{'fraction_non_alphanumeric': 0.03658893550590302, 'fraction_numerical': 0.03239340423455947, 'mean_word_length': 5.242387332521315, 'pattern_counts': {'":': 0, '<': 6, '<?xml version=': 0, '>': 2, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
ASSESSMENT OF BIOCHEMICAL CHANGES AMONG COVID-19 CASES IN A TERTIARY HOSPITAL OF BANGLADESH DURING EARLY PANDEMIC

Background : Corona virus disease 2019 (COVID-19) involves various organs of the body causing several biochemical changes which plays an essential role in estimating the patients’ condition and prognosis, directing treatment, and even evaluating the curative effects. The present study aimed to assess the biochemical changes among the COVID-19 patients during early pandemic. Methods : This cross sectional study was conducted at Combined Military Hospital (CMH) Dhaka among purposively selected 237 confirm COVID-19 cases. Data were collected through face to face interview and review of medical records using a pre-tested semi-structured questionnaire. The study was conducted in the Combined Military Hospital Dhaka from 15 April 2020 to 31 May 2020 Results : Highest number of the respondents were in the age group of 31-40 years (37.1%) with male predominance (83.1%). About 95.6% were Muslim and 58.6% were educated up to secondary level. About 87.8% had contact with a confirmed case and having 47.7%, 37.2%, 15.1% cardiovascular, endocrine and respiratory comorbidities respectively. Fever (34.6%) was the most common presenting symptoms followed by cough (22.9%), sore throat (10.6%). Neutrophilia observed in 26.16%, lymphopenia in 20.7%, thrombocytopenia in 14.3% cases, 30.0% with positive D-dimer test, 22.4% either sepsis or systemic infection in procalcitonin estimation, 28.3% with increased ferritin, 28.7% with positive C reactive protein, 21.1% with increased LDH. Chi-square analysis revealed a statistically significant association between cardiovascular and endocrine diseases with several biochemical changes (p<0.05). Conclusion : Early identification of various biochemical changes would help the physician for appropriate assessment and management.


INTRODUCTION
At the end of 2019, a cluster of pneumonia cases caused by a novel coronavirus (2019-nCov) were detected in Wuhan, China. Its rapid spread and progression and lack of specific therapeutic strategy resulted in an epidemic. Soon after, this novel virus became a global concern; on January 30, 2020, the World Health Organization (WHO) declared that the epidemic of 2019-nCoV was a public health emergency of international concern (PHEIC), and on February 11, 2020, the WHO designated the disease coronavirus disease 2019 (COVID-19) 1 . As on August 2020, more than 22.5 million cases of COVID-19 have been reported in more than 216 countries and territories, resulting in almost 78549 deaths; approximately 15.08 million people have recovered. The virus was confirmed to have spread to Bangladesh in March 2020. The first three known cases were reported on 8 March 2020 by the country's epidemiology institute, IEDCR 2 . Since then, the pandemic has spread day by day over the whole nation and the number of affected people has been increasing exponentially and till now Bangladesh has reported 279144 confirmed cases among which 160591 has recovered and 3694 died 3 . As a part of the total community, members of Bangladesh armed forces also suffers from this disease. On 6 April 2020, army revealed its first case of COVID-19 and about 7000 affected individual treated in Combined Military Hospital (CMH) Dhaka 4 . It is well established that about one-fourth of the cases are asymptomatic and about 95% patient cured without any complications 5 . The diseases usually presented with respiratory tract infection characterized by a broad spectrum of clinical manifestations with different degree of severity and an incubation period vary from 1 to 14 days. The disease severity ranges from asymptomatic to pneumonia evolving into acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), leading to death. It is well established that elderly (>65 years) and individuals with associated comorbidities, such as diabetes, hypertension, and chronic obstructive pulmonary disease, are more susceptible to severe disease 6 .
For detection of the virus as well as to the follow-up of patients and for epidemiological surveillance via determination of serological markers, clinical laboratories play an essential role. With the help of various validated test for SARS-CoV-2, it is easy for the physicians for the timely management of COVID-19 cases because they support the clinical decisionmaking process for controlling infections and detecting asymptomatic cases which expedites the speedy isolation, adequate treatment and consequently reduces contagion rates. Many laboratory parameters such as absolute neutrophilia, thrombocytopenia, hypoalbuminemia, the elevation of liver enzymes, creatinine and nonspecific inflammatory markers such as C-reactive protein (CRP) and Interleukin 6 (IL-6) make it possible to assess the severity of the disease and predict the risk of it evolving toward more serious afflictions such as acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC) and multiple organ failure (MOF). In addition, lymphopenia, elevated D-dimer, ferritin as well as LDH, CPK and troponin markers are the main predictors for the progression of the disease 7 .
Several studies have reported the clinical manifestations and blood biochemical features of patients with COVID-19. As blood biochemical changes play an essential role in estimating the patients' condition and prognosis, directing treatment, and even evaluating the curative effects, we aim to assess the biochemical changes among 237 COVID-19 cases reported to Combine d Military Hospital Dhaka during early pandemic.

METHODS
Combined Military Hospital Dhaka is a tertiary level iconic military hospital which started to receives Covid-19 patients from 08 April 2020 and dedicated to render treatment for the entitled personnel of armed forces. This cross sectional study was conducted at Combined Military Hospital Dhaka from 15 April 2020 to 31 May 2020 among purposively selected 237 confirm COVID-19 cases with an objective to assess the biochemical changes. A confirmed case of COVID-19 was defined by a positive result on a reverse-transcriptase polymerase chain reaction (rt-PCR) assay using a nasopharyngeal and throat swab specimen. Data were collected from the patient through face to face interview by semi structured questionnaire and review of medical records. Informed written consent was taken from all the respondents and neither any intervention or any invasive procedure was undertaken. Prior to the commencement of the study ethical clearance was taken from the competent ethical committee of Combined Military Hospital Dhaka. The questionnaire includes sociodemographic information, contact history, comorbidities, clinical features and relevant hematological and biochemical investigations such as Blood for complete picture (CBC), serum ferritin, D-dimer, C-reactive protein, Serum procalcitonin, Serum ALT, serum AST and Lactate dehydrogenase which obtained from medical record review. According to the objective of the study data processing and analysis were done by SPSS version 23. A two-tailed p<0.05 was considered statistically significant.

RESULTS
Highest number (37.1%) of the respondents were in the age group of 31-40 years which was followed by <30 years (30.0%). Average age of the respondents was 37 (±10.84) years with age range of 20 to 67 years. Male (83.1%) and Muslim (95.6%) respondents are clearly higher. In regards to the educational qualification, 58.6% were educated up to secondary level. About 84% were married and 84.4% were serving respondents. Majority (57%) of the respondents stayed at hostel/mess and equal (45.1%) numbers were smoker and non-smokers with 9.7% were occasional smoker [ Table-I].    To find out the factors associated with abnormal biochemical findings in relation to the chronic diseases like cardiovascular, respiratory and diabetes mellitus of the respondents, chi-square test was done which revealed that all the biochemical abnormalities were significantly associated with cardiovascular and diabetes mellitus except lymphocyte and thrombocyte count (p<0.05) but not with the respiratory diseases (p>0.05). Association of D-dimer with respiratory disease revealed statistically significant (p<0.05) (Table IV). All the studies revealed that fever was the most common presenting symptoms which was followed by cough, weakness, head ache, sore throat, loss of appetite, difficulty in breathing, altered sensation of taste or smell and body ache etc. 8,9,10,11,12,13 . Similarly, in a meta-analysis from China, most prevalent symptoms they found were fever (80.4%), cough (63.1%) and fatigue (46%) 19 To see the association between chronic illness and biochemical abnormalities, we conducted chi-square test which revealed that all the biochemical abnormalities were significantly associated with cardiac and endocrine diseases (p<0.05). Several studies and review conducted at China, Italy, Iran, Morocco, India, Iraq, UAE, USA revealed that various biochemical abnormalities are more prevalent among the COVID-19 patients with pre-existing comorbidities like hypertension, ischemic heart disease, diabetes which is similar to our study as well 23,[25][26][27][28][29][30][31] .

CONCLUSION
We conducted the study at the early days of the pandemic in CMH Dhaka where majority of the respondents showed normal hematological and biochemical abnormalities. Even though our findings revealed several abnormalities which helped the physicians in early recognition to the assessment of the disease severity. We also revealed that patient with pre-existing chronic diseases had several statistically significant biochemical abnormalities which helped in monitoring of such COVID-19 patients with disease progression, reduce mortality and there by useful in improving the recovery rate as well as monitoring of therapeutic intervention.

ACKNOWLEDGEMENT
The author thanks Major (Dr.) Md Faruk Ahmed and Major (Dr.) Zinnatun Nabi for their kind support during data collection. We also thank the Matron, ward master and all the in charges who support and help during data collection. Finally, we thank all the respondents who kindly contributed to this study.