Hematological and coagulation parameters as predictors of death by Coronavirus disease in hospitalized patients: a Brazilian follow-up study

Abstract This study aimed to evaluate the hematological and coagulation parameters according to the clinical outcomes of coronavirus disease (COVID-19). We analyzed the hematological and coagulation parameters of hospitalized patients with COVID-19 at admission, and two and three weeks during hospitalization. To assess the performance of these parameters in predicting poor outcomes, receiver operating characteristic (ROC) curves were created. We studied 128 patients with COVID-19 (59.2±17.7 years, 56% male). Non-survivors (n=54, 42%) presented significant alterations in hematological and coagulation parameters at admission, such as increased in white blood cells (WBC), neutrophil, and band cell counts, as well as elevated prothrombin time (PT), activated partial thromboplastin time, and D-dimer levels. During follow-up, the same group presented a gradual increase in D-dimer and PT levels, accompanied by a reduction in PT activity, hemoglobin, and red blood cell count (RBC). ROC curves showed that WBC, neutrophil, and band cell counts presented the best area under the curve (AUC) values with sensitivity and specificity of >70%; however, a logistic regression model combining all the parameters, except for RBC, presented an AUC of 0.89, sensitivity of 84.84%, and specificity of 77.41%. Our study shows that significant alterations in hematological and coagulation tests at admission could be useful predictors of disease severity and mortality in COVID-19.

"Flattening the curve": effective measures from Niterói city (Rio de Janeiro, Brazil) for COVID-19 control / "Achatando a curva": medidas eficazes da cidade de Niterói (RJ, Brasil) para o controle da COVID-19

Abstract Background In Brazil, some local city government's adopted several measures, which probably had a positive impact on COVID-19 control. Objective To report the distribution of COVID-19 cases in Brazil, Rio de Janeiro state and Niterói city. In parallel, we aimed to demonstrate the preventive strategies adopted by Niterói city. Method Data provided by the Brazilian Ministry of Health and Municipal Health Foundation of Niterói were used to report COVID-19 cases and deaths. For some analysis, data were grouped by week and normalized for 100,000 inhabitants. Results By July 18th, 2020, Brazil reported 2,074,860 cases and 78,772 deaths and Rio de Janeiro state registered 135,230 cases and 11,919 deaths; both still presenting ascendant curves for COVID-19 deaths. In contrast, the rate of new deaths per 100,000 inhabitants is consistently lower in Niterói city. Importantly, we estimated that 712 deaths were prevented by the measures adopted by Niterói city, in comparison to which was observed in Rio de Janeiro. Conclusion The early preventive measures adopted in Niterói city were effective in reducing both the viral spread and rate of deaths. In this regard, this discussion could be relevant for making future decisions during the COVID-19 outbreak in Brazil.

Resumo Introdução No Brasil, algumas cidades adotaram várias medidas que provavelmente tiveram um impacto positivo no controle da Covid-19. Objetivo Relatar a distribuição dos casos de Covid-19 no Brasil, no estado do Rio de Janeiro e na cidade de Niterói. Paralelamente, buscamos demonstrar as estratégias preventivas adotadas pela cidade de Niterói para o controle da Covid-19. Método Dados fornecidos pelo Ministério da Saúde e Fundação Municipal de Saúde de Niterói foram usados ​​para relatar o número de casos e óbitos causados pela Covid-19. Para algumas análises, os dados foram agrupados por semana e normalizados para 100.000 habitantes. Resultados Até 18 de julho de 2020, o Brasil registrou 2.074.860 casos e 78.772 mortes e o estado do Rio de Janeiro registrou 135.230 casos e 11.919 mortes; ambos ainda apresentando curvas ascendentes para mortes por Covid-19. Em contrapartida, a taxa de novos óbitos/100.000 habitantes é consistentemente menor na cidade de Niterói. Estimamos que 712 mortes foram evitadas pelas medidas adotadas pela cidade de Niterói, em comparação com o que foi observado no Rio de Janeiro. Conclusão As medidas preventivas adotadas pela cidade de Niterói foram eficazes na redução tanto da disseminação do vírus quanto da taxa de óbitos. Portanto, esta discussão se mostra relevante para a tomada de decisões futuras durante o surto de Covid-19 no Brasil.

Acute kidney injury associated to COVID-19 leads to a strong unbalance of circulant immune mediators.

BACKGROUND: Severe cases of coronavirus disease 2019 (COVID-19) have increased risk for acute kidney injury (AKI). The exacerbation of the immune response seems to contribute to AKI development, but the immunopathological process is not completely understood. OBJECTIVES: To analyze levels of circulant immune mediators in COVID-19 patients evolving with or without AKI. We have also investigated possible associations of these mediators with viral load and clinical outcomes. METHODS: This is a longitudinal study performed with hospitalized patients with moderate to severe COVID-19. Serum levels of 27 immune mediators were measured by a multiplex immunoassay. Data were analyzed at two timepoints during the follow-up: within the first 13 days of the disease onset (early sample) and from the 14th day to death or hospital discharge (follow-up sample). RESULTS: We studied 82 COVID-19 patients (59.5 ± 17.5 years, 54.9% male). Of these, 34 (41.5%) developed AKI. These patients presented higher SARS-CoV-2 viral load (P = 0.03), higher frequency of diabetes (P = 0.01) and death (P = 0.0004). Overall, AKI patients presented significantly higher and sustained levels (P < 0.05) of CCL-2, CCL-3, CCL-4, CXCL-8, CXCL-10, IFN-γ, IL-2, IL-6, TNF-α, IL-1Ra, IL-10 and VEGF. Importantly, higher levels of CCL-2, CXCL-10, IL-2, TNF-α, IL-10, FGFb, and VEGF were observed in AKI patients independently of death. ROC curves demonstrated that early alterations in CCL-2, CXCL-8, CXCL-10, IFN-γ, IL-6, IL-1Ra and IL-10 show a good predictive value regarding AKI development. Lastly, immune mediators were significantly associated with each other and with SARS-CoV-2 viral load in AKI patients. CONCLUSIONS: COVID-19 associated AKI is accompanied by substantial alterations in circulant levels of immune mediators, which could significantly contribute to the establishment of kidney injury.

Increased Indoleamine 2,3-Dioxygenase 1 (IDO-1) Activity and Inflammatory Responses during Chikungunya Virus Infection.

Chikungunya virus (CHIKV) infection causes intense cytokine/chemokine inflammatory responses and debilitating joint pain. Indoleamine2,3-dioxygenase 1 (IDO-1) is an enzyme that initiates the tryptophan degradation that is important in initial host innate immune defense against infectious pathogens. Besides that, IDO-1 activation acts as a regulatory mechanism to prevent overactive host immune responses. In this study, we evaluated IDO-1 activity and cytokine/chemokine patterns in CHIKV patients. Higher IDO-1 (Kyn/Trp ratio) activation was observed during the early acute phase of CHIKV infection and declined in the chronic phase. Importantly, increased concentrations of Tumor Necrosis Factor-α (TNF-α), Interleukin-6 (IL-6), Interferon γ (IFN-γ), C-C motif chemokine ligand 2/Monocyte Chemoattractant Protein-1 (CCL2/MCP-1) and C-X-C motif chemokine ligand 10/Interferon Protein-10 (CXCL10/IP-10) were found in the acute phase of infection, while C-C motif chemokine ligand 4/Macrophage Inflammatory Protein 1 ß (CCL4/MIP-1ß) was found at increased concentrations in the chronic phase. Likewise, CHIKV patients with arthritis had significantly higher concentrations of CCL4/MIP-1ß compared to patients without arthritis. Taken together, these data demonstrated increased IDO-1 activity, possibly exerting both antiviral effects and regulating exacerbated inflammatory responses. CCL4/MIP-1ß may have an important role in the persistent inflammation and arthritic symptoms following chikungunya infection.

Was It Chikungunya? Laboratorial and Clinical Investigations of Cases Occurred during a Triple Arboviruses' Outbreak in Rio de Janeiro, Brazil.

The co-circulation of chikungunya virus (CHIKV), dengue virus (DENV) and Zika virus (ZIKV) in Rio de Janeiro (RJ), Brazil, caused a challenging triple epidemic, as they share similar clinical signs and symptoms and geographical distribution. Here, we aimed to investigate the clinical and laboratorial aspects of chikungunya suspected cases assisted in RJ during the 2018 outbreak, focusing on the differential diagnosis with dengue and zika. All suspected cases were submitted to molecular and/or serological differential diagnostic approaches to arboviruses. A total of 242 cases suspected of arbovirus infection were investigated and 73.6% (178/242) were molecular and/or serologically confirmed as chikungunya. In RT-qPCR confirmed cases, cycle threshold (Ct) values ranged from 15.46 to 35.13, with acute cases presenting lower values. Chikungunya cases were mainly in females (64%) and the most frequently affected age group was adults between 46 to 59 years old (27%). Polyarthralgia affected 89% of patients, especially in hands and feet. No dengue virus (DENV) and Zika virus (ZIKV) infections were confirmed by molecular diagnosis, but 9.5% (23/242) had serological evidence of DENV exposure by the detection of specific anti-DENV IgM or NS1, and 42.7% (76/178) of chikungunya positive cases also presented recent DENV exposure reflected by a positive anti-DENV IgM or NS1 result. A significantly higher frequency of arthritis (p = 0.023) and limb edema (p < 0.001) was found on patients with CHIKV monoinfection compared to dengue patients and patients exposed to both viruses. Lastly, phylogenetic analysis showed that the chikungunya cases were caused by the ECSA genotype. Despite the triple arboviruses' epidemic in the state of RJ, most patients with fever and arthralgia investigated here were diagnosed as chikungunya cases, and the incidence of CHIKV/DENV co-detection was higher than that reported in other studies.

Serum ferritin at admission in hospitalized COVID-19 patients as a predictor of mortality.

INTRODUCTION: Some COVID-19 patients have higher mortality and the responsible factors for this unfavorable outcome is still not well understood. OBJECTIVE: To study the association between ferritin levels at admission, representing an inflammatory state, and hospital mortality in COVID-19 patients. METHODS: From May through July 2020, SARS-CoV-2 positive patients with moderate to severe clinical symptoms were evaluated at admission, regarding clinical and laboratory data on renal and hepatic function, hematologic parameters, cytomegalovirus co-infection, and acute phase proteins. RESULTS: A total of 97 patients were included; mean age=59.9±16.3 years, 58.8% male, 57.7% non-white, in-hospital mortality=45.4%. Age, ferritin, C-reactive protein, serum albumin and creatinine were significantly associated with mortality. Ferritin showed area under the curve (AUC) of 0.79 (p<0.001) for the cut-off of 1873.0ng/mL, sensitivity of 68.4% and specificity of 79.3% in predicting in-hospital mortality. Age ≥60 years had an odds ratio (OR) of 10.5 (95% CI=1.8-59.5; p=0.008) and ferritin ≥1873.0ng/mL had an OR of 6.0 (95% CI=1.4-26.2; p=0.016), both independently associated with mortality based on logistic regression analysis. CONCLUSION: The magnitude of inflammation present at admission of COVID-19 patients, represented by high ferritin levels, is independently predictive of in-hospital mortality.

Serum ferritin at admission in hospitalized COVID-19 patients as a predictor of mortality

ABSTRACT Introduction: Some COVID-19 patients have higher mortality and the responsible factors for this unfavorable outcome is still not well understood. Objective: To study the association between ferritin levels at admission, representing an inflammatory state, and hospital mortality in COVID-19 patients. Methods: From May through July 2020, SARS-CoV-2 positive patients with moderate to severe clinical symptoms were evaluated at admission, regarding clinical and laboratory data on renal and hepatic function, hematologic parameters, cytomegalovirus co-infection, and acute phase proteins. Results: A total of 97 patients were included; mean age = 59.9 ± 16.3 years, 58.8% male, 57.7% non-white, in-hospital mortality = 45.4%. Age, ferritin, C-reactive protein, serum albumin and creatinine were significantly associated with mortality. Ferritin showed area under the curve (AUC) of 0.79 (p < 0.001) for the cut-off of 1873.0 ng/mL, sensitivity of 68.4% and specificity of 79.3% in predicting in-hospital mortality. Age ≥60 years had an odds ratio (OR) of 10.5 (95% CI = 1.8-59.5; p = 0.008) and ferritin ≥1873.0 ng/mL had an OR of 6.0 (95% CI = 1.4-26.2; p = 0.016), both independently associated with mortality based on logistic regression analysis. Conclusion: The magnitude of inflammation present at admission of COVID-19 patients, represented by high ferritin levels, is independently predictive of in-hospital mortality.