#257 A rushed introduction to an uninvited guest
CLINICAL QUESTION
What are the presenting symptoms, clinical course, and risk factors for mortality?
BOTTOM LINE
Cough and fever are the most common symptoms. Differences in testing and reporting of cases limit prognostic estimations. At minimum, 80% of cases are clinically mild. Of those hospitalized in North America, ~25% will require ICU admission. Risk factors for mortality include age >65 years, co-morbidities, long-term care residents, and those with COVID-19 associated cardiac injury.
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EVIDENCE
- Case reports from countries that have experienced COVID-19 including China and Italy. North American evidence emerging.
- Epidemiology:
- Confirmed and presumptive cases worldwide will soon cross 1 million and 50,000 deaths.1,2
- Case numbers/fatality rates vary substantially depending on testing protocols, access to testing or care, length of time since illness (patient) or outbreak (population) started, transparency of reporting and potential misclassification of cause of death.3
- Presenting Signs/Symptoms:
- From 1099 hospitalized or outpatient cases in China:4
- Cough (68%), fever (44% on admission, 89% during hospitalization) most common symptoms.
- Lymphopenia: common lab abnormality (83%).
- Chest X-ray abnormalities in 59%: local/bilateral shadows or ground-glass opacity most common.
- Atypical symptoms (including gastrointestinal) have been reported and many symptoms (sore throat) are seen in other viral illnesses.4
- From 1099 hospitalized or outpatient cases in China:4
- Clinical Course:
- China: 80% of detected cases are mild (described as “non-pneumonia” or “mild pneumonia”), ~15% severe (dyspnea, respiratory rate >30/min, O2 saturation <93%), 5% critical (respiratory/multi-organ failure).5
- North America:6,7
- Between 8-12% of detected cases are hospitalized.
- ~25% of admitted patients require ICU.
- If requiring admission, mean time from:
- Symptom onset to hospitalization: 4-7 days.8,9
- Illness onset to ICU admission (if occurred):
- 5 to 12 days.8-10
- Mean hospital stay (survival or death)~2 weeks.4,9-11
- Mortality Risk Factors:
- Age:
- China:12 patients ≥65 years: ~6 times higher death rate than those <65.
- Italy: 96% of deaths in patients ≥60 years.3
- Mean age ~80 years.
- Co-morbidities:
- Mean number of co-morbid conditions:3 2.7.
- Examples: cardiovascular disease, diabetes, chronic respiratory disease, hypertension.5
- <1% of deaths in patients without co-morbidities.4
- Mean number of co-morbid conditions:3 2.7.
- Cardiac injury (with significantly elevated troponin levels on admission):13 mortality rate ~51%.
- Long-term care residents:14
- One American facility with 101/130 residents infected.
- Mortality rate 34%.
- One American facility with 101/130 residents infected.
- Age:
- Epidemiology:
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