1. Background
Most coronaviruses cause mild infections in humans (1). In the past decade, two coronaviruses belonging to betacoronaviruses, including Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), infected more than 10,000 people all around the world, with a mortality rate of 10% and 37% for SARS and MERS, respectively (2, 3). Recently, in December 2019, patients with clinical presentations of viral pneumonia were reported from Wuhan, Hubei, China (4, 5). The sequencing results of patients’ samples revealed that Wuhan patients were infected with a novel coronavirus (COVID-2019). Several reports all around the world, including Japan, South Korea, USA, Italy, and Germany, confirmed the prevalence of the novel coronavirus (2019-nCoV) (6, 7). Based on the WHO, pneumonia of COVID-19 is highly infectious, and this outbreak is one of the most important public health problems. It has distributed broadly due to human-to-human transmission in countries that have challenges with this agent (4, 5).
2. Objectives
In this study, we report and describe novel coronavirus-infected patients with pneumonia whose specimens were confirmed in the Pasture Institute of Iran. We also describe the clinical features of patients infected with the novel coronavirus.
3. Methods
3.1. Patient Isolation
Following the emergence of COVID-2019 in Iran, patients with pneumonia signs were considered to be infected with COVID-19. For the time being, 10 patients suspected to COVID-19 with cough and fever more than 38ºC, were transferred to an isolated region in ICU. furthermore after government alert, a rapid response team contain physician, virologist, and nursing was formed. The diagnosis of COVID-19 was according to the clinical characteristics, chest exam, laboratory findings, and virologic tests. The patients suspected to COVID-19 were isolated in a special airborne protection agent room.
3.2. Ethics Statement
This study was approved by the Infectious Disease Ethical Review Board.
3.3. Data Gathering
We investigated the clinical characteristics, chest imaging, liver function tests, and laboratory findings of patients suspected to COVID-19 (8, 9). The data were extracted from electronic medical records of infected patients.
4. Results
In this study, 10 out of 22 patients with positive clinical and laboratory results of COVID-19 infection were hospitalized and intubated in a special airborne protection agent room. The median age of the patients was 50 years. The demographic characteristics of the infected patients are summarized in Table 1.
| Variables | Patients (N = 10) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 | Patient 7 | Patient 8 | Patient 9 | Patient 10 | |
| Age | 45 | 56 | 65 | 42 | 55 | 40 | 56 | 60 | 40 | 43 |
| Sex | Female | Male | Male | Male | Male | Female | Male | Male | Female | Male |
| Smoking | No | Yes | Yes | Yes | Yes | No | Yes | Yes | No | Yes |
| Diabetes | No | Yes | Yes | No | No | No | Yes | Yes | No | No |
| Hypertension | Yes | Yes | Yes | No | Yes | Yes | Yes | Yes | No | No |
| Clinical symptoms | ||||||||||
| Fever | 40 | 38 | 38.5 | 38.4 | 39 | 40 | 38.5 | 40 | 37 | 37 |
| Dyspnea | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Phenomena | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Fatigue | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Headache | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Cough | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Haemoptysis | No | No | No | Yes | No | No | No | Yes | No | No |
| Bradycardia | + | Yes | Yes | Yes | Yes | Yes | Yes | Yes | No | No |
Demographic Characteristics of Infected and Intubated Patients with COVID-19
4.1. Laboratory Characteristics
All hospitalized patients showed leucopenia. The cardiac-related enzymes were higher in patients admitted to the ICU. The liver function test LFT results showed variations in infected patients. The laboratory findings are summarized in Table 2.
| Variables | Patients (N = 10) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 | Patient 7 | Patient 8 | Patient 9 | Patient 10 | |
| WBC (× 103/mlcl) | 13.9 | 5.7 | 12.75 | 20.1 | 16.2 | 5.5 | 6 | 9.7 | 4.7 | 3.6 |
| RBC (× 106/mlcl) | 4.84 | 3.46 | 3.91 | 3.32 | 3.84 | 3.61 | 3.98 | 4.61 | 4.51 | 4.45 |
| ALT (U/L) | 11 | 60 | 50 | 123 | 130 | 125 | 30 | 40 | 17 | 23 |
| AST (U/L) | 10 | 100 | 88 | 178 | 167 | 177 | 50 | 79 | 35 | 45 |
| Hb | 11.8 | 10 | 11.58 | 11.8 | 11.3 | 7.2 | 12.2 | 12.9 | 11.1 | 10 |
| HCT | 39.7 | 31.8 | 33.8 | 34.6 | 34.2 | 25 | 37.4 | 38.5 | - | - |
| Platelet | 231 | - | 343.0 | 155 | 166 | 158 | 314 | 244 | 200 | 151 |
| Lymphocyte (%) | 17 | 16 | 8.80 | 7.7 | 15 | 10 | 26 | 12 | 38 | 32 |
| Neutrophils (%) | 60 | 79 | 86.93 | 88 | 80 | 87 | 70 | 85 | 59 | 64 |
| CRP (mg/L) | 31 | 22 | 45 | 22 | 30 | 23 | 23 | `12 | 13 | 14 |
| LDH (U/L) | 451 | 605 | 555 | 456 | 1743 | 1516 | 666 | - | 520 | - |
| CPK (U/L_ | 38 | 149 | 140 | 960 | 138 | 392 | 200 | 251 | 201 | 546 |
| BUN | 50 | 25 | 47 | 13 | 156 | 38 | 22 | 32 | 40 | 18 |
| Ck-MB | 50 | 25 | 60 | 89 | 75 | 77 | 20 | 16 | 24 | 16 |
| Alk.ph | 237 | 115 | 244 | 250 | 155 | 177 | 180 | 133 | 113 | |
Clinical Characteristics of Infected and Intubated Patients with COVID-19
4.2. Chest Images
Chest CT images revealed the presence of abnormalities in all admitted patients. The CT scan and radiographic images of seven dead patients revealed bilateral multilobar ground-glass opacity, consolidation, and ground-glass opacity with interlobular septal thickening (crazy-paving) in the peripheral distribution in infected patients. The results are shown in Figure 1.
Chest radiography and CT scan results. CT scan shows bilateral multifocal ground-glass/crazy-paving and consolidation in peripheral distribution. AP chest radiographs show multifocal patchy consolidation in bilateral lungs.
5. Discussion
In early 2020, the outbreak of novel coronavirus (COVID-19) occurred, and it spread from China to other countries. Many viruses can cause respiratory infections, and there is evidence that viruses in the same family have similar pathogenesis (5).
We evaluated the clinical and laboratory characteristics of 22 patients that were ICU-admitted and confirmed cases of COVID-19 infection. Ten (45.4%) patients were intubated. In this study, we reported COVID-19 diagnosis in patients hospitalized in Tehran, Iran. The average age of patients was 50 years, and their disease was confirmed based on and CT scans, radiographic images, and real-time PCR.
Seven of 10 patients in this study died; they had diffused ground-glass opacities in radiographic images. Radiologic findings mostly indicated bilateral multilobar ground-glass opacity and consolidation with interlobular septal thickening (crazy-paving) in peripheral distribution (10-13). Most patients presenting with severe respiratory symptoms and respiratory failure were hospitalized in the ICU. Two of seven intubated patients died because of hemoptysis and respiratory failure. The rest of the patients (five of seven) died with the signs of acute heart failure, such as hypotension, cardiac arrhythmias, and cardiogenic shock. The liver and cardiac-related enzymes of all patients were elevated. Most patients had lymphopenia without leukocytosis (14). Our data showed that COVID-19 infection was more important in older people, and the more severity of infection in these patients was probably due to their weaker immune system or coexisting diseases (15, 16). Seven patients showed degrees of abnormality in their liver function, and their ALT and AST enzymes were above normal. Most abnormal myocardial enzymes revealed the elevation of CK-MB and LDH enzymes. Delayed referral and diagnosis may be the other important causes of mortality in these patients (14).
5.1. Conclusion
Most patients infected with the novel coronavirus were admitted to intensive care units because of respiratory problems, but the causes of death of patients, except for two patients, were related to sudden cardiac arrest and delayed referral and diagnosis. It is very important to diagnose high-risk patients in the early stage of infection.
