Clinical Manifestations, Laboratory Markers and Their Association with Mortality in Patients with Severe Covid-19 Infection in Third Wave of Epidemics in Myanmar

Abstract

Khin Phyu Pyar, Aung Phyoe Kyaw, Nyan Lin Maung, Zar Ni Htet Aung, Sai Aik Hla, Soe Win Hlaing, Soe Min Aung, Kyaw Zay Ya, Myo Thant Kyaw, Zay Phyo Aung, Zaw Lin Oo, Aung Thu, Zin Thu Aung, Han Lin Aung, Kyaw Zwa Tun, Lay Maung Maung, Ye Min Hein, Kyaw Thurein Lwin, Chan Pyae Aung, Moe Tun Zaw, Myo Maung Maung, Lynn Htet Aung and Thi Han Tun

Background: Coronavirus disease 2019 (COVID-19) has been a major threat to health around the world as it causes significant morbidity and mortality. The clinical manifestations range from a common cold to more severe diseases such as pneumonia, severe acute respiratory distress syndrome (ARDS), multi-organ failure, and even death. It is important to identify red flag signs for mortality, helpful for prioritization of treatment especially in poor resource setting. The study aimed to assess association of clinical and laboratory markers and the outcome in patients with severe COVID-19 infection in Myanmar.

Methods: A descriptive study was conducted in COVID-19 treatment centers in Myanmar- Yangon and Nay Pyi Taw, from February 2020 to August 2021. Data were collected by using standardized case report forms and then, a total of 404 confirmed COVID-19 inpatients (>18 years old) were included. The p value and odds ratio with a 95% confidence interval (CI) was used as a measure of association and the independent associated factors for severity of disease were investigated using logistic regression analysis.

Results: Among 404 patients, 258 (63.9%) were discharged; and 146 (36.1%) expired in hospital. Mortality was associated with clinical parameters such as age over 65 years (odds ratio 0.47, 95% CI 0.31– 0.72; p < 0.001), low initial SpO2 less than 85% (95% CI -7.46 – -3.96; p < 0.001), reduced Glasgow Coma Scale score less than ‘15’ (95% CI -0.70 – -0.20; p < 0.001), high Quick Sequential Organ Failure Assessment Score “2 and 3”(qSOFA score) (95% CI 0.08 – 0.91; p = 0.025), high CXR Brixia Score more than ‘8’ (95% CI 3.42 – 4.89; p < 0.001); and, laboratory criteria like total WBC count greater than 12 x 109/L (95% CI 1.81 – 4.33; p < 0.001), CRP greater than 0.5mg/L (95% CI -61.37 – -23.26; p < 0.001), ferritin greater than 400 ng/mL (95% CI -312.36 – -139.07; p < 0.001), D-dimer greater than 0.5 μg/ml (95% CI -3340.65 – -2945.21; p < 0.001), high serum creatinine greater than 1 mg% (95% CI 0.16 – 0.70; p = 0.002), LDH greater than 225 U/l (95% CI -166.53 – -46.66; p < 0.001), ALT greater than 40 IU/L (95% CI 11.82 – 39.32; p < 0.001) and AST greater than 37 IU/L (95% CI 21.26 – 55.16; p < 0.001).

Conclusions
Clinical manifestations significantly associated with mortality were low Glasgow Coma Scale score, initial SpO2 less than 85%, qSOFA score ‘2’ and above, and severe chest radiographic involvement (CXR Brixia Score more than ‘8’). Laboratory markers like neutrophil leukocytosis, high level of inflammatory markers (CRP, ferritin, LDH), high levels of transaminase (ALT and AST), high D-dimer, high creatinine were significantly related with mortality. Awareness, identification of these predictors on admission was essential for early anti-viral therapy and timely anti-inflammatory treatments; hence, better
outcome.

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