In December 2019, a novel β-coronavirus emerged in the Wuhan region of China, causing pneumonia-like illness. Later this virus was identified as the severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV2), this virus caused a widespread flu-like respiratory disease, which was named the Coronavirus Disease 2019 (COVID-19) (1, 2). Shortly after that, as the virus was spreading worldwide at an alarming rate, the World Health Organization (WHO) declared COVID-19 to be a global pandemic on March 11th, 2020. The reported mortality rate varied from country to country, from 7.2% in Italy to 2.3% that has been reported in China (3, 4). Until April 28th, 2020 the total number of people who have been infected globally reached more than 3 million, with more than 200 thousand fatalities. On the same date, Bosnia and Herzegovina (B&H) reported 1,585 individuals with COVID-19, of which 63 people had passed away (5). The first COVID-19 positive case in B&H was documented on March 17th, however, in the region of Tuzla (population 477,000) the first case to be registered positive was on March 28th, 2020. This is comparably late for the first discovered infection and comparing to other nations in Europe, which had earlier detection of COVID-19 infection. Interestingly, this coincided with the near end of the flu season and was 14th days after lockdown measures were activated in this part of B&H (social distancing measures due to COVID-19 were imposed on 14th of May). This is the first article that has analyzed hospitalized patient with COVID-19 in B&H as of yet and can provide insight into the nature of COVID-19 in this part of Europe (6–8)
SARS-CoV2 is an RNA virus, from the family of the coronaviruses. Coronaviruses were first identified in the 1960s, and since that time, seven of the coronaviruses are known to infect humans (9). Usually, coronaviruses cause mild flu-like symptoms and these viruses are transmitted when infected droplets come in contact with the mucous membranes of a susceptible human host, this can be either directly through person to person contact, or indirectly when one touches a contaminated surface and then touches their own face. Conjunctival tears, saliva, urine and stool are also being considered as possible pathways of infection of COVID-19 (10)
The process of virulence with COVID-19 is initiated when SARS-CoV2 viruses latch on receptors of the Angiotensin-Converting Enzyme 2 (ACE2). Different levels of ACE2 among population groups were speculated as a reason behind the range of severity of inflammation. Individuals who develop pneumonia due to COVID-19 infection experience infiltration of polymorphonuclear cells and macrophages in the interalveolar space, with further formation of hyaline membrane that increases the thickness of the alveolar wall, consequently reducing oxygen uptake in the lungs (10).
Obesity and high body mass index (BMI) association with more serious clinical presentation and outcome in COVID-19 infected patients is currently being investigated. The risk of mortality in obese patients was recognized before COVID-19, where in the previous influenza pandemics of H1N1 and H1N5, patients with a higher BMI were more likely to die (11, 12). In Shenzhen, China, 32% from 383 patients with COVID-19 were overweight, and 10.7% were obese. Those who were obese had 2.42 higher odds of their disease progressing to severe pneumonia (13). Moreover, a more extensive study from New York that included 4,103 COVID-19 positive patients assessed factors that were mostly correlated with the need for hospital admission and these were first being 65 years and older, followed by having a BMI above 40, and third, having a history of heart failure. In a retrospective cohort from France which included 124 patients admitted in the ICU, most of the patients who required invasive mechanical ventilation were obese with a BMI above 35 (85.7%), and they concluded obesity to be a risk factor for severity (14).
According to the CDC, older age groups and any age group with underlying medical comorbidity were found to have a higher risk of developing severe illness from a SARS-CoV2 infection. Medical comorbidities found in patients who had a more serious form of COVID-19 were moderate or severe asthma, chronic lung conditions, diabetes, serious heart disease, kidney disease undergoing dialysis, chronic liver disease, cancer or being immunocompromised, as well as obesity (15). In China, a summary report of 72,314 cases from the Chinese Center for Disease Control and Prevention found that the highest death rates were among those with cardiovascular disease, then by people with diabetes, followed by those who have had a chronic respiratory disease, hypertension, and cancer (16). As people age, they are more likely to suffer from a noncommunicable health condition, making them more likely to have the aforementioned health conditions (17).
This report aims to analyze the sample of 25 patients who tested positive for COVID-19 and whose condition required admission to Tuzla University Clinical Center, Bosnia and Herzegovina and to see the impact of different factors on the length of hospitalization (LOH). Additionally, the correlation between BMI and disease severity will be included. These patients were followed from admission to discharge. Further exploration of their clinical characteristics will be elaborated as a full understanding of the disease is still limited.