Extended Abstract

Introduction
The coronavirus disease 2019 (COVID-19) pandemic has given rise to more severe outcomes in individuals with underlying conditions, such as respiratory, cardiovascular, diabetic, and chronic liver diseases. These patients have experienced more severe clinical courses and higher mortality rates compared to the general population. The development of chronic liver diseases affects an estimated 1.5 billion people across the world. Cirrhotic patients, in particular, are considered immunocompromised individuals. Impaired innate and adaptive immune systems in these patients can predispose them to viral and bacterial infections.
Numerous studies worldwide have investigated the clinical course of COVID-19 in cirrhotic patients. While these studies have not shown significant differences in clinical symptoms of COVID-19 between cirrhotic patients and the general population, the most common clinical symptoms reported in cirrhotic patients have been fever, shortness of breath, cough, and respiratory secretions. Cirrhotic patients with COVID-19 have required more intensive care unit (ICU) admissions, mechanical ventilation, and renal replacement therapy, and have also experienced higher mortality rates compared to other non-cirrhotic liver disease patients and the general population. This study aimed to evaluate the clinical and laboratory manifestations and treatment outcomes of cirrhotic patients with COVID-19.
Methods
This retrospective descriptive study was conducted on 9 patients (4 women and 5 men) with cirrhosis infected with COVID-19 hospitalized at Shahid Sayyad Shirazi Educational and Therapeutic Center in Gorgan, Iran during 2019-20.
The inclusion criterion included patients with cirrhosis infected with COVID-19 diagnosed using a positive polymerase chain reaction (PCR) test. Of the 343 cirrhotic patients infected with COVID-19 during the first year of the pandemic, 9 were included in the study.
Demographic and clinical data, including initial symptoms and complaints, laboratory results, need for ICU admission, length of hospital stay, and treatment outcomes, were extracted from the patients’ medical records. The Child-Pugh score was used to classify the severity of liver disease.
Results
The mean age of the patients was 55.22±15.7 years. Hepatitis B and fatty liver were the causes of cirrhosis in 3 patients each, while hepatitis C, alcohol use, and Wilson’s disease were each responsible for cirrhosis in one patient. Liver disease severity was classified as Child-Pugh Class B in 7 patients, and Class A and Class C in one patient each. Comorbidities included cardiovascular disease and hypertension in 2 patients each, and diabetes and asthma in one patient each.
None of the patients had a previous history of COVID-19. Four patients reported contact with someone infected with COVID-19.
Clinical manifestations at the time of COVID-19 diagnosis included ascites in 6 patients, fever in 5 patients, respiratory distress and anorexia in 4 patients each, cough, oxygen saturation less than 93%, and muscle pain in 3 patients each, nausea and vomiting in 2 patients, and abdominal pain and decreased level of consciousness in one patient each. All patients had albumin levels below 4 g/dL. Hemoglobin was less than 12 g/dL in 7 patients. Thrombocytopenia was observed in 8 patients, leukocytosis in one patient, and leukopenia and pancytopenia in 4 patients each. Alanine transaminase (ALT) and aspartate transaminase (AST) levels were higher than 40 U/L in 6 and 5 patients, respectively.
The length of hospital stays ranged from 2 to 12 days, with a mean of 5 days. Of the 9 patients studied, only one died, a 60-year-old woman with a history of fatty liver disease, cardiovascular disease, and uncontrolled Class C cirrhosis. The deceased patient was hospitalized for 11 days, including 6 days in the ICU, and died of respiratory failure. The remaining 8 patients were discharged with improvement.
Conclusion
Based on the results of this study, the most common clinical manifestations in patients with liver cirrhosis infected with COVID-19 consisted of ascites, fever, respiratory distress, and anorexia, and the least common symptoms included abdominal pain and decreased levels of consciousness.
There seems to be no significant difference in clinical symptoms between the cirrhotic patients in this study and the general population with COVID-19.
The most common laboratory findings in the study patients at the time of COVID-19 diagnosis included hypoalbuminemia, thrombocytopenia, and anemia. It is worth mentioning that 4 patients in this study had pancytopenia.
According to the study results and underlying disorders in white blood cell (WBC) level of patients with cirrhosis, it seems that WBC level has no significant clinical value in COVID-19 diagnosis in cirrhotic patients.
Based on the Child-Pugh score, only one patient had Class C liver disease severity that died due to respiratory failure. Class A and Class B liver disease severity were determined in 7 and one patient, respectively.
Our study data are not sufficient to demonstrate a relationship between the severity of liver disease and mortality rate among cirrhotic patients infected with COVID-19; however, studies have revealed that patients with higher severity of liver disease according to the Child-Pugh score and a higher score of the model for end-stage liver disease (MELD) are more likely to develop severe COVID-19 and to die compared to other patients.
Ethical Statement
This study was approved by the Research Ethics Committees of Golestan University of Medical Sciences (IR.GOUMS.REC.1401.339).
Funding
This article has been extracted from the thesis of Dr. Mohana Yousefi in order to obtain a specialty fellowship in Internal Medicine from the Faculty of Medicine, Golestan University of Medical Sciences.
Conflicts of Interest
No conflict of interest.
 

Key message: The most common clinical manifestations in patients with liver cirrhosis infected with COVID-19 consisted of ascites, fever, respiratory distress, and anorexia, and the most common laboratory manifestations were hypoalbuminemia and thrombocytopenia.