Wen-Zhen Zeng, Bin Liu, Yu Jin, De-Hong Jiang, Shu-Guang Wen, Qing-Shan Lv

The Central Hospital of Yongzhou, 425000

Keywords:

ABSTRACT

1. Introduction

Since December 2019, many cases of pneumonia of unknown cause have been found in many countries and regions in the world. At that time, the most serious infection was happened in Wuhan. 2019 novel corona virus (2019-nCoV) is the pathogen of this unknown pneumonia. It is an acute infectious pneumonia. 2019-nCoV is a novel coronavirus that has not been found in humans[1,2]. The novel coronavirus pneumonia was named coronavirus disease 2019 (COVID-19) in February 11, 2020 by WHO[3]. Yongzhou City is located in the south of Hunan Province, close to Hubei Province, 700 kilometers away from Wuhan. In recent years, the number of Yongzhou people going out to work and start businesses in Wuhan has increased. The COVID-19 in Yongzhou has certain regional characteristics due to geographical location and the return of outbound personnel.

2. Materials and methods

2.1 Study patients

44 patients with COVID-19 were admitted in Yongzhou Central Hospital from January 21, 2020 to March 5, 2020.

2.2 Inclusion and exclusion criteria

Meet diagnostic criteria of “The novel coronavirus pneumonia diagnosis and treatment plan (trial version third) “[4]or “The novel coronavirus pneumonia diagnosis and treatment plan (trial version fourth)” [5] or “The novel coronavirus pneumonia diagnosis and treatment plan (trial version fifth)” [6] or “The novel coronavirus pneumonia diagnosis and treatment plan (trial version sixth)” [7] formulated by the National Health Commission of the People's Republic of China. In suspected cases, whose specimen of respiratory tract detected by RT-PCR shows 2019-nCoV nucleic acid positive, was defined as confirmed case. No cases were excluded or excluded.

2.3 Classification standard

According to general treatment plan of “The novel coronavirus pneumonia diagnosis and treatment plan (trial version fifth)” [6] COVID is divided into four types: ① Mild type, the clinical symptoms were mild, and there was no sign of pneumonia on imaging. ② Moderate type, with fever, respiratory tract and other symptoms, imaging can be seen as pneumonia. ③ Severe type, comply with any of the following: Occurrence of shortness of breath, respiratory rate ≥ 30 times / min, at rest, the oxygen saturation is ≤ 93%, PaO2 / FiO2 ≤ 300mmHg. ④ Critical type, comply with any of the following: In case of respiratory failure, mechanical ventilation, shock, or other organ failure, ICU monitoring and treatment are required. Among them, two OVID-19 cases were classified into severe type according to the clinical classification standard of the “The novel coronavirus pneumonia diagnosis and treatment plan (trial version third)” [4]. Severe type standard shoud comply with any of the following: The respiratory rate increased (≥ 30 times / min), dyspnea, cyanosis of lip and mouth, oxygen saturation ≤ 93%, Arterial partial pressure of oxygen (PaO2) / concentration of oxygen (FiO2) ≤ 300mmHg (1mmHg = 0.133kpa), Pulmonary imaging showed multilobed lesions or lesions progressed more than 50% within 48 hours, Other clinical conditions requiring hospitalization.

2.4 Treatment plan and criteria for de isolation and discharge

According to “The novel coronavirus pneumonia diagnosis and treatment plan (trial version third) “[4]or “The novel coronavirus pneumonia diagnosis and treatment plan (trial version fourth)” [5] or “The novel coronavirus pneumonia diagnosis and treatment plan (trial version fifth)” [6] or “The novel coronavirus pneumonia diagnosis and treatment plan (trial version sixth)” [7] formulated by the National Health Commission of the People's Republic of China. we dialectically treat patients according to the updated diagnosis and treatment plan. De isolation and discharge criteria: Temperature returns to normal for more than 3 days, respiratory symptoms improved significantly, pulmonary imaging showed that the absorption of acute exudative lesions improved significantly, nucleic acid test of respiratory secretions showed negative twice in a row (Sampling time should be at least 1 day apart).

2.5 Observation index

Collect the basic information, epidemiological characteristics, medical history, complications, clinical symptoms, laboratory indicators (blood routine and blood biochemistry, etc.), imaging chest CT, therapeutic drugs and other data of patients.

2.6 Statistical methods

Continuous data are presented as mean±SD, We used χ2to compare categorical variables and t test for continuous variables, with statistical significance defined as P＜0.05. all statistical analysis and graphical presentation using SPSS software version 23.0 and Microsoft Excel 2013 for Windows.

3. Results

According to table 1, among 44 COVID-19 patients, 1 cases were critical, 11 cases were severe, 28 cases were moderate, 4 cases were mild. 28 male (63.6%), 16 female (36.4%), the youngest was 5 years old and the oldest was 67 years old, the average age was (39.1 ± 14.5) years. In the severe and critical group (SC), there were 9 males and 3 females; 19 males and 13 females in the mild and moderate group (MM), there was no statistical difference between the two groups (P=0.543). In the SC group, the minimum age was 28, the maximum age was 67, and the average age was 45.5 ± 15.5, in the MM group the minimum age is 5, the maximum age is 65, and the average age is 36.7 ± 13.5, there was no statistical difference between the two groups (P=0.072). In the SC group, the shortest hospital stay was 7 days, the longest hospital stay was 24 days, and the average hospital stay was (16.5 ± 6.0), in the MM group the shortest hospital stay was 5 days the longest hospital stay was 24 days, and the average hospital stay was (12.4 ± 4.5) days, there was no statistical difference between the two groups (P=0.019).

Table 1 Basic information and epidemiology

3.1 Epidemiology

11 cases of the first generation had living or working history of travel in Wuhan. 15 cases of the second generation contacted with the first generation. Six cases of the third generation contacted with the second generation. There were 3 cases in the fourth generation, 1 case in the fifth generation, and 8 cases in which generation could not be defined (Fig 1. Fig 2.). In the SC group, the patients who can define generation, the average value was 1.64 ± 0.92, in the MM group, the patients who can define generation, the average value was 2.32±1.03, there was no statistical difference between the two groups (P=0.067). 28 cases with definite incubation period, incubation period 1-16 days, the average value was 8.3 ± 4.0. In the SC group, the patients who can define incubation period, the average value was 6.0±2.3, in the MM group, the patients who can define incubation period, the average value was 9.0±4.2, there was no statistical difference between the two groups (P=0.108).

Fig.1 and Fig.2: disease transmission

13b, 14b and 15b have been contacted with Wuhan home visiting personnel within 14 days after onset of the disease, pointed by an unmarked arrow, for working or living contact, the time marked was the time when the patient stays in the isolation ward of Yongzhou Central Hospital.

3.2 Medical history

Two cases had hypertension, two cases had type 2 diabetes, there was no statistical significance in the distribution of patients with hypertension and diabetes in the two groups (P=0.070). There were 8 cases of hypoproteinemia, 7 cases of hypokalemia, 7 cases of ALT increase, 5 cases of AST increase, 1 case of respiratory failure and 1 case of heart failure in the SC group, there were 11 cases of hypoproteinemia, 5 cases of hypokalemia, 9 cases of ALT elevation, 3 cases of AST elevation, 0 cases of respiratory failure and 0 cases of cardiac failure in the MM group, there was statistical significance in hypokalemia (P=0.014) and AST increase (P=0.042) in the two groups, there was no significant difference in hypoproteinemia (P = 0.54), ALT increase (P = 0.133), respiratory failure (P = 0.273) and heart failure (P= 0.273) (table 2).

Table 2. Medical history and complications (n%)

3.3 Symptom

Fever, cough and fatigue were the first symptoms in 4 of 44 patients, 12 cases with fever and cough as the first symptom, fever as the first symptom in 8 cases, 9 cases with cough as the first symptom, 2 cases with asthenia as the first symptom, among the patients with other symptoms, 1 had pharyngeal pain, 1 had chills, 1 had chest distress and epigastric discomfort, and 6 had no symptoms. In the SC group, 10 patients had fever, 9 coughing, 2 fatigue, 1 sore throat, 0 runny nose, 1 sore swelling, 1 chilly, 0 back pain, 1 upper abdominal discomfort, 0 diarrhea, 1 chest pain, 0 nagging, 0 nasal obstruction, 1 expectoration, 0 headache. In the MM group, there were 18 cases of fever, 20 cases of cough, 4 cases of fatigue, 0 cases of pharyngeal pain, 3 cases of runny nose, 1 case of general pain, 1 case of chills, 1 case of lumbago and backache, 0 case of upper abdominal discomfort, 2 cases of diarrhea, 2 cases of chest pain, 1 case of Nadia, 1 case of nasal obstruction, 0 case of expectoration, 1 case of headache and 6 cases of no symptoms. There was no significant difference between the SC group and the MM group in the clinical symptoms of the two groups (P ＞ 0.05) (table 3).

Table 3 Clinical symptoms on admission (n%)

3.4 Laboratory examination and imaging examination

In SC group, WBC decreased in 5 cases, WBC increased in 11 cases, neutrophil decreased in 5 cases, neutrophil increased in 11 cases, lymphocyte decreased in 11 cases, eosinophil decreased in 9 cases, C-reactive protein increased in 11 cases. There were 9 cases of ESR, 9 cases of LDH, 12 cases of CT, 12 cases of ground glass, 7 cases of subpleural or extrapulmonary lesions. In the MM group, leukocyte count decreased in 6 cases, leukocyte count increased in 12 cases, neutrophil count decreased in 4 cases, neutrophil count increased in 15 cases, lymphocyte count decreased in 6 cases, eosinophil count decreased in 18 cases, C-reactive protein increased in 23 cases. There were 21 cases of ESR increase (3 cases of moderate type lack of data), 17 cases of LDH increase, 19 cases of multileaf lesions on CT, 23 cases of ground glass lesions, and 15 cases of subpleural or extrapulmonary lesions. In all 44 patients, no obvious abnormality was found in procalcitonin, troponin and creatine kinase isoenzyme. There were significant differences between the two groups in leukocyte count (P = 0.01), neutrophil count (P = 0.019), lymphocyte count (P = 0.000) and CT lesions with multilobed lesions (P = 0.024). Among the two groups, leukocyte count decreased (P = 0.241), neutrophil count decreased (P = 0.086), eosinophil count decreased (P = 0.430), C-reactive protein increased (P = 0.322), ESR increased (P = 1.000), LDH increased (P = 0.322), CT lesions were ground glass (P = 0.101), CT lesions were mainly subpleural or extrapulmonary lesions (P = 0.498), with no statistical difference (table 4).

3.5 Treatment and prognosis

In the SC group, 11 patients used antibiotics, 12 patients used hormone, 10 patients used immunoglobulin, 5 patients used noninvasive ventilator to improve ventilation; In the MM group, 17 cases used antibiotics, 19 cases used hormone, 9 cases usedimmunoglobulin and 0 cases used noninvasive ventilator to improve ventilation. There were significant differences in antibiotic (P = 0.044), glucocorticoid (P = 0.024), immunoglobulin (P = 0.001) and noninvasive ventilator (P = 0.001) between the two groups. Only one of the 44 patients refused to take Chinese medicine as an assistant treatment. Because some patients were excluded from psychological counseling by psychological counselors, their orders were not recorded in detail. 44 cases (100%) were cured without death (table 5).

Table 4 Results of laboratory examination and chest CT (n%)

Table 5 Treatment plan (n%)

4. Discussion

Yongzhou is located in the south of Hunan Province, and Hunan is close to Hubei Province. Hunan people in Wuhan returned home for the new year, causing a large number of people to flow. At that time, Hunan became one of the key areas of covid imported epidemic. The epidemic situation in Yongzhou showed a trend of rising first and then falling. As the number of people returning home decreased, the number of imported cases decreased, and the epidemic situation full back, the trend of the epidemic curve of COVID-19 was the same as that of the whole country[8]. 2019 ncov has a strong infection ability to human body. It is mainly transmitted through respiratory droplets and contact, and does not exclude the transmission through aerosol and digestive tract. COVID-19 prefer to occur in men[9-11]. In terms of age distribution, most of them are young adults. The main reason for the rapid spread of the disease is that these people work or work outside and have a wide range of activities. In addition, the elderly and the patients with basic diseases are more seriously ill after infection, and the prognosis is relatively poor. Children and infants also have diseases[12]. Its incubation period is usually 3 to 7 days, and the longest is generally no more than 14 days. Symptoms of COVID-19 include fever, dry cough, fatigue, etc. A few patients may have symptoms such as sore throat, headache, stuffy nose, runny nose, myalgia, diarrhea and chest distress, the course of severe and critical patients may be low temperature fever or even no obvious fever, in severe cases, dyspnea or hypoxemia usually occurred in one week, critical cases can rapidly develop into acute respiratory distress syndrome, septic shock, metabolic acidosis, coagulation dysfunction and other symptoms[2,6,13,14]. In the early stage of the disease, the total number of peripheral blood leukocytes was normal or decreased, the number of lymphocytes was decreased, some patients could have the increase of glutamic acid, glutamic grass, creatine kinase, myoglobin and lactate dehydrogenase, most patients had the increase of C-reactive protein and ESR, and the procalcitonin was normal. In the early imaging features of covid-19, high-resolution chest CT showed multiple patchy ground glass shadows, often involving multiple parts of both lungs or one side of the lung, most of which occurred in the outer belt or under the pleura of both lower lungs, and most of the early positive and lateral chest films showed normal. Therefore, high-resolution chest CT was preferred as an early screening method for this disease[15]. Due to the combination of multiple basic diseases and organ failure, the severe and mortality rate of elderly patients is relatively higher[16]. There are no specific drugs, at present, the main treatment is symptomatic support, on the basis of it, we should actively prevent and cure complications, treat basic diseases, prevent secondary bacterial infection, and timely support organ function[7]. Among 44 COVID-19 patients in Yongzhou, fever, cough and fatigue were the main clinical symptoms and symptoms. 44 cases are pharyngeal pain, chills, chest distress and upper abdominal discomfort, occasionally, the first symptoms were pharyngeal pain, chills, chest tightness and epigastric discomfort. Severe and critical patients were more likely to have decreased lymphocyte count, it was consistent with the normal or decreased leukocyte count and lymphocyte count in the early stage of patients with COVID-19, during hospitalization, patients with severe and critical types are more likely to have increased leukocyte count and neutrophil count, it was suggested that the virus infection and inflammatory reaction were serious. In the treatment plan, antibiotics were used to treat the existing infection or prevent the secondary infection, hormones reduced the body's inflammatory response, and immunoglobulin improved the use rate of the body's immunity. During the period of hospitalization, most of them had poor appetite, which may be due to the decrease of their activities and the effect of taking antiviral drugs and other drugs, but the effect of virus on the digestive tract could not be excluded. In terms of liver function, there was a rise in glutamic pyruvic transaminase, a rise in glutamic oxaloacetic transaminase, and hypoproteinemia, it might be caused by the damage of liver function, or it might be caused by the increase of consumption caused by inflammation or the failure to keep up with its own diet and nutrition. The patients have more anxiety in mental aspect, it was related to the torture of physical discomfort and the lack of contact with relatives, the fear of family members and the fear of disease[17], however, whether there is a viral effect on the nervous system caused by mental disorders remains to be studied. Some studies have shown that the elevation of myocardial enzymes, especially the elevation of CK and CKMB, suggests that the patient's condition is serious and indicates that the patient's condition tends to worsen[18]. Among 44 patients in our hospital, there was a rise of creatine kinase in one critically ill patient, and there was no significant abnormality in the indexes of creatine kinase, isoenzyme of creatine kinase and troponin in the other patients, mainly the rise of lactate dehydrogenase. Severe and critical patients are more likely to develop hypokalemia, which may be related to the increased consumption of inflammation or the imbalance of water and electrolyte caused by the influence of virus infection on multiple system organs. On the basis of general supportive treatment, antiviral treatment, oxygen therapy and maintenance of water electrolyte balance, etc, according to the individual situation of patients, timely and appropriate use of hormones, immune agents, antibiotics and timely and effective use of non-invasive ventilator to assist breathing and improve ventilation, timely protection and prevention of related organ damage, Chinese medicine through detoxification and efficiency, psychological intervention to give confidence, nutritional support to improve the body immunity.

To sum up, this study was an analysis of covid-19 in Yongzhou City. Severe and critical patients were more likely to have hypokalemia and elevation of glutamic oxaloaminase, more likely to have increased leukocyte count, increased neutrophil count, decreased lymphocyte count and chest CT multileaf lesions. The use rate of antibiotics, glucocorticoid, immunoglobulins and noninvasive ventilator was high. The patients in this study were non high prevalence areas with a small number of cases, which can not represent the epidemiological and clinical characteristics of high prevalence areas and the whole country.