Clinical Characteristics and Outcome of Patients with Suspected COVID-19 in Emergency Department (RESILIENCY Study II)

Abstract

Objectives: COVID-19 may show no peculiar signs and symptoms that may differentiate it from other infective or non-infective etiologies; thus, early recognition and prompt management are crucial to improve survival. The aim of this study was to describe clinical, laboratory, and radiological characteristics and outcomes of hospitalized COVID-19 patients compared to those with other infective or non-infective etiologies. Methods: We performed a prospective study from March 2020 to February 2021. All patients hospitalized for suspected or confirmed COVID-19 were prospectively recruited. All patients were evaluated according to a predefined protocol for diagnosis of suspected SARS-CoV-2 infection. The primary endpoint was evaluation of clinical, laboratory, and radiological characteristics associated or not with COVID-19 etiology at time of hospitalization in an emergency department. Results: A total of 1036 patients were included in the study: 717 (69%) patients with confirmed COVID-19 and 319 (31%) without COVID-19, hospitalized for other causes. The main causes of hospitalization among non-COVID-19 patients were acute heart failure (44%) and bacterial pneumonia (45.8%). Overall, 30-day mortality was 9% among the COVID-19 group and 35% in the non-COVID-19 group. Multivariate analysis showed variables (fever >3 days, dry cough, acute dyspnea, lymphocytes < 1000 × 103/uL, and ferritin >250 ng/mL) independently associated with COVID-19 etiology. A decision tree was elaborated to early detect COVID-19 patients in the emergency department. Finally, Kaplan–Meier curves on 30-day survival in COVID-19 patients during the first wave (March–May 2020, n = 289 patients) and the second wave (October–February 2021, n = 428 patients) showed differences between the two study periods (p = 0.021). Conclusions: Patients with confirmed diagnosis of COVID-19 may show peculiar characteristics at time of hospitalization that could help physicians to distinguish from other infective or non-infective etiologies. Finally, a different 30-day mortality rate was observed during different periods of the pandemic.

Clinical update on COVID-19 for the emergency clinician: Presentation and evaluation

“…A complete blood count (CBC) can provide several markers of interest. For example, the CBC may reveal lymphopenia (absolute lymphocyte count <1.0 × 10 9 /L), which can be found in up to half of patients overall and 83% of hospitalized patients, portending an increased risk for the combined outcome of severe disease course and mortality compared to those with normal levels (76% vs. 26%, p < 0.001) [ 20 , 38 , [148] , [149] , [150] , [151] , [152] , [153] , [154] , [155] ]. Lymphopenia tends to worsen with the severity of COVID-19 symptoms and is associated with an increased risk for respiratory failure (odds ratio [OR] 2.69, p < 0.001) [ [152] , [153] , [154] , [155] ].…”

“…For example, the CBC may reveal lymphopenia (absolute lymphocyte count <1.0 × 10 9 /L), which can be found in up to half of patients overall and 83% of hospitalized patients, portending an increased risk for the combined outcome of severe disease course and mortality compared to those with normal levels (76% vs. 26%, p < 0.001) [ 20 , 38 , [148] , [149] , [150] , [151] , [152] , [153] , [154] , [155] ]. Lymphopenia tends to worsen with the severity of COVID-19 symptoms and is associated with an increased risk for respiratory failure (odds ratio [OR] 2.69, p < 0.001) [ [152] , [153] , [154] , [155] ]. Total leukocyte counts are variable but generally remain within a normal range of 4–10 × 10 9 /L, though median values for more severe patients are more commonly below this lower limit at 3.7–3.9 × 10 9 /L [ 18 , 20 , 151 , 155 ].…”

“…Chemistry and liver function testing can be obtained to evaluate for organ injury and other complications in COVID-19 patients. Serum creatinine has been found to be elevated in less than 10% of patients, although one study found elevated creatinine in 28.8% of patients [ 18 , [154] , [155] , [156] , [157] , [158] , [159] ]. Common electrolyte derangements found in COVID-19 include hyponatremia (20.4–50%) and hypokalemia (15.1–62%), with most exhibiting mild depletion (Na 130–135 mmol/L, K 3.0–3.5 mmol/L) [ 53 , [156] , [157] , [158] , [159] ].…”

“…Hyperglycemia is found in approximately half of patients, and in patients with diabetes, a venous blood gas panel should be considered to evaluate for COVID-19-triggered diabetic ketoacidosis [ 153 , 161 , 162 ]. Lactate dehydrogenase (LDH) is elevated (>250 U/L) in 27–92% of COVID-19 patients [ 18 , 20 , 149 , [151] , [152] , [153] , [154] , [155] ].…”

Fibrosis-4 (FIB-4) Index and mortality in COVID-19 patients admitted to the emergency department

“…Furthermore, FIB-4 patients had a more severe clinical presentation of COVID-19 as shown by a lower pO 2 and PaO 2 /FiO 2 . They also showed a pro-inflammatory and pro-thrombotic phenotype as shown by increased D-Dimer, CRP, Ferritin, all features associated with severe respiratory failure [ 20 – 22 ].…”