DHM COVID-19 Clinical Dispatch
Issue #2: Predictors of Severe COVID Disease
Bite-sized weekly clinical updates
Introduction
Welcome to the 2nd issue of the DHM COVID Clinical Dispatch!
Each week we choose a theme through which to highlight the latest literature and summarize what we are seeing from our local cases. If you missed it, check out our first issue here, focusing on GI symptoms in COVID.
Also check out a new feature this week: "What We're Reading," where our team breaks down some of the literature pertinent to our theme.
- The COVID-19 Clinical Working Group
Colorized scanning electron micrograph of an apoptotic cell (purple) heavily infected with SARS-COV-2 virus particles (yellow), isolated from a patient sample. Image captured at the NIAID Integrated Research Facility (IRF) in Fort Detrick, Maryland.
From the Files of C&C
The Case
50 year-old woman with obesity, HTN, IDDM (Hgb A1c 7.7), and RA-ILD s/p bilateral lung transplant in 2015 presented with 5 days of dry cough, fevers, myalgias and known COVID exposure was found to be COVID positive.
She was admitted, monitored, and then discharged with strict return precautions. One day later, she re-presented with hypoxemia, requiring intubation, paralysis, proning, and inhaled iNO. See below for a graphic representation of key parameters during her prolonged hospitalization.
Remainder of clinical course:
- March 27th: Enrolled in Remdesivir trial
- April 1st: LDH was first measured, ranging from 280-560 U/L
- April 4th: PICC line-associated DVT was found, shortly after rising d-dimer
- April 4th: Initiated on hydroxycholoroquine for 5 day course
- April 15th: Extubated, now out of the ICU, back in the RIU on 2L NC and improving
- April 17th: repeat testing positive
- April 21st: first COVID negative test
Remaining clinical questions:
- Which biomarkers should we be monitoring? When and how often should we be checking them?
- In individuals with elevated d-dimer, should we be adjusting prophylactic anticoagulation as they are doing in other institutions?
Quick Lit - One-Page Literature Review
Within Our Walls - UCSF COVID Data
Are any laboratory findings correlated with severe disease at UCSF?
Based on the sparse literature available, we dug into our local data to determine if any laboratory findings correlated with more severe disease in our patients. We highlight D-dimer levels in the graphic below.
It is difficult to interpret the limited data from our non-severe cases, though our patients with severe disease seem to have high D-dimer levels, overall. It remains unknown whether these findings are simply reflective of severe disease of any type, or as some have predicted - a pro-thrombotic state associated with severe COVID-19.
D-dimer of all COVID + patients at UCSF since diagnosis on whom D-dimer was measured. Acute care patients represented by blue and Critical care patients by orange. Data are courtesy of Dr. Logan Pierce and the UCSF COVID Dashboard (VPN required).
What We're Reading
Here are the articles that our team is reading this week, which are particularly relevant to this issue.
See our short summary or click the link for the full article!
- Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China (Intensive Care Medicine, March 03). This retrospective study found a higher rate of mortality in patients who were older, had pre-existing chronic illnesses or disease complications such as ARDS, acute kidney injury and secondary infection, and who had elevated blood inflammatory markers.
Prevalence of comorbidities in the novel coronavirus (COVID-19) infection: a systematic review and meta-analysis (IJID, March 12). This meta-analysis of seven studies and nearly 1600 patients found that in patients with COVID19, the most common clinical features were fever and cough, while the most common comorbidities were HTN, DM and CV disease. CV disease, respiratory disease and hypertension were most closely associated with severe disease.
Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China (JAMA, March 17). This retrospective review of 138 hospitalized patients with COVID-19 in Wuhan described differences in admission lab values and underlying co-morbidities in ICU vs non-ICU patients.
Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City (Pre-print on medrxiv, April). This NYC-based study showed that obesity and age were most heavily associated with hospital admission, while initial SpO2 < 88%, CRP>200 and D-dimer > 2500 were best correlated with critical illness or death.
Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study (Lancet, Feb 24). In this retrospective cohort, COVID-19 patients who were older, had chronic medical conditions or more severe ARDS at the time of ICU admission were at increased risk for mortality.
Clinical Characteristics of Coronavirus Disease 2019 in China (NEJM, Feb 28). This multi-center retrospective review of 1099 patients with COVID-19 in China described differences in baseline characteristics, symptoms, and diagnostic studies in patients with and without poor outcomes (ICU admission, intubation, or mortality).
Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis (European Respiratory Journal, March 26). This Chinese retrospective case study examined 1590 patients from 575 hospitals. They found that COPD, diabetes, hypertension and malignancy increased risk of ICU admission, ventilation, or death. Having at least one of these comorbidities predicted reaching one of these endpoints.
Issue 1: GI symptoms in COVID
