الفهرس 
SARS-COV-2: VIROLOGY, EPIDEMIOLOGY, AND CLINICAL FEATURESOnly 14 pages are availabe for public view
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Abstract
T
he coronavirus disease 2019 (COVID-19) is a pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARSCoV-2). The increased number of COVID-19 cases and fatalities is a global threat. With early recognition of the cases along with vaccination, the spread of the pandemic can be restrained. Infections often present with non-classical complaints in elderly leading to delayed diagnosis and clinical decision.
COVID-19 infection causes a variety of symptoms that range from asymptomatic or mild cases up to severe cases presented with severe pneumonia with or without multi-organ failure. Studying the different presenting patterns of COVID 19 stratified by age will allow for early identification and hence proper triage of cases.
The aim of the work was to describe the factors affecting the outcome in moderate to severe COVID-19 cases, and to study the side effects of different drugs used in treatment of COVID-19 in geriatric quarantine hospital in Ain Shams University during the period from 6/6/2020 to 5/8/2020.
The study enrolled all patients with moderate to critical COVID 19 pneumonia quarantined at Geriatric hospital in Ain Shams University (n=314) stratified according to age into three groups: those >18 to 39, 40-59, >60 years. Epidemiological, demographic, clinical presentations were obtained from medical records by retrospective reviews after, confidentiality and anonymity of participants was ensured. Missing data in medical records were reported to allow for future improvement in data collection.
Our study concluded that there was a significant association between age and the disease severity. Gender had no significant association with the severity of COVID-19 infection.
Severe cases were more prevalent among those over 60 years. Fever, dyspnea, hypoxia, respiratory distress and dry cough were the most prominent presentations among all groups. Dyspnea was the most prevalent among elderly group n= 72(38.70%). Although fever was a common presentation in elderly, it occurred at a lower incidence compared to other groups. There was an increased prevalence of delirium among elderly group yet not of statistical significance.
Comorbidities had a strong association with COVID-19 infection in elderly. Diabetes mellitus, hypertension, ischemic heart disease and cerebrovascular stroke or infarction were more prevalent among group (C) followed by group (B).
In the current study, the possible COVID 19 related complications included respiratory failure, ARDS, secondary bacterial pneumonia, diabetic emergency as DKA or hyperosmolar or hypoglycemia, acute coronary syndrome, thromboembolism, stroke, confusion, acute liver injury, pancreatitis, acute kidney injury(AKI), bleeding, shock, cytokine storm, seizure, and psychiatric complications. However, the difference between the studied groups regarding complication was significant for respiratory failure, ARDS, diabetic emergencies, AKI, shock and psychiatric illness. They were more common among group (c) while the prevalence of the other complications were comparable among all groups.
The current study presented the sensitivities and specificities of different laboratory markers in predicting COVID 19 related mortality. Elevated LDH, ferritin, CRP, and IL6 were significant predictors of mortality. Moreover, low albumin and lymphopenia could significantly predict mortality. ALT and D.dimer did not predict COVID 19 related mortality.
As regards the use of drugs that have antiviral properties, our study showed that most of the patients in all groups received a combined treatment of hydroxychloroquine and azithromycin. Less than 20% of the cases (59/314) did not receive any antiviral treatment because they had a QT interval prolongation in on admission. Although Remedsivir is the only FDA approved Antiviral for COVID 19, only eleven cases in this study received it in a combination of the three drugs, which include remedsivir, hydroxychloroquine and azithromycin. This was because our study was performed during early phase of the disease spread in Egypt, while EVA Pharma became a licensed manufacturer for the antiviral treatment “Remdesivir – EVA Pharma” under voluntary license, after reaching an agreement with Gilead Sciences Inc on 24th June, 2020.
Only 13 subjects did not continue the HQ/ Azithromycin course due to acquired QT interval prolongation grade 3 during follow up.
The use of anticoagulants and antiplatelets was statistically significant more common in group C. 60 elderly cases used combined antiplatelet and anticoagulant.
The anti-inflammatory drugs used in this study included systemic steroids, tocilizumab and immunoglobulins, which were used either alone or in combination. The most commonly used anti-inflammatory drug in all groups was systemic steroid. Different preparations of steroids were used i.e. intravenous dexamethasone, oral prednisolone and intravenous methylprednisolone, of which the most commonly used, was intravenous Methylprednisolone.
The use of steroids in the current study was associated with multiple adverse events including hyperglycemia, hypertension, edema, hypokalemia and gastrointestinal bleeding. These complications were rare among group A<40 years.
In this study, there were limited number of patients that received tocilizumab and they were mainly from group B and C, the starting date of using tocilizumab was from the 2nd to 4th day of admission, the study investigated the common side effects of tocilizumab. They were mainly hepatotoxicity, thrombocytopenia, and lymphopenia.
The highest rate of admission to the ICU was among group C 78.5% followed by group B 55.4% then group A which is 50% (p<0.0001), Similarly mortality rates increased with age, they were 40.3%, 23.9%, and 19.7% in group C, B, and A respectively.
As regards the length of hospital stay and length of ICU stay, there was no statistical significant difference among the three age groups involved in the current study,
The regression model used to detect independent predictors of mortality among cases in the current model revealed that the severity of the disease was the only significant predictor of mortality after adjustment of age, presence of DM, HTN, CLD, CKD, HF, and chronic pulmonary conditions, hypoxia on admission, hydroxychloroquine use and number of comorbidities.