Coronavirus disease 2019 (COVID-19) is a form of respiratory and systemic zoonosis caused by a virus belonging to the Corona viridae family. Originated from the town of Wuhan in China, it is still spreading around the world, thus assuming the dramatic features of a pandemic emergency (1). COVID-19 has been declared as Pandemic by WHO on 11th March 2020.
The clinical characteristics of COVID-19 have been broadly defined (1) & it is highlighted that the laboratory medicine plays an essential role in the early detection, diagnosis, prognosis and management of the disease.
Various publications are now available in internationally renowned scientific & clinical journals which suggest that there is a remarkable reduction in Absolute Blood Lymphocyte Count & Hemoglobin associated with the increase in Total Blood WBC Count, Absolute Blood Neutrophil Count, ESR, Prothrombin Time, D-Dimer, C-Reactive Protein & Pro-calcitonin. This is in addition to various routine Biochemical parameters which also get deranged & signifies the severity & poor prognosis of the patient outcome. These lab findings, especially elevated Ferritin levels, suggest an imminent "Cytokine Storm" which might lead to complications like Acute Respiratory Distress Syndrome (ARDS), Pneumonia & Multi-organ Failure (MOD). Elevated Troponins & CK-MB signifies myocardial injury & subsequent fulminant Myocarditis, which is associated with adverse prognosis.
Important laboratory findings in patients with unfavorable progression of coronavirus disease 2019 (COVID-19) (1)
- Increased White Blood Cell Count
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- Increased Neutrophil Count
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- Increased Cardiac Troponin
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- Decreased Lymphocyte Count
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- Increase Creatine Kinase - MB (CK-MB)
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- Increased Lactate Dehydrogenase (LDH)
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- Increased Prothrombin Time (PT)
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- Increased Alanine Aminotransferase (ALT)
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- Increased Procalcitonin (PCT)
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- Increased Aspartate Aminotransferase (AST)
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- Increased C-Reactive Protein (CRP)
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- Increased Total Bilirubin
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- Neutrophil-to-Lymphocyte Ratio (NLR)
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Neutrophil-to-Lymphocyte Ratio Predicts Severe Illness in Patients with 2019 Novel Coronavirus at the Early Stage:
Neutrophil-to-lymphocyte ratio (NLR) is a simple parameter to assess the inflammatory status of a subject by early identification of risk factors for 2019-nCoV severe illness. In a study by Forget etal (2), it was identified that normal NLR values in an adult, non-geriatric, population in good health are between 0.78 and 3.53. Whereas, in another study by Jingyuan Liu (3), it was concluded that Patients with age ≥50 having NRL ≥3.13 are at risk of severe illness, and they should get rapid access to intensive care unit, if necessary. Early application of NLR with age was beneficial to patients' classification management and relief of medical resource shortage.
Dysregulation of immune response in patients with COVID-19:
Chuan Qin et al suggested that the novel coronavirus mainly acts on lymphocytes, especially T lymphocytes (4). Surveillance of NLR and lymphocyte subsets (B Cells, T Cells & NK Cells) can be helpful in the early screening of critical illness, diagnosis and treatment of COVID-19. Dysregulation of immune response, especially T lymphocytes, is most likely to be involved in the pathophysiology of COVID-19 infection
Hematologic Microscopic Parameters in patients with COVID-19 infection:
Bingwen Eugene FAN et al(5) wrote in an accepted article to the editor that Microscopic peripheral blood film review shows a higher number of patients who are lymphopenic & have the presence of a few reactive lymphocytes, of which a subset appears to be lymphoplasmocytoid. This contrasts with the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 where reactive lymphocytes were not observed in a study on Heamatologic parameters in SARS in Singapore and only in 15.2% of cases in a similar study in Hong Kong(5).
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References:
- Laboratory Abnormalities in patients with COVID-19 Infection: https://doi.org/10.1515/cclm-2020-0198
- What is the normal value of the neutrophil‑to‑lymphocyte ratio?: Forget et al. BMC Res Notes (2017) 10:12 DOI 10.1186/s13104-016-2335-5
- Neutrophil-to-Lymphocyte Ratio Predicts Severe Illness Patients with 2019 Novel Coronavirus in the Early Stage https://doi.org/10.1101/2020.02.10.20021584
- Dysregulation of immune response in patients with COVID-19 in Wuhan, China; Chuan Qin et al Clinical Infectious Diseases, ciaa248, https://doi.org/10.1093/cid/ciaa248
- Hematologic parameters in patients with COVID-19 infection: Bingwen Eugene FAN et al, doi:10.1002/ajh.25774