Discussion
In this study, we report detailed epidemiologic and clinical features of 19 patients with PCR-confirmed SARS-CoV-2 infection in Germany. The most common symptoms at the onset of COIVD-19 were fever, fatigue, and cough. The median duration from symptom onset to hospital presentation was 10 (2-28) days. This duration was longer in patients who required supplemental O2 [10 (5-21 days)] compared to patients who did not require O2 [7 (2-28 days)]. Nine (47%) patients had a history of known household contact. In contrast to a previous study from Beijing, the ratio of severe cases of the COVID-19 infection was 42% in our study while they had 17.6% only(8). Moreover, 42% of our patients required O2supplementation, and 21% died. Although this finding should be interpreted cautiously due to the small sample, a previous study in Italy on 1,591 patients reported 81.7% patients needed respiratory support where 88% needed invasive endotracheal intubation and 11% need noninvasive mechanical ventilation as well as 13% needed oxygen mask. Besides, they showed an ICU mortality rate of 26% (9). Other previous studies demonstrated that 26 to 33% of patients might require intensive care(1, 10, 11) while 76 to 90% of patients require supplemental oxygen(1, 11, 12) and they had 4 to 15% mortality rate(1, 10, 11).
Thirty-two percent of our cases presented with coexisting gastrointestinal symptoms (abdominal pain, nausea, vomiting, or diarrhea). Indeed, gastrointestinal symptoms have been reported in 2-10% of SARS-CoV-2 patients in Wuhan, the origin of the infection. Moreover, they occurred 1-2 days before the development of respiratory illness (dyspnea and fever, for example)(1). Zhang et al. have explained this finding after detecting angiotensin-converting enzyme-II receptors, the gate of SARS-CoV-2 into host cells, throughout ileum and colon(13). Accordingly, SARS-CoV-2 virus can potentially be transmitted through both the respiratory as well as gastrointestinal routes.
It is noteworthy as well that hypertension was the most common comorbidity among our patients (47%). Despite our small sample size, this finding agrees with a large study on 5,700 patients where hypertension coexisted in 56.6% of positive cases(14). The latter reported obesity and diabetes as the second and third most common comorbidities with rates of 41.7% and 33.8%, respectively. Whereas our patients revealed hypothyroidism and cardiac diseases in the second position (6 patients; 32%); and diabetes and benign prostatic hyperplasia equally in the third position (3 patients; 16%). Further analysis is required to provide optimum protection and screening facilities to patients at risk.
In our analysis, among the abnormalities aforestated, most patients showed lymphopenia and elevated AST as well as ALT, whereas all patients revealed high CRP and LDH. This is consistent with a recent study that reported a high-accuracy association between abnormal laboratory findings and being positive for SARS-CoV-2 to the extent that they can even predict the PCR results(15).
Moving on to diagnosis, diagnosing SAR-CoV-2 based on PCR testing is challenging due to the high rate of false-negative results(16), hence the importance of radiology. CT is the radiological investigation of choice in SARS-CoV-2(17), but chest radiograph was beneficial in our cases. Of note, chest radiograph is considered insensitive early in the course of illness, and it is a screening tool in hospitals with limited resources; it can show abnormalities late in disease. However, chest x-ray revealed abnormal lung infiltrates in 15 (79%) of patients. This is consistent with Wong and colleagues, who studied chest X-ray findings in 64 patients and reported baseline abnormalities in 51 (79.7%) patients in the form of consolidations and ground glass opacities(18). Thence, the cost-effectiveness of chest radiographs worths further research for determining its discriminatory power. Accordingly, health authorities should repeat the PCR, isolate suspected cases, use CT (due to having a higher accuracy) and test as many as possible of suspected cases otherwise infected cases could undetectably transmit the virus.
Indeed, the infection continues to spread in around 212 countries and territories with the confirmed cases and deaths exceeded the total numbers of infected and died patients with SARS and MERS-CoVs. Yet, the real numbers of cases remain undoubtedly much higher due to limited screening and testing. In contrast, the announced relatively low numbers in low and middle-income countries could be attributed to their strict protocols of fewer PCR tests because of limited resources, whereas the Infectious Diseases Society of America has suggested a prioritization of testing. The priority is given mainly to symptomatic healthcare staff, immunocompromised, elderly, and critically-ill patients with severe respiratory distress with no obvious reason. Besides, according to the “iceberg” theory, some countries (the UK) test severe cases only while others test for mild cases as well (Germany) which resulted in a much lower mortality rate between both countries (14.8% versus 4.4%, respectively). Moreover, these high numbers of infection may be partially attributed to late lockdown and screening since many of these greatly affected countries have big cities and airports for tourists from all over the world.