Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection.

BACKGROUND: The variability of Covid-19 severity between patients has driven efforts to identify prognosticating laboratory markers that could aid clinical decision-making. Procalcitonin is classically used as a diagnostic marker in bacterial infections, but its role in predicting Covid-19 disease severity is emerging. We aimed to identify the association between procalcitonin and Covid-19 disease severity in a critical care setting and whether bacterial co-infection is implicated. METHODS: We retrospectively reviewed Covid-19 patients with procalcitonin concentrations measured in a critical care setting at our institution between February and September 2020. Laboratory markers including peak procalcitonin values and a range of bacterial culture results were analysed. Outcomes were the requirement and duration of invasive mechanical ventilation as well as inpatient mortality. RESULTS: In total, 60 patients were included; 68% required invasive mechanical ventilation and 45% died as inpatient. Univariate analysis identified higher peak procalcitonin concentrations significantly associated with both the requirement for invasive mechanical ventilation (OR: 3.2, 95% CI 1.3-9.0, P = 0.02) and inpatient mortality (OR: 2.6, 95% CI 1.1-6.6, P = 0.03). Higher peak procalcitonin concentrations was an independent predictor of mortality on multivariate analysis (OR 3.7, 95% CI 1.1-12.4, P = 0.03). There was a significant positive correlation between increased peak procalcitonin concentrations and duration on invasive mechanical ventilation. No significant difference was found between peak procalcitonin concentrations of patients with positive and negative bacterial cultures. CONCLUSIONS: Elevated procalcitonin concentrations in Covid-19 patients are associated with respiratory failure requiring prolonged invasive mechanical ventilation and inpatient mortality. This association may be independent of bacterial co-infection.

Atypical presentation of COVID-19 in hospitalised older adults.

BACKGROUND: It is increasingly recognised that older patients may not present with typical symptoms of COVID-19. AIMS: This study aims to evaluate the incidence, characteristics and clinical outcome of older adults with atypical presentations of COVID-19. METHODS: A retrospective analysis of adults ≥ 65 years with confirmed COVID-19 admitted to our institution between 1 March and 24 April 2020 was performed. Patients were categorised into typical or atypical groups based on primary presenting complaint in the community. RESULTS: One hundred twenty-two patients (mean age 81 ± 8 years; 62 male) were included. Seventy-three (60%) were categorised into the typical group and 49 (40%) into the atypical group. In the atypical group, common presenting complaints were fall in 18 (36%), reduced mobility or generalised weakness in 18 (36%) and delirium in 11 (22%). Further assessment by paramedics and on admission found 32 (65%) to have typical features of COVID-19, fever being the most common, and 22 (44%) were hypoxic. This subset had worse outcomes than those in the typical group with a mortality rate of 50% versus 38%, respectively, although this was not statistically significant (P = 0.27). No significant difference in mortality or length of hospital stay between the groups was demonstrated. CONCLUSION: Older patients with atypical presentation of COVID-19 in the community are equally susceptible to poor outcomes. Early detection may improve outcomes and limit community transmission. Primary care practitioners should be vigilant and consider prompt onward referral.

Pulmonary embolism in COVID-19: Clinical characteristics and cardiac implications.

BACKGROUND: The thrombogenic potential of Covid-19 is increasingly recognised. We aim to assess the characteristics of COVID-19 patients diagnosed with pulmonary embolism (PE). METHODS: We conducted a single centre, retrospective observational cohort study of COVID-19 patients admitted between 1st March and 30th April 2020 subsequently diagnosed with PE following computed tomography pulmonary angiogram (CTPA). Patient demographics, comorbidities, presenting complaints and inpatient investigations were recorded. RESULTS: We identified 15 COVID-19 patients diagnosed with PE (median age = 58 years [IQR = 23], 87% male). 2 died (13%), both male patients >70 years. Most common symptoms were dyspnoea (N = 10, 67%) and fever (N = 7, 47%). 12 (80%) reported 7 days or more of non-resolving symptoms prior to admission. 7 (47%) required continuous positive airway pressure (CPAP), 2 (13%) of which were subsequently intubated. All patients had significantly raised D-dimer levels, lactate dehydrogenase (LDH), C-reactive protein (CRP), ferritin and prothrombin times. The distribution of PEs correlated with the pattern of consolidation observed on CTPA in 9 (60%) patients; the majority being peripheral or subsegmental (N = 14, 93%) and only 1 central PE. 10 (67%) had an abnormal resting electrocardiogram (ECG), the commonest finding being sinus tachycardia. 6 (40%) who underwent transthoracic echocardiography (TTE) had structurally and functionally normal right hearts. CONCLUSION: Our study suggests that patients who demonstrate acute deterioration, a protracted course of illness with non-resolving symptoms, worsening dyspnoea, persistent oxygen requirements or significantly raised D-dimer levels should be investigated for PE, particularly in the context of COVID-19 infection. TTE and to a lesser degree the ECG are unreliable predictors of PE within this context.