Non-severe vs severe symptomatic COVID-19: 104 cases from the outbreak on the cruise ship "Diamond Princess" in Japan

ABSTRACT

BackgroundThe ongoing outbreak of the coronavirus disease 2019 (COVID-19) is a global threat. Identification of markers for symptom onset and disease progression is a pressing issue. We compared the clinical features on admission among patients who were diagnosed with asymptomatic, mild, and severe COVID-19 at the end of observation. MethodsThis retrospective, single-center study included 104 patients with laboratory-confirmed COVID-19 from the mass infection on the Diamond Princess cruise ship from February 11 to February 25, 2020. Clinical records, laboratory data, and radiological findings were analyzed. Clinical outcomes were followed up until February 26, 2020. Clinical features on admission were compared among those with different disease severity at the end of observation. Univariate analysis identified factors associated with symptom onset and disease progression. FindingsThe median age was 68 years, and 54 patients were male. Briefly, 43, 41, and 20 patients on admission and 33, 43, and 28 patients at the end of observation had asymptomatic, mild, and severe COVID-19, respectively. Serum lactate hydrogenase levels were significantly higher in 10 patients who were asymptomatic on admission but developed symptomatic COVID-19 compared with 33 patients who remained asymptomatic throughout the observation period. Older age, consolidation on chest computed tomography, and lymphopenia on admission were more frequent in patients with severe COVID-19 than those with mild COVID-19 at the end of observation. InterpretationLactate dehydrogenase level is a potential predictor of symptom onset in COVID-19. Older age, consolidation on chest CT images, and lymphopenia might be risk factors for disease progression of COVID-19 and contribute to the clinical management. FundingNot applicable. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched the PubMed database from its inception until March 1, 2020, for articles published in English using the keywords "novel coronavirus," "2019 novel coronavirus," "2019-nCoV," "Severe acute respiratory syndrome coronavirus 2," "SARS-CoV2," "COVID-19," "mass infection," "herd infection," "cruise ship," "Diamond Princess," "asymptomatic," and "subclinical." There were no published clinical studies featuring COVID-19 as a result of mass infection on board a cruise ship. We found published articles entitled "Characteristics of COVID-19 infection in Beijing" and "Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China a descriptive study," which compared patients with asymptomatic, mild, and severe COVID-19. However, none of the studies described potential markers for symptom onset or disease progression in patients with COVID-19. Added value of this studyWe present the differences in clinical characteristics of 104 patients with laboratory-confirmed COVID-19 as a result of mass infection on the Diamond Princess cruise ship who were treated at Self-Defense Forces Central Hospital, Japan from February 11 to February 25, 2020. On admission, 43, 41, and 20 patients had asymptomatic, mild, and severe COVID-19, respectively, whereas 33, 43, and 28 patients were determined to have asymptomatic, mild, and severe COVID-19, respectively, at the end of observation. During the observation period, 10 of the 43 (23.3%) asymptomatic patients on admission developed symptoms of COVID-19. Conversely, eight of the 84 (9.5%) patients with asymptomatic and mild COVID-19 on admission developed severe disease during the observation period. The serum lactate dehydrogenase (LDH) levels were significantly higher in 10 patients who were initially asymptomatic on admission to the hospital and developed symptomatic COVID-19 during the observation period compared with 33 patients who remained asymptomatic throughout the observation period. The prevalence rates of consolidation on chest computed tomography (CT) images and lymphopenia were significantly higher in eight patients who developed severe COVID-19 during the observation period compared with the 76 patients with asymptomatic or mild disease at the end of the observation. Older age, consolidation on chest CT, and lymphopenia on admission were more frequent in patients with severe COVID-19 (n = 28) than those with mild COVID-19 (n = 43) at the end of observation. LDH level might be marker for symptom onset in patients with COVID-19, whereas older age, consolidation on chest CT imaging, and lymphopenia are potential risk factors for disease progression. The current report findings will contribute to the improvement of clinical management in patients with COVID-19. Implications of all the available evidenceSerum LDH level is a potential predictor of symptom onset of COVID-19, whereas older age, consolidation on chest CT imaging, and lymphopenia have potential utility as markers for disease progression.