| Abstract|| |
Background: Till date, SARS CoV2 (COVID-19) is a pandemic viral infection in the world with the main and strong impact on respiratory airway, but this virus can affect any system of the human body. Aims: This research is aimed to dictating the effect of SARS CoV2 infections on hematological, biochemical, and arterial blood gas parameters by using their mean values. Settings and Design: This retrospective study was included a total no. of 97 SARS CoV2 positive patients from 27 March to 15 May 2020. All positive patients were consented and took all the significant details. Materials and Methods: We review the total 97 COVID-19 positive patients after obtaining all the hematological and other relevant clinical data from laboratory and medical records. The subjects were tabulated into three categories named; admitted (Gp A), discharged (Gp B), and expired (Gp C) patients and compared their hematological, biochemical parameters, and arterial blood gas analysis by using blood or serum and processed by proper methods. Statistical Analysis: The data was cleaned, edited, checked for completeness, and processed then entered in SPSS version 20 statistical software. Results: Blood samples were collected of all positive patients. Most of the patients had X-ray changes. Blood parameters showed that patients who were expired (Gp-C) suffered from anemia, lymphopenia, leucoytosis, neutrophilia, and thrombocytopenia with high ALT, pCO2 and low pO2 than admitted and expelled patients. Conclusions: Result from this study provides that WBC count, absolute lymphocyte count, neutrophil count, and pO2 were independently associated and an important forecaster of mortality from SARS CoV2. All healthcare provides to regularly monitor above parameters indicators of COVID-19 infected patients to improve their quality of life and to reduce the risk of mortality rate.
Keywords: Arterial blood gas, leucocytosis, lymphopenia, predictors, SARS CoV2 (COVID 19)
|How to cite this article:|
Karuna V, Vivek V, Verma N, Singh R. Affiliation and essence of SARS CoV2 (COVID-19) on blood parameters of infected patients: A retrospective study. Indian J Pathol Microbiol 2021;64:111-6
|How to cite this URL:|
Karuna V, Vivek V, Verma N, Singh R. Affiliation and essence of SARS CoV2 (COVID-19) on blood parameters of infected patients: A retrospective study. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Apr 15];64:111-6. Available from: https://www.ijpmonline.org/text.asp?2021/64/1/111/306527
| Introduction|| |
SARS Cov2 is a novel coronavirus which was enunciated as name on 11 February 2020: by ICTV (International Committee on Taxonomy of viruses) and by WHO as “COVID-19.” Consideration its alarming levels of spread and severity, this viral infection was declared a pandemic disease on 11 March, 2020 by WHO. According to the World Health Organization this is the sixth time global public health emergency, out of which three major regressions, first in 2002; China (SARS), second in 2012, Saudi Arabia (MERS) and again in China on December 2019 (COVID-19) was noted. These three viruses are different.,,,,,, Coronavirus contain a large family of viruses with 7 different strains named: 229E and NL63 (alpha), OC43, HKU1, MERS-COV, SARS-CoV, and SARS-CoV-2 (beta). All infections by these strains results in fatality by causing acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). These strains mostly affect mammalians.,,,,, COVID-19 is a unique virus with a unique characteristics. This virus affects mostly respiratory system via nasal route and infects ciliated cells of airways by binding of virus spike protein to the cell receptor ACE2. That's why this virus is present in highest concentrations in the nasal swabs or sputum.,, ACE2 present in the many tissues including blood and bone marrow. Between 7 and 14 days of infection inflammatory mediators and cytokines, including interleukin (IL)-6, IL-10, IL-8, granulocyte-colony stimulating factor (G-CSF), monocyte chemoattractant protein 1 (MCP1), macrophage inflammatory protein (MIP) 1α, and tumor necrosis factor (TNF)- α increased, which affect hematopoietic system.,, During the epidemic, a total of 3,917,366 probable positive cases were reported to the World Health Organization from world with an estimated case mortality rate of 7.00% (N- 274361) from December 2019 to May 10, 2020. The origin of the COVID-19 had been much discussed. While extensive studies had been conducted on this issue and concluded that this virus is the origin from recent cross-species transmission and some believed that this virus was discovered from bats., In view of nature, this virus has quite similar and differ property as SARS in terms of infectious period, transmissibility, clinical severity, and extent of community spread. COVID-19 showed heat resistance and transfer from contaminated hosts to others via surfaces and hands, etc.,, COVID-19 manifests an array of clinical spectrum from fever, dry cough, breathing difficulties, headache, and life-threatening pneumonia to asymptomatic. This presentation motivates us to provide urgent needs for development of efficient and targeted modes of prevention by diagnosis and management to prevent mortality of COVID cases.,
We undertook this study to determine and compare the laboratory parameters among admitted, discharged, and expired patients, which could play a major role in assessing the prognosis in these patients.
| Materials and Methods|| |
It was a retrospective cross-sectional analytic study involving 97 COVID-19 infected patients aged <10 to <70 years followed at our institution, from March to May 2020. During the study period there were about 18,658 people leaving with SARS CoV-19 with death rate 590 in India. This study was approved by the ethics committee of our institute. Samples including sputum (if sputum comes or present) and nasopharyngeal swabs of all patients those had complains of fever, respiratory tract illness, close contact with a suspected/probable cases and residing in an infected area were collected and diagnosed by utilizing two success tests: GeneXpert, Cepheid test (CB NAAT- Cartridge Based Nucleic Acid Amplification Test) and quantitative RT-PCR (Real time-polymerase chain reaction) GeneMwg Viral DNA/RNA Purification Kit (96)- Argene SARS-CoV-2 Gene. These kits were recommended by ICMR (Indian Council of Medical Research). Blood Samples were collected from all patients during admission and repeated if required. Prior collection of blood vials were labeled properly. About ten milliliters (10 ml) of venous blood was drawn using a sterile butterfly hypodermic syringe and needles by an experienced laboratory technologist from each subject and dispensed as follows: Three (3) ml of blood into K2EDTA (Ethylene diamine tetra-acetic acid) for hematology, 3 ml into heparin for ABG while Four (4) ml into plain vacutainer to extract serum, used for biochemical analysis. EDTA and heparin sampled vials were inverted several times to prevent coagulation. Serum was obtained after keeping the sample for 30 min at room temperature. Yellow bag was used to transfer the blood immediately from COVID-19 ward to the laboratory with all safety precautions. Hematological parameters were determined using the 5 part Medonic hematology analyzer, biochemical assayed levels were determined using the Automated Selectra pro-m chemistry analyzer and electrolyte GE 300, whereas the blood gas analysis was done using Siemens RAPIDLAS 1265. The analyzer relies on spectrophotometric system for measurement of analyses using spectrophotometric techniques, such as end-point, rate and turbidometric assays. To ensure good quality of machines pre-testing was done on negative patients as a control. Patients with negative report for COVID-19 were excluded from the analysis. The patients were categorized as: (1) admitted [uncured patients and had positive COVID 19 report], (2) discharged [cured patients after recovery], (3) expired [dead patients] patients labelled as A, B, and C group, respectively. Mean values of hematological, biochemical variables, and arterial blood gas (ABG) were compared against normal ranges of these measures including: hemoglobin concentration, WBC (White blood cells), ANC (Absolute neutrophil count, ALC (Absolute lymphocyte count), and platelets counts, AST, ALP, ALP, Na and K and pH, pCo2 and pO2, respectively. All the relevant clinical details were obtained from medical records. Parameters of children under the age of 9 years were correlated according to their respective normal ranges.
| Results|| |
Total 97 COVID-19 positive patients were enrolled in this study. Majority of the patients, 38.15%, were within 51–70 years of age. Males (N-68; 70.11%) were commonly involved with M:F ratio of 2.3:1 [Table 1]. Total infected patients were divided accordingly into three groups (A, B, and C) and mostly patients belongs to group A ((N-58; 59.80%) followed by group B (N-34; 35.05%) and Group C (N-05; 05.15%). The common symptoms noted in all three groups were cough, fever, shortness of breath, sore throat, and vomiting. Analysis of symptomatic sign showed that group C was more likely than group B to have cough (37.11%), followed by shortness of breath (12.37%) and chest tightness (20.00%). 54 (58.69%) out of 97 cases showed changes in lungs on X-ray chest [Table 2]. 12/97 (12.37%) cases showed comorbidity, mostly fell in the group A (07/12; 58.33%). Respiratory system was the commonest organ to be infected which was more prevalent in group C (05.16%) [Table 3].
[Table 4] compares the mean of hematological, biochemical parameters, and ABG among three groups against normal ranges. Parameters with mean exceeding the normal range were WBC, polymorphs, ALT, ALP, and pCo2 and these were higher in group C than group A and B. Anemia, lymphopenia, thrombocytopenia, and low pO2 were also noted in group C. AST was higher in all groups with more in group A followed by group C and B. Mean of platelet count was higher in Gp A, higher range of Na and pH was noted in Gp B, however higher K (potassium) range was noted in Gp C. The mean count of Na, pH, and K, however, were in the normal range.
|Table 4: Comparison of initial haematological laboratory tests between Group-A, B and C in SARS CoV-2 patients|
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[Table 5] showed subdivision of hematological parameters. Out of the total number of study participants, 18.56% (18/97) had anemia, 03.09% (03/97) had leukocytosis, 11.34% (11/97) had neutrophilia, 13.40% (13/97) had lymphopenia, and thrombocytopenia was observed in 14.43% (14/97) cases. Out of all three groups, Gp C was common to exhibit anemia (N-01/05; 20.00%), leukopenia (N-02/05; 40.00%), leucocytosis (N-03/05; 60.00%), neutrophilia (N-05/05; 100.00%), lymphopenia (N-02/05; 40.00%), and thrombocytopenia (N-01/05; 20.00%). There was no significant difference between Hb, WBC, lymphocyte, and platelets parameters of group A and B. However, Gp B had slightly raised neutrophils as compared to group A (N-02/34; 05.88%).
| Discussion|| |
Before discussing what the impact of COVID-19 on blood parameters, I would like to discuss some points regarding COVID-19 infection which was based on publicly available data during the study period. The patho-physiology of COVID-19 is a complex process which proceeds through the three clinical stages from asymptomatic presentation, mild and severe acute respiratory illness to death. The disease begins with an asymptomatic incubation period of 1–2 days, during which the virus binds to the epithelial cells in the nasal cavity via ACE 2 receptor. The second phase of infection is clinically manifested and develops innate immunity. 80% of patients belong to this phase. Phase 3rd is a critical stage with complications of acute respiratory distress syndrome (ARDS), sepsis and septic shock, multiorgan failure, including cardiac and acute kidney injury. This virus travels via airway system to affects alveolar type II cells and also to progress infection into ARDS. Impact on various systems, other than respiratory, like enteric, hepatic, or neurologic diseases, were also reported.,,,, This virus is minute in size (65–125 nm in diameter) and has a single-stranded RNA (26–32 kbs in length) and crown-like spikes on the outer surface of the virus; thus, it was named as a coronavirus. Viruses do not replicate outside the living cell but may persist for a longer duration into the contaminated environmental surfaces. Fecal matter showed presence of virus was also reported. Before contacting to the infected patient we should care of few things like space of isolation ward, infection control, waste disposal, and safety of healthcare workers.,,,,
In India, the virus was isolated by the Indian Council of Medical Research-National Institute of Virology (ICMR-NIV), using Vero CCL-81 cells by observing cytopathic effects (CPEs) and cycle threshold (Ct) values in real-time reverse transcription-polymerase chain reaction (RT-PCR), electron microscopy, and next-generation sequencing (NGS). A study was done to obtain the genomic sequence of COVID-19 resulted that virus is divergent from SARS-CoV to be considered a new human-infecting betacoronavirus.,,,
This study was conducted on 97 COVID-19 infected cases (March to May 2020) with the goal to know the impact of SARS CoV2 on blood parameters of infected patients, To the best of our knowledge, we are, for the 4th or 5th times, reporting the prevalence of changes in blood parameters with COVID-19 patients.
The frequency of COVID-19 infection in this study was found to be highest among the age group 51–70 years of age, indicating that older patients were higher risk to have disease, although all age group can be affected. As indicated, similar findings were reported in the earlier and recent studies. The implication of the result was reduction in immune response. In the research of Yanli et al., males were more commonly involved. This study also showed that among the total no. of cases, the admitted plus discharged and dead patients were 94.85% and 5.15%, respectively. Our study was quite similar to that study.,,,, As mentioned in many studies, the common symptoms were fever, drowsy, cough, dyspnea, shortness of breath, abdominal pain, nausea, vomiting, and diarrhoea. In our study, the common clinical presentation was cough followed by fever and shortness of breath. In my research comorbidity of respiratory system was COPD (Chronic obstructive pulmonary disease), chronic bronchitis, and post-tuberculosis, those were the common cause of death in Gp C accounting 41.66% of all comorbid patients that indicate the cause of mortality. Similar finding was recorded in the study conducted by Hsiao et al. In recent study of Jason et al., comorbidity of diabetes was significantly associated with higher risk of death in COVID-19 infection, but in our study no patient had evidence of diabetes.,,,
The aim of the study was to correlate the hematological, biochemical, and ABG findings among three groups as mentioned above. These are common laboratory investigations to be performed on hospitalized patients with the complaint of cough, fever, and respiratory distress. These parameters render useful clew regarding the diagnosis and complications of infectious disease. Anemia, leucocytosis, neutrophilia, lymphopenia, and thrombocytopenia were hematological findings of our study. As mentioned in many studies, these were the commonest hematological parameters of SARS 2002. Similar to the study of Henry et al., Gp C (Expired) of present study showed higher WBC, low lymphocyte count, platelets count and hemoglobin.,, Previous studies found a significant association between hemoglobin and COVID-19. The prevalence of anemia in our patients, defined as a hemoglobin concentration of less than 11.5 g/dl that (mean of haemoglobin) was strongly associated with the Gp C patient, those were severe and expired, which correlates well with the study conducted by Lippi et al., showed significantly lower hemoglobin in severe patients than in those with milder forms. Anemia observed in this study could be due to poor nutritional status of the study participants. But, other reasons were not clear anywhere why this finding was significantly associated with this viral infection. It is also important to bear in mind that anemia in SARS CoV2 individuals can be multifactorial with conditions such as comorbidity, opportunistic infections, nutritional deficiencies, and drug induced.
Lymphopenia was more evident and effective in COVID-19 infection, a finding that was in accordance with the Literatures of Evangelos, Zhu and Li et al. ACE 2 receptors expressed on the surface of lymphocytes that directly infect and lyses the cells and resulted in lymphopenia. Among the total no. of cases, 02.06% showed lymphopenia that is 100.0% present in Gp C. This number was significantly smaller as compared to the outcome of Huang and Xu et al. studies., Association of low mean lymphocyte count also the finding of SARS 2003 at mentioned in the publication of Zhongping, 2005 and Yanget et al. in 2003., Mean of absolute lymphocyte count (ALC) was normal in Gp A and B. Present study was similar to the study of Li et al. was done in 5 dead patient, he confirmed the result by increased the no. of patients up to 12. They also correlated the lymphocyte count and treatment, at last they noted that decreased lymphocyte count was the cause of bad prognosis and increase count was in favor of good progression. We concluded that lymphopenia was 40.00% in Gp C (Group of Expired) and 11.76% in Gp B (Group of Expelled patients). These findings indicate the impact of lymphocyte on survival and death rate.,,,
The other important observation of this study was thrombocytopenia. Study of Yanli et al. mentioned in their research that thrombocytopenia raise the cause of mortality rate three times. One study mentioned why platelets decreased in COVID-19 and the reason was this virus enters into the platelets via CD 13 receptors and destroyed them., Normal platelet counts were observed in Gp A and B patients, while low in Gp C individual. The changes in platelet count were also closely related to the mortality and monitoring is important for the prognosis of SARS CoV2 patients. However, good hematological parameters are in favor of survival, as shown in Gp B patients. Significant association of thrombocytopenia with COVID-19 points that thrombocytopenia is a good indicator of cause of morbidity and mortality in the population.
AST (aspartate aminotransferase) and ALT (alanine aminotransferase) both are the enzyme of liver disease. In agreement with this study we recorded significant elevated levels of serum AST and ALT which was similar to the case series of patients with SARS (Hasio et al., 2006). In the present study, we observed a much higher incidence of elevated ALT in Gp C patients that may be the cause of mortality. The frequency of liver enzymes elevation in COVID-19 had also been reported in the case study of Henry et al., noted raised AST and ALT level in the severe form of disease. No more studies and articles we get those commented on AST and ALT parameters. To study the function of lungs, Arterial blood gas (ABG) test was done which included Ph, pCO2 and pO2. ABG measures oxygen, carbon dioxide levels, and acid–base balance in blood. High pCO2 and low pO2 indicates the severity of lung injury and mode of ventilation.,, In my study, alteration in pCO2 and pO2 were observed in Gp C patient, however, they were within normal range in Gp A and B. That is the good signal of cause of mortality in COVID-19.
Based on above findings, we concluded that COVID-19 can lead to significant alteration in the blood parameters. Low lymphocytes was observed in this study, a finding which suggests dampening of the immune response due to severe phase of COVID-19 infection, a phenomenon that characterize the sustenance of infection by immune evasion mechanism. This study provides additional information to healthcare providers to regularly monitor and check up hematological and biochemical indicators to detect, prevent and to improve the quality of life and also to reduce the risk of mortality.
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Conflicts of interest
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Department of Pathology, L.L.R.M Medical College, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]