Analysis of Clinical Characteristics
From January 31, 2020 to March 7, 2020, 1,179 COVID-19 patients were admitted to and 77 died (incl. 51 males and 26 females) in EHWU East Branch. The average age at death was 71 years old, the number of COVID-19 deaths in males was higher than that in females (66.2% vs 33.8%), and the average age at death in males was lower than that in females (69 vs 75). All patients were permanent residents of Wuhan. Among them, 81.8% were caused by mass gathering, and their initial symptoms include fever (81.8%), dyspnea (32.5%), cough (19.5%), fatigue (15.6%), neurological symptoms (5.2%), and abdominal pain, diarrhea (3.9%); 72.8% had underlying diseases, hypertension (58.9%) was the most common one, followed by diabetes (32.1%), heart disease (32.1%), chronic lung disease (14.3%), nephropathy (13.5%), cerebrovascular disease (12.5%), liver disease (7.1%), cancers (3.6%), etc.; and 33 patients (43.0%) had a history of smoking. (Table 1) According to the assessment results within 24 hours after admission, 71 were critical cases, 4 were severe cases and 2 were ordinary ones. Among the ordinary patients, one patient died of cerebral hemorrhage after kidney transplantation, while the other suffered from massive cerebral infarction and died of cerebral herniation.
Among the 77 deaths, peripheral white blood cell count increased in 36 cases (46.8%) and decreased in 9 cases (11.7%). Fifty cases (64.9%) had increased neutrophil count, 67 cases (87.0%) had decreased lymphocyte count, 43 cases (55.8%) had decreased hemoglobin, and 25 cases (32.5%) had decreased platelet count. C-reactive protein (CRP) increased in 69 cases (89.6%) and procalcitonin increased in 57 cases (74.0%). Troponin increased in 34 cases (44.2%) and brain natriuretic peptide increased in 26 cases (33.8%). Seventeen cases (22.1%) had elevated alanine aminotransferase and 38 cases (49.4%) had elevated aspartate aminotransferase. Creatinine, lactic dehydrogenase and D-dimer increased respectively in 19 cases (24.7%), 68 cases (88.3%) and 59 cases (76.6%). CD4 + cell count decreased in 52 cases (98.1%), CD8+ cell count decreased in 43 cases (81.1%) and lactic acid increased in 68 cases (88.3%). (Table 2)
All the 77 patients underwent imaging examination (chest X-ray or CT) from disease onset to death. Diffuse lesions (multiple ground-glass exudation shadows) of both lungs were found in the early stage, and were developed into large areas of lung consolidation on both sides in the later stage, along with bronchiectasis and “white lungs” (asbestosis). Spontaneous pneumothorax and subcutaneous and mediastinal emphysema occurred in 2 patients without mechanical ventilation.
Treatment Plans and Causes of Death
Early treatment with oseltamivir was given to 58 patients, after admission, 75 patients received antiviral treatment with arbidol, 2 patients received lopinavir/ritonavir, and all patients received antibiotic treatment. As for respiratory support, 24 cases (31.2%) were on non-invasive ventilators, 24 (31.2%) received mask oxygen therapy, 16 (20.8%) received high-flow nasal cannula (HFNC) oxygen therapy, and 1 received extracorporeal membrane oxygenation (ECMO). ARDS (87.0%) was the main cause of death, followed by sepsis (18.2%), neurological diseases (3.9%), heart disease (2.6%) and gastrointestinal bleeding (2.6%). The mean survival time (from disease onset to death) was 17.4 days. Only 7 patients (9.1%) underwent endotracheal intubation, and the mean time from admission to endotracheal intubation was 6 days. (Table 1)
In this study, subgroup analysis was carried out based on a series of baseline characteristics, including gender, age, survival time and whether complicated with hypertension, and the results were shown as follows: (1) Among the initial symptoms of deaths, females were more prone to cough and dyspnea (especially in the early stage), and more likely to be complicated with diabetes; while the incidence of sepsis in males seemed to be higher than that in females. In addition, anemia was more common in females; while elevated CRP, creatinine and creatine kinase, and decreased platelets and CD4 + cells were more common in males (Figure 1). (2) The majority of young and middle-aged deaths (≤ 65 years old) were males. Elderly patients seemed to be more prone to fatigue and myocardial injury, while middle-aged and young patients were more likely to have elevated alanine aminotransferase and creatine kinase (Figure 2). (3) The majority of short-term survival cases were males. In the short-term survival subgroup, symptoms in abdomen and nervous system were more likely to be found in the early stage, and the proportion of patients complicated with heart disease rather than diabetes or chronic lung disease was higher. The incidence of sepsis was higher in this subgroup, and laboratory tests were characterized by decreased platelets and elevated creatine kinase (Fig. 3). (4) Dyspnea was more common in the deaths complicated with hypertension, while fatigue and neurological symptoms were more common in the deaths without hypertension. Compared with the deaths without hypertension, CRP and LDH increased, and CD4 + cells and CD8 + cells decreased significantly in the deaths complicated with hypertension (Figure 4). (Table 3)
A 31-year-old male patient, previously healthy, was admitted to hospital on February 5, 2020 due to “fever for 13 days and dyspnea for 2 days”. Before that, he had been exposed to a covid-19 patient. Oral administration of “Oseltamivir 75mg bid and Moxifloxacin 0.5g qd" was given, however the effect was poor. With two positive SARS-CoV nucleic acid assays in throat swab specimens conducted by other hospital, he was transferred to our hospital. Physical examinations: shortness of breath (28 times / min), oxygen saturation (by fingertip pulse oximeter) of 75%, subcutaneous crepitus found in the anterior chest along with low breath sound of both lungs. Auxiliary examinations: blood routine examination: 15.5 × 109/L, neutrophil count: 14.45 ×109/L, lymphocyte count: 0.4 ×109/L; arterial blood gas analysis (oxygen mask at a flow rate of 8L/min): pH:7.48, PO2: 45mmH2O, PCO2: 30mmH2O，Lac: 4mmol/L; CRP: 137.2mg/L; PCT: 0.048ng/L; BNP: 152 pg/ml; creatinine: 52umol/L, creatine kinase: 473u/L, LDH: 894u/L, ALT: 40u/L, AST: 30u/L； Cell immunity: CD4+ cells: 125/uL, CD8+ cells: 160/uL. Chest CT: bilateral pneumothorax, subcutaneous and mediastinal emphysema in the chest wall and neck; consolidation, exudation and local compressive atelectasis of both lungs. Admission diagnosis: 1. critical case of COVID-19; 2. ARDS; 3. bilateral spontaneous pneumothorax; and 4. subcutaneous and mediastinal emphysema. After admission, the patient was given high-flow nasal oxygen therapy (flow rate: 60L/min, oxygen concentration: 100%), closed chest drainage and subcutaneous emphysema incision and drainage of both lungs, and antiviral therapy with abidol 200mg tid (oral administration) + ribavirin 0.5g bid (intravenous infusion). After the above treatment, the dyspnea was relieved, and oxygen saturation reached 93%. Two days after admission, dyspnea worsened and oxygenation index decreased further. The patient died on February 9. (Figure. 5)