|
Clinical Characteristics, Outcomes, and Predictors of Disease Severity in Hospitalized Coronavirus Disease 2019 Patients: A Cross-Sectional Study in Gorgan, Iran (2021)
|
Bahman Aghcheli1    , Seyed Amirreza Hejazian2 , Ghazaleh Alizad3 , Sadeghali Azimi4 , Alireza Tahamtan *5 |
1- Assistant Professor of Medical Virology, Infectious Diseases Research Center, Gonabad University of Medical Sciences, Gonabad, Iran.
2- General Physician, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran.
3- M.Sc in Immunology, Department of Immunology, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran.
4- Assistant Professor of Infectious Diseases, Golestan University of Medical Sciences, Gorgan, Iran.
5- Associate Professor of Medical Virology, Infectious Diseases Research Center, School of Medicine, Department of Microbiology, Golestan University of Medical Sciences, Gorgan, Iran. , alireza.tmn@gmail.com |
|
Keywords: COVID-19 [MeSH], SARS-CoV-2 [MeSH], Signs and Symptoms [MeSH], Iran [MeSH]
Article ID: Vol27-40 |
|
|
Full-Text [PDF 738 kb]
(116 Downloads)
| Abstract (HTML) (564 Views)
|
|
Type of Study: Short Communication |
Subject:
Health System
|
|
|
|
|
|
|
Abstract: (6 Views) |
Extended Abstract
Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a member of the Coronaviridae family, was identified in December 2019 as the causative agent of a pneumonia outbreak in Wuhan, China. Viral transmission occurs primarily through respiratory droplets and aerosols. This virus causes coronavirus disease 2019 (COVID-19), which encompasses a broad spectrum of clinical manifestations, ranging from asymptomatic cases to severe respiratory failure and multi-organ dysfunction. Common symptoms include fever, cough, dyspnea, loss of sense of taste or smell, fatigue, and neurological manifestations (such as headache and dizziness). In severe cases, the disease may progress to acute respiratory distress syndrome (ARDS), necessitating intensive care and mechanical ventilation. Complications such as myocardial injury, renal failure, and secondary infections are associated with increased mortality rates, particularly among high-risk populations, such as cancer patients. Rapid and accurate viral identification is achieved through real-time reverse transcription quantitative polymerase chain reaction (RT-qPCR). This assay confirms the infection by detecting viral genetic material (ribonucleic acid [RNA]) in nasopharyngeal fluid specimens. Patients with severe COVID-19 frequently develop respiratory failure, shock, disseminated intravascular coagulation (DIC), and multi-organ failure, requiring admission to the intensive care unit (ICU).
Based on studies conducted across various countries, the most significant predictors of severe COVID-19 include advanced age, male gender, and the presence of comorbidities like cardiovascular diseases, diabetes, hypertension, and chronic obstructive pulmonary disease (COPD), alongside elevated levels of C-reactive protein (CRP) and D-dimer, and lymphopenia. Immune senescence in old people culminates in functional impairment of both the innate and adaptive immune systems. Key changes in this regard include diminished
T-lymphocyte activity, compromised antibody production by
B-lymphocytes, and functional deficits in macrophages and neutrophils. These immunological deficiencies not only increase susceptibility to infections but, in the context of COVID-19, lead to the emergence of non-specific clinical manifestations-such as profound weakness, altered consciousness, and multi-organ dysfunction-rather than classic respiratory symptoms. These atypical features present significant diagnostic and therapeutic challenges, necessitating specialized attention to unusual symptoms and the implementation of more extensive paraclinical assessments within this high-risk age group. Such findings assist clinicians in the timely identification of patients requiring immediate medical intervention, thereby preventing severe complications. While vaccination is recognized as the most effective public health strategy-with over 13 billion doses administered globally-COVID-19 continues to pose substantial challenges due to its severe complications and persistent mortality rates.
Predictive models incorporating demographic, clinical, and laboratory factors are essential for identifying high-risk groups and guiding interventions. This study was conducted to determine the clinical characteristics, outcomes, and predictors of disease severity among hospitalized COVID-19 patients in Gorgan, Iran.
Methods
This descriptive-analytical, cross-sectional study was conducted on the data of 736 hospitalized COVID-19 patients (58.6% male; mean age = 55 years; age range = 1–94 years) at the Fifth Azar Educational-Therapeutic Center in Gorgan during 2021.
Data were collected from patients' electronic medical records using a census method. A convenience sampling method was employed, and patients were selected based on the completeness of their electronic medical records. Patients were categorized based on disease outcome (recovery/death) and disease severity (ICU admission/general ward admission). Demographic data (age and gender), symptoms, and comorbidities were extracted from electronic health records. Clinical manifestations included dyspnea, fever, cough, sore throat, myalgia, confusion, nausea, headache, sneezing, chest pain, tachypnea, weakness and fatigue), diarrhea, rhinorrhea, and abdominal pain. Comorbidities consisted of cardiovascular diseases, diabetes, COPD, renal failure, arthritis, neurological disorders, malignancy, immunodeficiency, and hepatic failure. Furthermore, clinical syndromes and complications included ARDS, congestion, coma, and pneumonia.
Inclusion criteria comprised a confirmed diagnosis via
RT-qPCR, while exclusion criterion included incomplete data or transfer to other medical centers. Demographic, clinical, and laboratory data were subsequently extracted.
Results
Regarding clinical outcomes, 230 patients (31.3%) deceased, while 506 (68.7%) recovered. Among deceased patients, 135 (31.2%) were male; similarly, 297 (68.8%) of the recovered patients were male. In terms of disease severity, 156 patients (21.2%) required ICU admission, whereas 580 (78.8%) were treated in non-ICU wards. Within the ICU-admitted group, 80 patients (18.5%) were male, compared to 352 (81.5%) males in the non-ICU group. ICU-admitted patients (with high disease severity) had a significantly higher mean age compared to other patients (median age = 65 years, P<0.002). Disease severity was significantly higher in female patients compared to male patients (P<0.03). The most prevalent clinical symptoms reported were dyspnea (64.6%), fever (57.7%), and cough (56.3%); among these, dyspnea demonstrated the strongest association with adverse clinical outcomes (P<0.001). Regarding comorbidities, cardiovascular diseases (17.9%, P<0.01) and COPD (6.6%, P<0.006) were significantly associated with an increased risk of mortality. Notably, all cases of coma (n = 9) and ARDS (n = 7) resulted in patient mortality. Moreover, pneumonia (n = 142) was also significantly correlated with unfavorable disease outcomes (P<0.030).
Conclusion
According to the results of this study, advanced age was significantly associated with the disease severity and mortality of COVID-19. Notably, women in this study experienced significantly higher rates of severe disease forms. This discrepancy may be attributed to specific demographic factors of the study region, genetic variations, or environmental factors.
In the present study, dyspnea, fever, and cough were the most prevalent clinical manifestations. Dyspnea was identified as the strongest predictor of adverse clinical outcomes, which aligns with the findings of other researchers. Conversely, while some studies have reported fever as the most common symptom, this variation may be related to the clinical stage of the disease at the time of presentation or the specific characteristics of the study population.
In the current research, ICU-admitted patients were significantly older, exhibited a higher prevalence of comorbidities, and presented with more severe symptoms, most notably dyspnea. Cardiovascular diseases, COPD, and diabetes were identified as the most significant predictors of the requirement for intensive care. These findings underscore the critical importance of rigorous monitoring for elderly patients with underlying diseases. Furthermore, in the assessment of comorbidities, cardiovascular diseases and COPD demonstrated the strongest correlations with adverse clinical outcomes. These results are consistent with previous reports indicating that chronic diseases increase the risk of developing severe forms of COVID-19.
Geographical diversity serves as a key determinant in the transmission patterns and clinical severity of COVID-19. This regional variability is primarily influenced by multidimensional factors, including climatic variables (fluctuations in temperature, relative humidity, and ultraviolet radiation intensity), demographic characteristics (population density, age structure, and social mobility), healthcare infrastructure (access to medical centers and health system capacity), genetic and epigenetic variations across populations, as well as behavioral patterns and adherence to health protocols. This geographical heterogeneity may stem from variations in environmental viral stability, differences in host immune responses, diversity of circulating strains, and disparities in initial viral exposures. Consequently, these findings highlight the necessity of adopting disease control strategies tailored to the specific local characteristics of each region.
Ethical Statement
This study was approved by the Ethics Committee at Golestan University of Medical Sciences (IR.GOUMS.REC.1401.069).
Authors' Contributions
Bahman Aghcheli (Ph.D): Project execution, Data collection, Data analysis, Drafting of the initial manuscript, Approval of the final manuscript.
Seyed Amirreza Hejazian (M.D): Project execution, Data collection, Data analysis, Approval of the final manuscript.
Ghazaleh Alizad (M.Sc): Project execution, Data collection, Data analysis, Approval of the final manuscript.
Sadeghali Azimi (M.D): Project administration and design, Project execution, Data collection, Approval of the final manuscript.
Alireza Tahamtan (Ph.D): Project administration and design, Project execution, Data collection, Data analysis, Interpretation of the results, Drafting of the initial manuscript, Approval of the final manuscript.
Conflicts of Interest
No conflicts of interest.
Acknowledgement
This study has been derived from the doctoral dissertation (approval code: 112698) by Seyed Amirreza Hejazian in Doctor of Medicine (MD) at the School of Medicine, Golestan University of Medical Sciences. The authors would like to thank the staff of the Fifth Azar Educational-Therapeutic Center in Gorgan for their valuable cooperation.
Key Message: Advanced age, comorbidities, and dyspnea are among the most significant predictors of severe COVID-19 outcomes. Elderly patients and individuals with comorbid conditions require intensive care and more rigorous monitoring, as these groups are at a heightened risk of developing severe forms of the disease. Furthermore, dyspnea has been identified as a critical clinical indicator of disease severity.
|
|
| References |
1. Ma W, Tang S, Yao P, Zhou T, Niu Q, Liu P, et al. Advances in acute respiratory distress syndrome: focusing on heterogeneity, pathophysiology, and therapeutic strategies. Signal Transduct Target Ther. 2025 Mar;10(1):75. https://doi.org/10.1038/s41392-025-02127-9. [ DOI] [ PubMed] 2. Krieger E, Kudryavtsev AV, Sharashova E, Samodova O, Postoev VA. Risk factors for all-cause mortality during the COVID-19 pandemic compared with the pre-pandemic period in an adult population of Arkhangelsk, Russia. Sci Rep. 2025 Jan;15(1):1050. https://doi.org/10.1038/s41598-025-85360-0. [ DOI] [ PubMed] 3. Faksova K, Walsh D, Jiang Y, Griffin J, Phillips A, Gentile A, et al. COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals. Vaccine. 2024 Apr;42(9):2200-211. https://doi.org/10.1016/j.vaccine.2024.01.100. [ DOI] [ PubMed] 4. Schultz MJ, van Oosten PJ, Hol L. Mortality among elderly patients with COVID-19 ARDS-age still does matter. Pulmonology. 2023 Sep-Oct;29(5):353-55. https://doi.org/10.1016/j.pulmoe.2023.02.013. [ DOI] [ PubMed] 5. Hoffman T, Margalit I, Tabah A, Ruckly S, Barbier F, Singer P, et al. Risk Factors for Mortality Among Older Adults with Hospital-Acquired Bloodstream Infections in the Intensive Care Unit: A Multicenter Cohort Study. Infect Dis Ther. 2025 Feb;14(2):483-92. https://doi.org/10.1007/s40121-024-01104-z. [ DOI] [ PubMed] 6. Narin Çopur E, Ergün D, Ergün R, Atik S, Türk Dağı H, Körez MK. Risk Factors Affecting the Severity, Mortality, and Intensive Care Unit Admission of COVID-19 Patients: A Series of 1075 Cases. Viruses. 2025 Mar;17(3):429. https://doi.org/10.3390/v17030429. [ DOI] [ PubMed] 7. Zhong L, Huang L, Zhang M, Tian C, Zhang L, Song G. Exploring the differences in mortality and its associated factors among young-old and old-old COVID-19 patients. Front Med (Lausanne). 2025 Jul;12:1608667. https://doi.org/10.3389/fmed.2025.1608667. [ DOI] [ PubMed] 8. Kocowska-Trytko M, Terlecki M, Olszanecka A, Pavlinec C, Rajzer M. Sex and other predictors of mortality in long-term follow-up of patients with cardiovascular disease and COVID-19: a single-center retrospective study. Sci Rep. 2025 Apr;15(1):13245. https://doi.org/10.1038/s41598-025-93402-w. [ DOI] [ PubMed] 9. Triebelhorn J, Rüthrich MM, de Miranda SMN, Schneider J, Westhoff T, Scherer M. The impact of age, sex, and comorbidities on COVID-19 mortality of hospitalized patients during the SARS-CoV-2 pandemic: data from the multicentric prospective cohort study of the Lean European Open Survey on SARS-CoV-2 (LEOSS). Infection. 2025 Jun 17. Online ahead of print. https://doi.org/10.1007/s15010-025-02583-z. [ DOI] [ PubMed] 10. Fernandes CYM, Hirata BKB, Vitiello GAF, Castilha EP, de Sousa-Pereira N, Guembarovski RL, et al. Male Sex as a Predictor of Worse Prognosis and Clinical Evolution in Patients with Cancer and SARS-CoV-2 Infection, Independent of the rs41386349 PDCD1 Polymorphism. COVID. 2025;5(7):104. https://doi.org/10.3390/covid5070104. [ Link] [ DOI] 11. Qi S, Ngwa C, Morales Scheihing DA, Mamun AA, Ahnstedt HW, Finger CE, et al. Sex differences in the immune response to acute COVID-19 respiratory tract infection. Biol Sex Differ. 2021;12:66. https://doi.org/10.1186/s13293-021-00410-2. [ Link] [ DOI] 12. Liao QQ, Zhu ZF, Zhu KW, Yang Z, Liu GL, Li XQ, et al. Symptoms can predict COVID-19 pneumonia in patients infected with SARS-CoV-2 Omicron variants. Sci Rep. 2024 Dec;14(1):30037. https://doi.org/10.1038/s41598-024-81156-w. [ DOI] [ PubMed] 13. Kurniyanto, Setianegari Y, Kurniaty L, Luhulima DEJ, Utomo BSR, Langi LA, et al. Factors associated with death and ICU referral among COVID-19 patients hospitalized in the secondary referral academic hospital in East Jakarta, Indonesia. J Clin Virol Plus. 2022 Jun;2(2):100068. https://doi.org/10.1016/j.jcvp.2022.100068. [ DOI] [ PubMed] 14. Kim SH, Lee H, Kim MJ, Kim Y, Min KH, Yoo KH, et al. Risk of acute exacerbation of chronic obstructive pulmonary disease after COVID-19 recovery: a nationwide population-based cohort study. Respir Res. 2025 Mar;26(1):116. https://doi.org/10.1186/s12931-025-03123-x. [ DOI] [ PubMed] 15. Magesh S, John D, Li WT, Li Y, Mattingly-App A, Jain S, et al. Disparities in COVID-19 Outcomes by Race, Ethnicity, and Socioeconomic Status: A Systematic-Review and Meta-analysis. JAMA Netw Open. 2021 Nov;4(11):e2134147. https://doi.org/10.1001/jamanetworkopen.2021.34147. [ DOI] [ PubMed] |
|
| Send email to the article author |
|
|
|
Aghcheli B, Hejazian S A, Alizad G, Azimi S, Tahamtan A. Clinical Characteristics, Outcomes, and Predictors of Disease Severity in Hospitalized Coronavirus Disease 2019 Patients: A Cross-Sectional Study in Gorgan, Iran (2021). J Gorgan Univ Med Sci 2025; 27 (4) :92-99 URL: http://goums.ac.ir/journal/article-1-4613-en.html
|
