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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 75-80

Clinical presentation of COVID-19-positive and -negative patients in Lagos Nigeria: A comparative study


1 Mainland Hospital, Yaba, Nigeria
2 Nigeria Centre for Disease Control, Nigeria Field Epidemiology and Laboratory Training Program, Abuja, Nigeria
3 Department of Anaesthesia, Lagos State University Teaching Hospital, Ikeja, Nigeria
4 Department of Disease Control, Lagos State Ministry of Health, Lagos, Nigeria

Date of Submission07-May-2021
Date of Decision21-Jul-2021
Date of Acceptance24-Jul-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Dr. Olusola Adedeji Adejumo
Mainland Hospital, Yaba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_547_21

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  Abstract 


Background: A lot has been documented about the pathophysiology and clinical presentation of coronavirus disease 2019 (COVID-19). We compared the clinical features of real-time reverse transcriptase polymerase-chain-reaction (RT-PCR) confirmed COVID-19 positive and negative patients admitted in Lagos State. Methods: Medical records of all patients admitted in 15 isolation centres across Lagos state between 27th February 2020 and 30th September 2020, were abstracted and reviewed. We compared the clinical features, co-morbidities and clinical outcomes of COVID-19 positive and negative patients. Results: A total of 3157 records of patients admitted in 15 isolation centres in Lagos State were reviewed of which 302 (9.6%) tested negative to RT-PCR COVID-19. There was no gender difference between COVID-19 positive and negative patients (P = 0.687). The average age of the negative patients was higher (46.8 ± 18.3 years) than positive patients (41.9 ± 15.5 years) (P < 0.001). A higher proportion of the COVID-19 negative patients had co-morbidity (38.1% vs. 27.8%), were symptomatic (67.5% vs. 44.6%) and higher mortality (21.9% vs. 6.6%) than positive patients (P < 0.001). The percentages with hypertension (26.2% vs. 21.0%, P = 0.038), diabetes (17.2% vs. 9.4%, P < 0.001), cardiovascular disease (2.3% vs. 0.9%, P < 0.029) and cancer (2.3% vs. 0.5%, P < 0.002) were more among patients without COVID-19. More patients without COVID-19 presented with fever (36.1% vs. 18.8%), cough (33.7% vs. 23.1%) and breathlessness (40.8% vs. 16.1%) than the positive patients (P < 0.001). Conclusion: Anosmia and dysgeusia were strongly associated with COVID-19. Clinical decision-making should only be used to prioritise testing and isolation of patients suspected to have COVID-19, especially in settings with limited access to diagnostic kits.

Keywords: Clinical presentation, coronavirus disease 2019, Lagos state, Nigeria, real-time reverse transcriptase-polymerase chain reaction


How to cite this article:
Adejumo OA, Ogunniyan T, Adesola S, Gordon I, Oluwadun OB, Oladokun OD, Abdulsalam IA, Falana AA, Anderson OS, Anumah A, Dawodu OT, Owuna HJ, Osoba EG, Disu AO, Adetola AV, Oloniniyi NB, Fadoju PK, Ogunsanya AO, Osundaro OA, Bowale A. Clinical presentation of COVID-19-positive and -negative patients in Lagos Nigeria: A comparative study. Niger Postgrad Med J 2021;28:75-80

How to cite this URL:
Adejumo OA, Ogunniyan T, Adesola S, Gordon I, Oluwadun OB, Oladokun OD, Abdulsalam IA, Falana AA, Anderson OS, Anumah A, Dawodu OT, Owuna HJ, Osoba EG, Disu AO, Adetola AV, Oloniniyi NB, Fadoju PK, Ogunsanya AO, Osundaro OA, Bowale A. Clinical presentation of COVID-19-positive and -negative patients in Lagos Nigeria: A comparative study. Niger Postgrad Med J [serial online] 2021 [cited 2022 Sep 28];28:75-80. Available from: https://www.npmj.org/text.asp?2021/28/2/75/325559




  Introduction Top


The coronavirus disease 2019 (COVID-19) symptomatology and clinical presentation have been reported in the literature since the pandemic started in China in December 2019.[1],[2] The presentation of COVID-19 patients varies from asymptomatic phase to mild symptoms, and severe infection and death could result from acute respiratory failure. Most patients have a fever, cough, tiredness, loss of appetite, breathlessness and body weakness. Other constitutional symptoms such as sore throat, headache, nausea, vomiting or diarrhoea were standard clinical features of COVID-19.[3],[4],[5],[6] In some patients, respiratory symptoms are preceded by the inability to smell (anosmia) or taste (ageusia).[7],[8] Dizziness, agitation, seizures, sensory loss, speech and vision difficulty are reported neurological manifestations in COVID 19 patients.[9],[10] Most patients recover without hospitalisation and treatment; however, some patients deteriorate and develop multiple complications.[3],[4],[5],[6] Some studies have shown that being elderly (age above 60 years) and having underlying non-communicable diseases such as diabetes, high blood pressure, cardiac conditions, chronic lung diseases, cardiovascular diseases, dementia, chronic kidney diseases, immunosuppression, obesity, cancer and smoking as risk factors associated with severe COVID-19 disease.[11],[12],[13]

In Nigeria, Lagos State has the highest burden of COVID 19 cases, and the number of COVID-19 patients grew exponentially after the detection of the first case in February 2020.[14] One of the challenges encountered at the beginning of the response was a low testing rate. Before the involvement of the private sector in testing for COVID-19, the testing coverage was inadequate. By the end of May 2020, 293/million population has been tested (about 5% of Ghana's achievement).[15] Furthermore, there was an inadequate supply of personal protective equipment, which aggravated the fear of contagion among health workers. These led to the admission of many patients as suspected cases of COVID-19 before laboratory confirmation using the real-time reverse transcriptase-polymerase chain reaction (RT-PCR) was conducted.[16],[17],[18]

The symptoms and clinical presentation of COVID-19 patients in Nigeria are similar to those reported in studies from other climes.[19],[20] The clinical features of COVID-19 are sometimes non-specific and identical to other diseases, especially respiratory diseases. These similarities make it difficult for health workers to identify COVID-19 patients without RT-PCR assay tests. Although several studies have described the clinical presentation and characteristics of COVID-19 patients in Nigeria,[19],[20] none to the best of our knowledge has compared the presenting symptoms of COVID-19-positive and -negative patients. This analysis could help identify the clinical features independently related to COVID-19; consequently, aid in better triaging and managing patients, especially in a resource-poor setting like Nigeria.


  Methods Top


Study design

We reviewed the medical records of RT-PCR confirmed COVID-19-positive and -negative patients admitted into fifteen isolation centres in Lagos state between 27 February 2020, and 30 September 2020.

Study sites and study population

We conducted this study in 15 isolation centres across Lagos State, managing suspected and confirmed COVID-19 patients. According to the World Health Organisation (WHO) guidelines, COVID-19 was diagnosed based on a positive RT-PCR assay from either the nasopharyngeal or sputum specimen tested for SARS-Cov 2.[21] The management of patients depends on RT-PCR diagnosis of COVID-19 and severity of symptoms. Suspected COVID-19 patients were managed based on presenting symptoms and co-morbid conditions pending the RT-PCR results. In a negative RT-PCR assay result, patients were discharged and referred to a specialist for further management, while the COVID-19-positive patients were managed as per protocol. Lopinavir-ritonavir, Vitamin C, Vitamin D, zinc, dexamethasone, clopidogrel, aspirin or clexane were used to manage COVID-19 patients depending on the severity of symptoms. In addition, the patient's co-morbid conditions were also considered during the treatment for COVID-19.

The guidelines of the National Centre for Disease Control were used to assess the severity of COVID-19 disease.[22] Mild cases could be asymptomatic or presented with non-specific symptoms such as fever, cough, sore throat, nasal congestion, loss of smell, loss of taste, diarrhoea, vomiting and abdominal pain.[22] Severe cases include mild symptoms above with high-grade fever (>38°C) or suspected respiratory infection and one of the following: high respiratory rate (>30 breath/min), severe respiratory distress, SpO2 < 90% in room air and any risk factor for severe infection. The risk factors for severe COVID-19 infection are the elderly (aged ≥60), diabetes, hypertension, cardiac diseases, chronic lung disease, cerebrovascular disease, chronic kidney disease, immunosuppression, cancer and smoking.[23] Symptomatic patients were discharged 10 days after onset of symptoms plus at least 3 days after resolution of symptoms (fever and respiratory symptoms). In comparison, asymptomatic patients were discharged 10 days after a positive test, according to the WHO recommendation.[21] Patients were followed up at the COVID-19 clinic for 3 months after discharge.

Data analysis

Descriptive statistics were used to characterise the clinical presentation and outcome of patients grouped by COVID-19 status. The variables of interest such as patients' age, gender, presence and types of comorbidity, presenting symptoms, risk factors, RT-PCR results and outcome (discharged or dead) were extracted from the electronic database of medical records of all the isolation centres in Lagos State and transported to IBM statistics for analysis. Normally distributed continuous variables were represented as mean and standard deviation. The Student's t-test was used to compare the means of two groups. Nominal variables were presented as percentages and compared using the Chi-squared test or Fisher's exact test. The analysis should be treated as descriptive because we did not adjust for multiple comparisons. The P < 0.05 was considered significant.

Ethical approval

The Health Research and Ethics Committee of the Lagos State University Teaching Hospital granted the ethical approval for this study.


  Results Top


A total of 3157 records of patients admitted to all isolation centres in Lagos State were reviewed. The majority was under 60 years of age and males (85.4% and 65.9%, respectively). The mean age of the patients was (42.4 ± 15.9 years) [Table 1]. Among those admitted at the isolation centres, 2848 (90.2%) tested positive for COVID-19. The majority had no co-morbidity (71.2%) and no risk factors for severe infection (67.0%). About 47% presented with symptoms. Overall, 92.0% of those admitted were successfully discharged, with 254 deaths (8%) [Table 1].
Table 1: Sociodemographic and clinical details of admitted patients

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There was no gender difference between COVID-19-positive and -negative patients (P = 0.687). The average age of the COVID-19-negative patients was higher (46.8 ± 18.3 years) than COVID-19-positive patients (41.9 ± 15.5 years) (P < 0.001). A higher proportion of the COVID-19-negative patients had comorbidities (38.1% vs. 27.8%), were symptomatic (67.5% vs. 44.6%), and also had risk factors (45.0% vs. 31.8%); P < 0.001 [Table 2]. As regards presenting symptoms, fever (35.1% vs. 18.8%), cough (33.4% vs. 23.2%), shortness of breath (39.7% vs. 16.1%) and body weakness (14.2% vs. 5.7%) were significantly more among COVID-19-negative cases compared to the positive cases (P < 0.05). However, the proportion of patients with loss of taste and loss of smell were higher among the COVID-19-positive cases compared to the negative cases (2.6% vs. 0.7% and 4.0% vs. 1.3%, respectively) [P < 0.05; [Table 3]]. The proportion of patients with diabetes (17.2% vs. 9.4), hypertension (26.2% vs. 21.0%), cancer (2.3% vs. 0.5%), cardiovascular disease (2.3% vs. 0.9%) and being elderly (26.5 vs. 13.4%) were found to be higher among COVID-19-negative patients compared to positive cases [P < 0.05; [Table 4]].
Table 2: Socio-demographic and clinical details of coronavirus disease 2019-positive and -negative patients

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Table 3: Symptoms of coronavirus disease 2019 positive and coronavirus disease 2019-negative patients

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Table 4: Risk factors among coronavirus disease 2019 positive and coronavirus disease 2019-negative patients

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  Discussion Top


Several studies have described the symptomatology of COVID-19 in Nigeria; we are not aware of any study that compared the clinical features and outcomes of COVID-19-positive and -negative patients. This study found that the mean age of patients without COVID-19 was higher than patients with COVID-19. Furthermore, a higher proportion of patients without COVID-19 had a fever, cough, shortness of breath, co-morbidity and died compare to patients with COVID-19. Loss of smell and taste was prominent among COVID-19-positive patients.

Being elderly and co-morbidities (such as hypertension, diabetes mellitus and obesity) are important risk factors associated with poor outcomes in COVID-19 disease.[24],[25],[26] In this study, we observed a higher proportion of the elderly (aged 60 years and above) and patients with hypertension, diabetes mellitus, cardiovascular disease and cancer were COVID-19 negatives. During the first wave of COVID-19 in Lagos, Nigeria, many patients (mostly the elderly) were referred to the isolation centres as suspected COVID-19 cases because the presenting symptoms were similar to COVID-19 symptoms may be responsible for our findings. Studies from China and the US reported that most elderly and those with comorbidities were COVID-19 positive, contrary to our discovery.[27],[28],[29]

Our study showed a significantly higher proportion of patients without COVID-19 reported cough symptoms than patients with COVID-19. In a study carried out among suspected cases of COVID-19 in Singapore, upper respiratory symptoms such as cough, sore throat and catarrh were more among patients without COVID-19 than positive cases.[30] This finding further supports the theory that SARS-CoV-2 has an affinity for the lower respiratory airways.[6],[27],[31] In our study, a higher percentage of patients without COVID-19 presented with fever, body weakness and shortness of breath than COVID-19-positive patients. This finding differs from that reported from other studies from the US, Singapore and China, contrasting the two categories of patients.[28],[30],[32]

On the other hand, more patients without COVID-19 had anosmia and dysgeusia than patients with COVID-19. This finding is in tandem with reports from other studies, showing a higher incidence of olfactory and gustatory dysfunction associated with COVID-19 infection.[30],[33],[34] This finding further corroborates the hypothesis that anosmia and ageusia/dysgeusia should be screening symptoms for COVID-19. They tend to differentiate COVID-19 symptoms from other respiratory diseases, making clinicians have a higher index of suspicion when patients present with these symptoms.

As regards clinical outcome, more patients without COVID-19 died than patients with COVID-19 in this study. This finding is comparable to that described in some related studies as well.[28],[30] The associated panic and undue attention were given to treating COVID-19 in all suspected patients, thus resulting in inappropriate management of COVID-19-negative patients could be responsible for our finding. In addition, before the involvement of the private sector, very few laboratories were accredited to diagnose COVID-19 which resulted in the long turnaround time of RT-PCR results. Sometimes, the release of COVID-19 test results took up to a week which contributed to the increased mortality among COVID-19-negative patients. In some extreme cases, some attending physicians insisted on confirmatory COVID-19 results before attending to patients.

Limitations

The study design relied on the review of medical records from 15 isolation centres; thus, the information provided by the patients cannot be ascertained. In addition, variation in clinician's assessments may result in misestimation of clinical features. Furthermore, our findings cannot be generalised to the whole country because of the peculiarity of Lagos State.


  Conclusion Top


This study has highlighted some unique findings. First, anosmia and dysgeusia are the only symptoms that were strongly associated with COVID-19. Second, clinical decision-making can be used to prioritise testing and isolation of patients suspected of COVID-19, especially in resource-poor settings. Finally, virological testing remains the mainstay of diagnosing COVID-19, and it is essential for improved clinical outcomes among patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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