalized ratio abnormalities in our study are consistent with Fei Zhou et al. study.
The current study documents radiological peripheral lung infiltrates in 72.1% of the patients that is consistent with international studies., Ground-glass appearance on chest X-ray was observed 18.1% in our study. This frequency difference as compared to previous studies can be justified by early presentation of patients and radiological finding at the time of admission., Our study documents fewer complications and a lower mortality rate 4.8% (n = 19) compared to the above international studies (28.2% and 13.9%, respectively)., A national study (Al Sofayan et al.) documents a mortality rate of only 0.65% because this study included all suspected patients of COVID-19 who presented to health-care facility. We have learned a lot from the evolving experience of this pandemic and dramatically updated management guidelines. As a result, lower complications and mortality in this study can be justified by the above factors along with the different population effects.
The strengths of our study included the relatively more information of epidemiological, clinical, serological, and radiological characteristics of COVID-19 patients in one study in Makkah area.
| Conclusion|| |
COVID-19 is associated with significant mortality, especially in older age groups and those with chronic medical conditions. Important distinguishing factors include advanced age, dyspnea, hypoxia, lymphocytopenia, monocytosis, eosinopenia, thrombocytopenia, CRP, ferritin, LDH, and D-dimer which lead to severe disease and mortality. This study will give better understanding to clinicians for appropriate management by evaluating the patient's clinical signs and hematological, serological, and radiological features.
This was a single-center study.
The author would like to thank Dr. Ahmad Farooq and Dr. Abdul Hamid, Infection Prevention and Control Department, to facilitate to availability of data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hui DS, Zumla A. Severe acute respiratory syndrome: Historical, epidemiologic, and clinical features. Infect Dis Clin North Am 2019;33:869-89.
Wu Z, Mc Googan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42.
Barry M, Al Amri M, Memish ZA. COVID-19 in the shadows of MERS-CoV in the Kingdom of Saudi Arabia. J Epidemiol Glob Health 2020;10:1-3.
Chen Y, Liu Q, Guo D. Emerging coronaviruses: Genome structure, replication, and pathogenesis. J Med Virol 2020;92:418-23.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Fan BE, Chong VC, Wei Chan SS, Lim GH, Lim KG, Tan GB, et al
. Hematologic parameters in patients with COVID-19 infection. Am J Hematol 2020;95:131-4.
Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al
. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.
Deng Y, Liu W, Liu K, Fang YY, Shang J, Zhou L, et al
. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 in Wuhan, China: A retrospective study. Chin Med J (Engl) 2020;133:1261-7.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al
. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.
Kiers D, Tunjungputri RN, Borkus R, Scheffer GJ, de Groot PG, Urbanus RT, et al
. The influence of hypoxia on platelet function and plasmatic coagulation during systemic inflammation in humans in vivo
. Platelets 2019;30:927-30.
Børvik T, Evensen LH, Morelli VM, Melbye H, Brækkan SK, Hansen JB. Impact of respiratory symptoms and oxygen saturation on the risk of incident venous thromboembolism-the Tromsø study. Res Pract Thromb Haemost 2020;4:255-62.
Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S, et al
. Chest X-ray in new coronavirus disease 2019 (COVID-19) infection: Findings and correlation with clinical outcome. Radiol Med 2020;125:730-7.
Kaufman AE, Naidu S, Ramachandran S, Kaufman DS, Fayad ZA, Mani V. Review of radiographic findings in COVID-19. World J Radiol 2020;12:142-55.
Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera-Antezana JP, et al
. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis 2020;34:101623.
Alsofayan YM, Althunayyan SM, Khan AA, Hakawi AM, Assiri AM. Clinical characteristics of COVID-19 in Saudi Arabia: A national retrospective study. J Infect Public Health 2020;13:920-5.
[Table 1], [Table 2], [Table 3], [Table 4]