Background
In December, 2019, a pneumonia associated with the 2019 novel coronavirus (2019-nCoV) emerged in Wuhan, China. We aimed to further clarify the epidemiological and clinical characteristics of 2019-nCoV pneumonia.
Methods
In this retrospective, single-centre study, we included all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data. Outcomes were followed up until Jan 25, 2020.
Findings
Of the 99 patients with 2019-nCoV pneumonia, 49 (49%) had a history of exposure to the Huanan seafood market. The average age of the patients was 55·5 years (SD 13·1), including 67 men and 32 women. 2019-nCoV was detected in all patients by real-time RT-PCR. 50 (51%) patients had chronic diseases. Patients had clinical manifestations of fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). According to imaging examination, 74 (75%) patients showed bilateral pneumonia, 14 (14%) patients showed multiple mottling and ground-glass opacity, and one (1%) patient had pneumothorax. 17 (17%) patients developed acute respiratory distress syndrome and, among them, 11 (11%) patients worsened in a short period of time and died of multiple organ failure.
Interpretation
The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection.
This is an extended descriptive study on the epidemiology and clinical characteristics of the 2019-nCoV, including data on 99 patients who were transferred to Jinyintan Hospital from other hospitals across Wuhan. It presents the latest status of the 2019-nCoV infection in China and adds details on combined bacterial and fungal infections. Human coronavirus is one of the main pathogens of respiratory infection. The two highly pathogenic viruses, SARS-CoV and MERS-CoV, cause severe respiratory syndrome in humans and four other human coronaviruses (HCoV-OC43, HCoV-229E, HCoV-NL63, HCoV-HKU1) induce mild upper respiratory disease. The major SARS-CoV outbreak involving 8422 patients occurred during 2002–03 and spread to 29 countries globally.MERS-CoV emerged in Middle Eastern countries in 2012 but was imported into China.The sequence of 2019-nCoV is relatively different from the six other coronavirus subtypes but can be classified as betacoronavirus. SARS-CoV and MERS-CoV can be transmitted directly to humans from civets and dromedary camels, respectively, and both viruses originate in bats, but the origin of 2019-nCoV needs further investigation.2019-nCoV also has enveloped virions that measure approximately 50–200 nm in diameter with a single positive-sense RNA genome.Club-shaped glycoprotein spikes in the envelope give the virus a crown-like or coronal appearance. Transmission rates are unknown for 2019-nCoV; however, there is evidence of human-to-human transmission. None of the 99 patients we examined were medical staff, but 15 medical workers have been reported with 2019-nCoV infection, 14 of whom are assumed to have been infected by the same patient.The mortality of SARS-CoV has been reported as more than 10% and MERS-CoV at more than 35%.At data cutoff for this study, mortality of the 99 included patients infected by 2019-nCoV was 11%, resembling that in a previous study. However, additional deaths might occur in those still hospitalised.
We observed a greater number of men than women in the 99 cases of 2019-nCoV infection. MERS-CoV and SARS-CoV have also been found to infect more males than females.The reduced susceptibility of females to viral infections could be attributed to the protection from X chromosome and sex hormones, which play an important role in innate and adaptive immunity.Additionally, about half of patients infected by 2019-nCoV had chronic underlying diseases, mainly cardiovascular and cerebrovascular diseases and diabetes; this is similar to MERS-CoV.Our results suggest that 2019-nCoV is more likely to infect older adult males with chronic comorbidities as a result of the weaker immune functions of these patients.Some patients, especially severely ill ones, had co-infections of bacteria and fungi. Common bacterial cultures of patients with secondary infections included A baumannii, K pneumoniae, A flavus, C glabrata, and C albicans.The high drug resistance rate of A baumannii can cause difficulties with anti-infective treatment, leading to higher possibility of developing septic shock.For severe mixed infections, in addition to the virulence factors of pathogens, the host's immune status is also one of the important factors. Old age, obesity, and presence of comorbidity might be associated with increased mortality.
When populations with low immune function, such as older people, diabetics, people with HIV infection, people with long-term use of immunosuppressive agents, and pregnant women, are infected with 2019-nCoV, prompt administration of antibiotics to prevent infection and strengthening of immune support treatment might reduce complications and mortality.
In terms of laboratory tests, the absolute value of lymphocytes in most patients was reduced. This result suggests that 2019-nCoV might mainly act on lymphocytes, especially T lymphocytes, as does SARS-CoV. Virus particles spread through the respiratory mucosa and infect other cells, induce a cytokine storm in the body, generate a series of immune responses, and cause changes in peripheral white blood cells and immune cells such as lymphocytes. Some patients progressed rapidly with ARDS and septic shock, which was eventually followed by multiple organ failure. Therefore, early identification and timely treatment of critical cases is of crucial importance. Use of intravenous immunoglobulin is recommended to enhance the ability of anti-infection for severely ill patients and steroids (methylprednisolone 1–2 mg/kg per day) are recommended for patients with ARDS, for as short a duration of treatment as possible. Some studies suggest that a substantial decrease in the total number of lymphocytes indicates that coronavirus consumes many immune cells and inhibits the body's cellular immune function. Damage to T lymphocytes might be an important factor leading to exacerbations of patients.The low absolute value of lymphocytes could be used as a reference index in the diagnosis of new coronavirus infections in the clinic.
In general, the characteristics of patients who died were in line with the early warning model for predicting mortality in viral pneumonia in our previous study: the MuLBSTA score.The MuLBSTA score system contains six indexes, which are multilobular infiltration, lymphopenia, bacterial co-infection, smoking history, hypertension, and age. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection.This study has several limitations. First, only 99 patients with confirmed 2019-nCoV were included; suspected but undiagnosed cases were ruled out in the analyses. It would be better to include as many patients as possible in Wuhan, in other cities in China, and even in other countries to get a more comprehensive understanding of 2019-nCoV. Second, more detailed patient information, particularly regarding clinical outcomes, was unavailable at the time of analysis; however, the data in this study permit an early assessment of the epidemiological and clinical characteristics of 2019-nCoV pneumonia in Wuhan, China.
In conclusion, the infection of 2019-nCoV was of clustering onset, is more likely to infect older men with comorbidities, and can result in severe and even fatal respiratory diseases such as ARDS.
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