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The clinical features of COVID-19 in a group of Iraqi patients: A record review

Background: The number of coronavirus infection cases has increased rapidly since early reports in the December 2019 in China. But data on the clinical features of infected peoples is variable from one country to the other. Objective: Studying clinical features of patients with a positive RT PCR COVID – 19, in a group of Iraqi patients. Patients and Methods: This is a record review study of 200 patients with a confirmed COVID 19, conducted in Al Imamain Al Kadhimain Medical City from 1 May to 30 August 2020, the diagnosis of patients during this period. Data about demographic and the clinical characteristics have been recorded. Results: The study included 200 patients with 133 (66.5%) males and 67 (33.5%) females, and age range of 1489 years, with mean age 46.4 years. A history of contact with a COVID -19 positive case was found in 80 patients (40%), Ischemic Heart Disease in 11 patients (5.5%), hypertension 34 (17%), diabetes mellitus 36 patients (18%). The most frequently seen age group was between 21-39 years (76 patients 38%). The most frequently seen symptoms were fever 76.5% and generalized weakness 73%. A statistically significant association was found between age and dyspnea (p = 0.014) and also diarrhea (p = 0.035), as well as between gender and rhinorrhea (p = 0.08) and nausea and/ or vomiting (p = 0.005). Conclusion: In this study fever and generalized weakness were the most common symptoms in COVID patients. The clinical features of COVID disease can be affected by age and gender of patients.

a complex pathogen because of the ability for infecting multiple hosts, and causing different diseases in spite of a common association with the acute respiratory infections in the humans (5). The droplet transmission can occur when the person is in close contact (about one meter) with another person who has the respiratory symptoms (like cough or sneeze) and is at a high risk to have the nasal and/ or oral mucosa or the conjunctiva exposed to the potentially infective droplets (of more than 5-10 μm in diameter) (6). A recent study revealed that the viral load detected in asymptomatic people was similar to that in symptomatic patients, which suggests the transmission potential from symptomatic or asymptomatic people (7). To limit the spread, regionally and globally many countries have adopted measures including lockdowns, closing airports and borders, and restrictions of travel to decrease the transmission (8). The incubation period of COVID -19 can be up to 14 days from the time of exposure, (a median is 4 -5 days) (7). The Infection is reported in all age groups including children. The majority of cases are mild, presenting with a flu-like illness. The common features of COVID -19 are fever, cough, fatigue and myalgia (9). The features of upper respiratory infection as rhinorrhea and sputum are uncommon, except in children, with leucopenia (25%) and lymphopenia (63%) (9). Severe cases of pneumonia, dyspnea, tachypnea and disturbance of gas exchange happen in about 5% of patients leading to severe dysfunction of the lungs with the need for mechanical ventilation, shock and multiple organ failure (10). The rapid transmission of COVID -19 among individuals and within communities and countries mandates the implementation of the proper physical and mental health health precautions (11). Several reports have shown the important event which leads to an increase in the mortality rate from COVID_19 infection which is the Acute Respiratory Distress Syndrome (ARDS) that results from nonmodulated inflammatory responses which may lead to death (12, 13). Elderly patients and those with comorbidities may face an increased risk of death from COVID -19. However, younger patients without comorbidities may present with lethal complications such as disseminated intravascular coagulopathy (DIC) and myocarditis (14). The accuracy of diagnosis by viral RNA swabs in a clinical practice may vary depending on the site and the quality of sample. The sensitivity of RT-PCR in one study of 205 patients was shown to be 93% for the Broncho-alveolar lavage (BAL), 72% for sputum, 63% for nasal swabs, and 32% for throat swabs (15). Accuracy also depends on the stage of the disease (16) and degree of the viral multiplication and clearance (17).

Patients and Methods: Study design and participants
This is a record review study of 200 patients who had been confirmed as COVID -19, conducted in Al Imamain Al Kadhimain Medical City from 1 May to 30 August 2020, when the diagnosis were during this period, patients were either hospitalized or treated as outpatients.
Definitions COVID -19 was confirmed by the detection of SARS-CoV-2 RNA, in the swab samples from throat using a virus nucleic acid detection kit COVID-19, by a real-time polymerase chain reaction (RT-PCR). The case definition of the confirmed infection with SARS-Cov-2 was made according to the guidance from World Health Organization (WHO) (18). Confirmed patients were either hospitalized or treated as outpatients, these whom treated as outpatients have a record saved in public health department, from which data took.

Data collection
A COVID -19 data collection form was designed to collect the data including demographics and clinical features. The following information was collected for each patient: Age, gender, risk factors (ischemic heart disease, hypertension, and diabetes mellitus), COVID -19 exposure history, symptoms (fever, dyspnea, nausea\vomiting, cough, rhinorrhea, sore throat, diarrhea, generalized weakness, and headache). Inclusion criteria: All patients who have clinical features of COVID -19 and positive a RT -PCR from the throat. Exclusion criteria: 1-Patients with negative RT -PCR of throat.
2-Patients with incomplete data in the medical records. Statistical Analysis: The collected data were entered and analyzed using SPSS (Statistical Packages for Social Sciences) version 20. Data were classified into qualitative and quantitative. The quantitative data were classified into parametric and non-parametric according to the normality tests. For nominal qualitative data, the Chi square and the Fisher exact tests were used for association. For quantitative data the mean measuring tests was used. P-value of < 0.05 was considered as statistically significant.

Results
Two hundred patients were included in this study, of whom 133 (66.5%) were males and 67 (33.5%) were females, with an age range of 14-89 years and a mean age of 46.4 years. A history of contact with a COVID -19 case was found in 80 patients (40%), ischemic heart diseases (IHD) in 11 (5.5%), hypertension in 34 (17%), and diabetes mellitus in 36 (18%), table 1. Table 2 shows the distribution of the patients by age group. More than a third of the cases fell in the 21-39 years group with 76 patients (38%), followed by those 40-59 years with 66 patients (33%), and those ≥60 years with 52 patients (26%).   Table 3 show that fever was the most frequent symptom (76.5%), followed by generalized weakness (73%), cough and dyspnea (65%) each, headache (59%), sore throat (58%), nausea and vomiting (28%), and rhinorrhea and diarrhea (25%) each. The table also shows the distribution of these clinical features by gender with a statistically significant association between gender and rhinorrhea (p = 0.08) and nausea and/ or vomiting (p = 0.005), both being higher among females than males. Table 4 shows a statistically significant association between age group and dyspnea (p = 0.014) and diarrhea (p = 0.035), but not with other symptoms.   Clinicians must be aware about COVID-19 and consider the possibility of the COVID-19 even in the absence of fever, generalized weakens, or even respiratory symptoms to ensure the appropriate investigation for the diagnoses. Dyspnea and diarrhea had a statistically significant association with age in the present study, while other symptoms did not. Liu (37) found that only sore throat had a statistically significant association with age. Nicholas (38) found an age risk in the susceptibility to infection and the probability to have clinical symptoms of COVID-19, ranging from about 20% in children to about 70% in older adults. The present study found a statistically significant association between gender and rhinorrhea and nausea and/or vomiting. A previous study found that male patients were susceptible to have more severe symptoms in comparison with females (39). The definite factors underlying such difference remain unknown. The differences between males and females in their immune response to infectious diseases, inflammation and autoimmunity show that females appear to respond more vigorously to viral infections and produce more antibodies in response to the infection and vaccination (40). The limitations of this study include not classifying the patients according to the WHO classification for severity (mild, moderate, severe and critical cases), and the small number of cases in comparison to the cases of COVID-19 in Iraq. In conclusion, this study showed that fever and generalized weakness were the most common symptoms in COVID patients. The clinical features of COVID disease can be affected by the age and gender of patients.