Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 has rapidly evolved as an epidemic outbreak and infected more than six and a half million individuals all over the world. Besides this, billions of others are directly affected by the citizens are affected by measures of social distancing and the socio-economic impact. COVID19 is a systemic infection causing a significant impact on the hematopoietic system and hemostasis mechanism. [3] The incubation period of this virus can be up to 14days following exposure. According to the center for disease control and prevention (CDC), the individuals with COVID-19 have had a wide range of symptoms reported ranging from mild to severe illness. These symptoms may appear from the second day till the incubation period. These symptoms may include but not limited to cough, fever, chills, muscle pain, the heaviness of chest, shortness of breath or difficulty breathing, sore throat, and loss of taste or smell. Warning signs of COVID-19 include breathing difficulty, persistent pain or pressure in the chest, inability to wake or stay awake, sings of central cyanoses like bluish lips or face, and confusion. [4] Multiple studies have reported presenting symptoms of COVID-19 worldwide among which several symptoms are common, but due to geographical locations, these symptoms may differ.
In this study, we analyzed the COVID-19 cases in multiple centers in Bangladesh to assess these symptomatic and hematological variations from the rest of the world. Following exclusion, our study revealed that the primary presenting symptoms of 320 COVID19 patients in treated in multiple centers in Bangladesh include fever, cough, chest tightness, weakness, anorexia, myalgia, diarrhea, nausea, sleep disturbance, headache, sore throat, respiratory distress, rhinorrhea, abdominal pain, rash or skin lesion, vomiting, vertigo, and restlessness. Among these primary presenting symptoms, fever and cough were most common, and vomiting and vertigo were relatively uncommon. Chest tightness and weakness were relatively common in COVID-19 cases but not as much as fever and cough, which was present in the maximum number of cases affected by SARS-CoV-2 [Figure 2 A & B]. This study can help healthcare professionals in Bangladesh and others to narrow down the suspected COVID-19 affected cases and perform testing accordingly. In Bangladesh, unlike developed countries, real-time reverse transcription-polymerase chain reaction (RT-PCR) is the only available test which is recommended by the Institute of Epidemiology, Disease Control and Research (IEDCR) for the healthcare settings. The real-time RT-PCR is of the high value of interest for the detection of COVID19 disease due to its simplicity and specificity. [5–7] But unfortunately RT-PCR test has the risk of eliciting false-negative and false-positive results, as the sensitivity and specificity of the RT-PCR test are not 100%. [8] However, a chest computed tomography (CT) was reported 98% and 97% sensitive in two different studies. [9, 10]
One of the early studies regarding clinical characteristics of COVID-19 done on 1099 patients in china revealed that the most common symptoms were fever, cough, and fatigue which resembles findings of our study (68.8%, 57.3%, and 41.9%). [Figure 2 A & B] A study on the systematic review focusing on upper airway symptoms revealed that the common symptoms of COVID19 were fever, cough, and fatigue. [11] These studies with our study confirm that fever and cough are the two most common onset symptoms of COVID-19, including in Bangladesh. Diarrhoea, on the other hand, was uncommon (3.8%) [12] Which is not uncommon in COVID-19 cases analyzed in our study, 30.6%. Symptoms like Hemoptysis (0.9% Vs 0%) and breathing difficulty (18.7% Vs 19.1%) show similarity with our findings. But Sore throat 13.9% Vs 19.7%; Headache 13.6% Vs 23.4%; Nausea & Vomiting 5% Vs 29% & and 9.1%; Mayalgia 14.9% Vs 35% and Skin rash 0.2% Vs 14.7% has revealed a very different trends of presenting symptoms then the other reported studies. Our findings of Diarrhoea (30.6%) are similar to Song et al. This study reported SARS-CoV-2 induced diarrhoea could be the onset symptom in patients with COVID-19. [13] Up to 30% of patients with the Middle East respiratory syndrome (MERS) and 10.6% of patients with SARS had diarrhoea as the onset symptom. [14] Bao et al. revealed that vomiting is also associated as the onset symptom in some cases of COVID-19, [15] which was also present in the COVID-19 cases found in our study (9.1%). A similar result was also found in the case of rash/skin lesion in this study, which resembles a case study where a young male with full-body rash was a presenting symptom of COVID-19. [16] 16.6% of the patients in our study complained of mild to moderate amounts of abdominal cramp or pain. This finding also similar to a case study reported earlier that the acute abdomen was the early symptom of COVID-19. [17] During the data collection we have noticed 2 severe cases of COVID19 with hemoptysis. As all the severe cases had per existing comorbid conditions, so were not included in his study. We have also observed three cases presented only with anorexia and two cases of severe myalgia later were diagnosed as SARS-CoV-2 infection. As an additional finding, restlessness was complained by 85 (25.63%) of patients this was 34.76% of symptomatic males and 25.51% of the symptomatic females [Table 2]. Based on our study findings minimally symptomatic patients or symptoms like abdominal cramp or pain, Myalgia, localize skin lesion or rash, sleep disturbance, and restlessness are important presenting symptoms for this region of COVID19 disease besides common other symptoms.
According to our study males have a higher infection rate than females 208 (65%) & 112 (35%). [Figure 1A] Also only 18.12% of patients were asymptomatic whereas symptomatic cases were 81.88%. [Figure 2C] This is due to lack of test availability and also tests were made available only to the definite symptomatic patients or those who have radiological or laboratory findings suggestive of SARS-CoV-2 infection. The duration of symptoms had no variation depending on gender and age. [Figure 1 C, Fig. 2F] Male patient’s home isolation and treatment number are higher than the female patients. [Figure 1D] Incase of age group 31 to 40 years are the most affected n = 127/320 and 10 to 20 are the least n = 30/320. [Figure 1E] Cases with or without fevers were high 68.75% and 31.25% compare to Wei-jie Guan et al. [11] Duration of fever has no significant difference regarding presenting temperature. [Figure 1F] But temperature > 1000F was relatively higher then < 1000F 47.5% and 21.25% of total patients, this is 152 (69.09%) and 68 (30.90%) [Table 1] of patients with fever and does not correlate with the other study. [11] Male patients were more affected with cough than female and dry cough was more common than sputum. [Figure 2E] Fever, weakness, anorexia, Myalgia, nausea, headache, breathing difficulty, vomiting, and restlessness were more prominent in the case of male than female patients. [Table 2, Fig. 3A & B] Chest tightness, sore throat, skin lesion/rash, and vertigo were more common in female patients. [Table 2, Fig. 3A & B] Other than that diarrhea, sleep disturbance and rhinorrhoea/nasal congestion have an almost similar presentation in both sexes.
SARS-CoV-2, on the other hand, is a systemic infection with a significant impact on the hematopoietic system and hemostasis, according to the critical review by Terpos et al. done on hematological findings of COVID-19. They have found that COVID-19 disease has prominent manifestations from the hematopoietic system and is often associated with a major blood hypercoagulability. The study indicated that Lymphopenia might be considered as a cardinal finding with prognostic potential. On the other hand, Neutrophil/lymphocyte ratio and peak platelet/lymphocyte ratio may also have prognostic value in determining severe cases. Furthermore, blood hypercoagulability is common among hospitalized COVID‐19 patients. Elevated D-dimer levels are consistently reported as well. Thus, the study concluded that in patients with COVID-19 either for hospitalized or not, they are at high risk for venous thromboembolism, and an early and prolonged pharmacological thromboprophylaxis with Low molecular weight heparin (LMWH) is highly recommended. [18]
We had analyzed the on-admission laboratory values of 50 patients with a moderate degree of COVID-19 disease to assess the overall expression. The study revealed an increased level of ESR, CRP, SGPT, Serum Ferritin, Prothrombin time, and D-Dimer. However, the level of Hemoglobin and RBC were decreased and also revealed leukocytosis, neutrophilia, and lymphocytopenia. [Figure 2 C & D] The differential expression of WBC analysis revealed normal mean Neutrophil, Lymphocyte, Monocyte, and Eosinophil count. [Figure 3F] Analysis of biochemical values according to gender revealed differences between males and females in a few parameters. Increased levels of SGPT and S. Ferritin were found among males, and increased levels of D-Dimer were found among females (One in one patient). [Figure 3E] There were no differences in the levels of CRP and prothrombin times between males and females in patients with COVID-19. [Figure 3E] Hemoglobin count was decreased in the case of males (71.42%) than females (36.36%), though RBC count was normal in all the males and decreased among 27.27% of female patients. [Figure 3D] Difference between the decrease hemoglobin count and increased SGPT against male and female patients was found significant. [Figure 3G] All these suggests us to provide more attention towards gender in cease of laboratory findings for COVID19 diagnosis and prognosis
One of our important observations was in delay in diagnosis and therefore treatment from the time of appearance of symptoms, 5.67 ± 3.56 days. [Figure 1C] This is probably explained by delay in publishing test results (2 to 3days from sample collection) unwilling to take tests by patients due to testing and social hazards, and strict indications followed for the PCR test (Fever, breathing difficulty, chest discomfort, Chest X-ray findings, and associated hematological findings) by the COVID19 tertiary center doctors due to limited resources.