Comparison of Clinical, Radiological and Laboratory Findings in Discharged and Dead Patients With COVID-19 in Ilam Province, West of Iran

Objective: COVID-19 is the last global threat which WHO conrmed it as a pandemic on March 11, 2020. In the Middle East, Iran was the rst country where the SARS-Cov-2 was detected. The epidemiological and economic challenges of Iran make this country a particularly relevant subject of study. In the current study, we aimed to evaluate the clinical, radiological and laboratory ndings in hospitalized COVID-19 conrmed cases in Ilam province, west of Iran. and methods: Overall, Electronic medical records, including clinical symptoms, radiological images, laboratory ndings, and the comorbidities of In addition, the medication regimens used in these were evaluated. The patients were classied in discharged and died groups according to their outcomes. Then, clinical, radiological and laboratory ndings as well as treatment regimens and underlying diseases were compared in these two groups.


Introduction
In December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19) infected a large number of people in Wuhan, China. This RNA virus from coronaviruses family can give rise to respiratory tract infections of different severities. SARS-CoV-2 infection varies from the normal cold to more serious conditions and is similar to the coronavirus, a main cause of SARS. SARS-CoV-2 has also been demonstrated to have a strong a nity to human respiratory receptors.
In recent years, global attention has been drawn to COVID-19 due to the fast growing number of new cases, as well as its transmission via human to human interaction through droplets, contacts, and aerosols (1,2). COVID-19 has become a worldwide concern and a signi cant public health challenge, particularly since the rapid escalation of the infected cases and affected countries.
Unlike SARS-CoV and Middle East Respiratory Syndrome (MERS)-CoV, the spread of SARS-CoV-2 is greater. In the same year, Iran was reported as one of the countries with the highest prevalence rate of cases so that it was severely hit by the severity of the virus. The rst COVID-19 case recorded o cially in the country (Qom province) dated on 19 February 2020 (4). In view of the fact that Iran was the rst country in the Middle East where the virus was identi ed, it is speculated that this country is responsible for the transmission of the disease in neighboring countries, such as Iraq, Pakistan, and Afghanistan. Owing to the epidemiological conditions and the complexity of the political and economic di culties, Iran is taken into account as a particular subject of study (5).
For the COVID-19, there are no speci c clinical features but may range from no symptoms (asymptomatic cases) to severe pneumonia and death. The patients are often manifested with fever, cough, dyspnea, rhinorrhea, headache, myalgia, and arthralgia (6). Some SARS-CoV-2 infected patients also develop the severe complications of COVID-19, including acute respiratory distress syndrome (ARDS) and death; however, the reason for such behavior is unknown. Development of severe COVID-19 disease depends on multiple risk factors, comprising of sociodemographic factors and comorbid conditions (7, 8).
Identi cation of the epidemiological, clinical and laboratory features of COVID-19 could contribute to proper decision making in the control of this epidemic disease. The present study was conducted with the aim of analyzing the epidemiological and clinical attributes of COVID-19 patients following the diagnosis of the disease by detecting the viral nucleic acid using RT-PCR.

Study design
We conducted the present single-center retrospective descriptive study. The study was carried out on COVID-19 cases hospitalized in Shahid Mostafa Khomeini Hospital (Ilam, Iran) and approved by the COVID-19 registry system of the Ilam University of Medical Sciences (code: A-10-2579-5). The approach to the disease was in accordance with the guidelines provided by Iran National Health and adapted from the WHO guidelines, as well as based on the latest studies on COVID-19 (9). Inclusion/Exclusion criteria All patients who were hospitalized from 20 April 2020 to 21 May 2021 and their clinical, laboratory, and radiological information were available at the registration center were included in the study. Patients whose demographic data, laboratory tests, clinical signs, and/or radiological ndings were not available in the registry system were excluded from the study. Also, pregnant patients and patients with hematological disorders were not included in the study.

Ethical considerations
The protocols of this study were approved by the Ethics committee of Ilam University of Medical Sciences and accomplished in conformity the ethical principles of the declaration of Helsinki. Written informed consents were received from all the patients, and their information was kept con dential.

Clinical assessment
Cases with fever, rhinorrhea, sore throat, cough, and probable respiratory distress were considered as patients with suspected COVID-19, particularly if they had a positive history of close relationship with a highly suspected or con rmed COVID-19 patient or had a travel history to a COVID-19-affected country or city (10). The disease was diagnosed considering the clinical features, chest exam, laboratory ndings, and reverse-transcription polymerase chain reaction (RT-PCR) test by the use of both throat and nose swab samples (11).
The diagnosis of the patients was carried out clinically via lung radiographical characteristics and also veri ed according to the laboratory-based data, i.e. RT-PCR by throat and nose swab samples from the upper respiratory tract, a test that accurately explains the characteristics of the diagnostic kit. The extraction of total RNA and also RT-PCR for coronavirus genes were performed using High Pure RNA Isolation Kit (Roche Diagnostics, Penzberg, Germany) and Taqman® Premix (TaKaRa, Dalian, China), respectively, according to the protocol recommended by manufacturer.

Laboratory assessment
Peripheral venous blood samples were collected on admission or during the hospital stay. Red and white blood cell count, leukocyte subtypes count, blood type, hematocrit count, hemoglobin count, and platelet count were the routine blood tests carried out by using an automated hematology analyzer (Sysmex Corporation, Kobe, Japan). Platelet, lymphocyte, and neutrophil counts, serum urea and creatinine, Creactive protein (CRP), erythrocyte sedimentation rate (ESR), aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin level, lactate dehydrogenase (LDH), and so on were other laboratory data.

CT image acquisition
Radiological evaluations were made according to CT images. Two expert radiologists assessed the presence of any radiological deformity based on the evidence or description in the medical records and nally rechecked the results. The signi cant CT imaging ndings in each lobe, three lobes in the right lung and two lobes in the left lung, were scored. Scores of 1 and 2 were given to the alterations in Groundglass opacities (including crazy paving) of <3 cm and >3 cm, respectively. Also, CT score of 0 was de ned as normal, while those of 1-7 and 8-15 were interpreted as less than severe and severe, respectively.

Statistical analysis
The analysis of the data were conducted by the aid of descriptive statistics (e.g. mean, frequency tables, standard deviation, and variance) and also by analytical tests (e.g. Chi-square, Pierson correlation coe cient test, and ANOVA), using SPSS version 27. The probability level of less than 0.5 was considered to be statistically signi cant (p <0.05).

Presenting characteristics
The study population included 2204 patients with COVID-19 whose laboratory tests were con rmed. The mean age of patients was 56.67% who had an age range of 3-100 years. Among the patients included in this study, 451 were under the age of 40, of whom 8 died (1.8%), and 1747 were over the age of 40, of whom 94 died (5.4%). There was a signi cant difference between age and mortality rate. Among the patients, 1209 (54.85%) were male and 995 (45.14%) were female. In this study, 23.1% of patients were admitted to the ICU, and 3.2% of patients were rehospitalized. Among the hospitalized patients, 95.4% O 2 demanded.
Among COVID-19 comorbidities, there was a signi cant difference between death and the presence of chronic obstructive pulmonary disease (COPD) and cancer with p=0.015 and p =0.012, respectively. Various symptoms were reported at the onset of the disease. Among them, symptoms such as acute respiratory distress syndrome (ARDS) (p = 0.001), joint ache (p = 0.050), cough (p = 0.010), malaise (p = 0.001), nausea (p = 0.007), vomiting (p = 0.027), and myalgia (p = 0.001) were signi cantly different between the survivor and deceased groups.

Laboratory ndings
According to the observations, blood creatinine levels have increased in deceased group compared to the survivors, which based on statistical analysis is a signi cant. In deceased patients, white blood cell (WBC) (p = 0.001) and absolutely neutrophil count (p = 0.001) increased and absolutely lymphocyte count (p = 0.001) decreased. Calcium and sodium levels were decreasing and increasing in the deceased group, respectively. Although no signi cant correlation was reported with calcium depletion, this correlation was signi cant for sodium increment. Alkaline phosphatase (ALP), albumin, carbon dioxide and ferritin decreased and bilirubin, aspartate aminotransferase (AST), blood urea nitrogen (BUN), glucose, Lactate dehydrogenase (LDH), alanine aminotransferase (ALT) and Creatine Phosphokinase (CPK) increased in the deceased group but no signi cant correlation was observed. There was a signi cant increase in erythrocyte sedimentation rate (ESR) in the deceased group with p = 0.001. Although C-reactive protein (CRP) was increased in the deceased group, there was no signi cant difference between CRP and mortality rates. Information on laboratory ndings is available in Table II.

Radiological ndings
The results of CT scan and radiographs of patients' lungs showed different patterns. The most common abnormality was multiple mottling and ground glass opacity (964: 43.7%), followed by bilateral pneumonia (799: 36.3%). No cases of cavitation were observed. There were signi cant correlations between bilateral pneumonia, multiple mottling and ground glass opacity, bilateral patchy shadowing, and pleural effusion with death. There was a signi cant difference between the number of lung lobes involved in the disease and the incidence of death.

Interventions
According to Iranian treatment protocols, two groups of drugs were used to treat COVID-19(12). The rst group included Oseltamivir, Hydroxychloroquine, Ribavirin and lopinavir/ritonavir and the second group included Recigen, Zifron, Vit D and Remdesivir (Table III). Among the various drug regimens, the most common was the combination of Oseltamivir, Hydroxychloroquine, and lopinavir/ritonavir (45.5%). There was a signi cant difference between survivor and deceased groups receiving plasma therapy (p = 0.049).
During treatment, 96.1% of patients needed oxygen so they were intubated or used mechanical intubation. There was a signi cant difference between the two groups in both intubation (p = 0.001) and mechanical intubation (p = 0.001) methods (Table III).

Outcomes
The mortality rate among patients was 14%, of which 4.6% of deaths were due to COVID-19. Most causes of death for reasons other than COVID-19 included diabetes, high blood pressure, heart attack, and heart failure. The results showed that history of contact with suspected cases (p = 0.001) and history of contact with dyspnea cases had signi cant difference (p = 0.001). Patients with a history of contact with suspected and dyspnea cases had a higher mortality rate. The average number of admission days in ICU in the survivor and deceased groups was 4.79 (±5.292) and 6.43 (±5.961), respectively.
There was a signi cant difference between the number of hospitalization days and death (p = 0.024). Among the patients studied in this study, 1864 (96.6%) were discharged from the hospital.
Analyzes showed that there was a signi cant difference and an inverse correlation between partial recovery with death rate in patients. Patients who had a history of visits medical centers two weeks before hospitalization were more likely to die than those without a history, which showed a signi cant difference (p = 0.001). Also, the analyses showed a signi cant correlation between the history of visiting medical centers and the rate of mortality.

Discussion
This retrospective study reports the demographics, clinical symptoms, and the results of laboratory tests ndings of 2204 patients with con rmed COVID-19 infected, who were treated at Shahid Mostafa Khomeini Hospital, (Ilam, Iran).
Although the number of infected men was more than women, this difference was not signi cant. In a meta-analysis study, Hannah Packham et al reported that there was no difference in the proportion of men and women with COVID-19 (13). However, George M. Bwire reported that biological and lifestyle differences have led to reports in various studies that men are more likely to be infected than women. Of course, women are more likely than men to take preventive measures, such as the use of face masks and frequent hand washing (14).
The average age of the patients was 56.67 years but most deaths occur at an average age of 64.16 years. Previous studies reported a broadly similar age distribution (15-17). Mortality was signi cantly higher in people over 40 years of age, which is almost in the age range reported by the study of M. Nikpouraghdam et al in Iran (18). Based on these results, old age can be considered as a risk factor for death.
The frequency of blood groups A + / _ , O + / _ , B + / _ and AB + / _ among patients was estimated as 40.5/1.4%, 29.1/3.7%, 16.3/1.4% and 6.5/0.6% respectively. The frequency of blood groups A + / _ , O + / _ , B + / _ and AB + / _ among individuals who died of this infection was estimated as 48.4/3.2%, 29.3/3.2%, 9.7/1.6% and 8.1/0.0% respectively. This study con rmed the relationship between ABO blood groups and COVID-19 sensitivity in patients. Patients with blood type A had a higher frequency compared to non-blood type A and patients with blood type AB had a much lower frequency compared to non-blood type AB.
In the meta-analysis performed by Liu, blood groups A and B were signi cantly more at risk for COVID-19, whereas this was not the case for blood group AB, people with blood type O were not susceptible to the disease (19). The researchers found that in people with blood type O, the production of natural anti-A and anti-B antibodies could potentially prevent viral attachment to host cells, a mechanism that could explain their lower risk of infection compared to other blood groups (20).
However, in this study, blood group O along with blood group A are more common among patients, which may be due to the fact that blood group O (36.49%) and A (32.09%) are the most blood common group among Iranians (21).
In this study, patients with severe illness developed ARDS (7.9%), required ICU admission (23.1%), intubation (13.7%), mechanical intubation (13.7) and oxygen therapy (96.1%). Among those who died, 99% needed oxygen, 89% needed incubation, and 71% needed mechanical incubation. The need for invasive mechanical ventilation in this patient population was less than that in Italy (88%) (23), but it was more than China (47% and 42%) (24, 25), and equal to Washington State (71%) (26). The mortality rate in patients who required ICU and mechanical intubation was statistically signi cantly higher than patients who did not require ICU and mechanical intubation.
According to our results, a total of 54.7% of patients had at least one underling disease in line with that reported by Grasselli (68%)(23) and Wang et al (72.2%)(24): HTN (31.2%), diabetes (22.8%), heart disease (21.9). As with other studies (18, 27), our results it also showed that having co-morbidities can have a statistically signi cant effect on mortality. Compared to the two groups, only the presence of cancer and COPD was statistically signi cant.
Based on our data, most abnormal radiologic ndings consisted of bilateral pneumonia, multiple mottling and ground-glass opacity, bilateral patchy shadowing, and pleural effusion. As with other publications, our data show that CT scans can play an important role in diagnosing and assessing the severity of the disease (28). Many studies have referred to bilateral pneumonia and bilateral ground-glass opacities on CT scans of people with COVID-19, which have also been seen in our study (24, 29, 30). These symptoms were more common in the deceased patients than in the survivors.
Among laboratory ndings, WBC, absolute neutrophil count, Na+, BUN and ESR were higher among in the deceased patients in comparison to the survivors, and the results are in accordance with the previous studies (31). According to the results of a meta-analysis study, patients with Covid-19 with lymphopenia are more likely to develop severe disease (32). In the present study, the number of lymphocytes decreased in people who died compared to those who survived. Contact with infected people has played an important role in the spread of the disease, according to past studies (33, 34).
In this study, the history of occupational contact, contact with suspected cases and referral to medical centers during the two weeks before hospitalization were signi cantly higher in people who died than in other patients. In Brazil, a total of 34.4% patients had a recent international travel history and 61.1% patients had a history of close contact either with a positive or suspected case of COVID-19 (35). In the study of Xi-Min Qiao et al 53.33% of patients had the history of travel to Wuhan, 26.67% of patients had close contact with con rmed patients, and 6.67% of patient had close contact with suspected patients (36).
In the study of Nopsopon T et al no participants with a history of travel to the high-risk area or close contact with PCR-con rmed COVID-19 case developed SARS-CoV-2 antibodies. No association between history of travel to a high-risk area and close contact with PCR-con rmed or suspected COVID-19 case, was found (37).
Some people believe that alcohol consumption is bene cial for the prevention and treatment of COVID-19 (38). Among patients, 11 (0.5%) patients consumed alcohol and 82 (3.70%) were current smokers; also 41 (1.9%) patients were addicted. No relationship was found between severity of COVID-19 and smoking, and drinking alcohol in this study. The prevalence of low alcohol consumption in our study is probably due to the fact that in Iran, like many Muslim majority countries where alcohol consumption is prohibited (39). Mengyuan Dai's ndings indicated that COVID-19 patients with a history of cigarette smoking tend to have more severe outcomes than non-smoking patients. However, alcohol consumption did not reveal signi cant effects on neither development of severe illness nor death rates in COVID-19 patients (40). In the study of Jin-jin Zhang et al, current smokers (1.4%) were rare (41).
In the study of Suman Saurabh et al, alcohol use was found to increase the risk of symptomatic disease as compared with asymptomatic infection. Current tobacco smoking but not smokeless tobacco use appeared to reduce the risk of symptomatic disease (42). The smoking and drinking chewing rates in Rui Zhong , s study were 15.4 and 26.4%, respectively. The chi-square test showed no statistical signi cance with the classi cation of COVID-19. The smoking rate of COVID-19 patients was lower than that the general population (43). The studies of Zhang J. J. et al, 2020 in China on COVID-19 and smoking showed that only 12.6% of patients were smokers, Which was more than the smoking rate in our study (2.8%) (43).
Two groups of drugs were used to manage COVID-19 based on Iranian treatment protocols and disease severity in individual (12). Group one included Oseltamivir, Hydroxychloroquine, Ribavirin and lopinavir/ritonavir. There was no signi cant difference between the group of survivors and the deceased patients used this drug group. A clinical trial was conducted in United Kingdom, to investigate various drug candidates or therapies including Hydroxychloroquine against severe COVID-19 (44). The result demonstrated no e cacy of Hydroxychloroquine against COVID-19 (44). In this study, there was no signi cant difference between the group of survivors and the deceased patients used Hydroxychloroquine and Oseltamivir. But in the second group, which included Recigen and Zifron as interferon-β1b, Vit D and Remdesivir, there was a signi cant difference between the survivors and the deceased patients.
Getu Zhaori et al, found that among the reports on monotherapies, only remdesivir, and among combined antiviral agents, only the combined regimen with interferon-β1b, lopinavir-ritonavir and ribavirin were effective and safe based on evidences from RCTs (45). In the study of Pan H et al, remdesivir, Hydroxychloroquine, lopinavir, and interferon regimens had little or no effect on hospitalized patients with COVID-19, as indicated by overall mortality, initiation of ventilation, and duration of hospital stay (46). infections. In that study, IFN-β-1a demonstrated potent antiviral activity and acceptable safety pro les, suggesting its e cacy in coronavirus treatment (48). The results of the Pooya P et al study are also in favor of using Interferon beta-1a in addition to recommended antiviral treatment in COVID-19 patients (49).
These data suggest that mortality was associated with older age, multiple co-morbidities, abnormal CT scans at admission, direct admission to the ICU, low lymphocyte count, history of suspected exposure, and intubation. Also, drugs including interferon beta (Recigen or Zifron) and Remdesivir are also effective in reducing mortality.

Conclusion
According to the results of the current study, it can be concluded mortality was associated with older age, multiple co-morbidities, abnormal CT scans at admission, direct admission to the ICU, low lymphocyte count, history of suspected exposure, and intubation. In fact, it seems that COVID-19 patients in west of Iran have a special pro le of disease. Identifying the characteristics of the disease would translate into the implementation of practical measures to improve results.    Tables   Table I. Clinical, radiological, and comorbidities features of patients with COVID-19.