Clinical-Epidemiological Characteristics in Outpatients with Mild to Moderate Covid-19, in the South of Mexico City

Introduction

In December 2019, an outbreak of pneumonia of unknown cause occurred in the People’s Republic of China in Wuhan, Hubei Province. This led to a thorough investigation by the Wuhan health authorities and reported to the World Health Organization (WHO) the presence of 27 cases of Acute Respiratory Syndrome of unknown etiology [1, 2]. Chinese scientists isolated a new strain of coronavirus and carried out genetic sequencing, which was made available to WHO, facilitating laboratories in different countries to produce specific PCR diagnostic tests to detect the new infection. The isolated virus belongs to the Beta coronaviruses of group 2B with at least 70% similarity in the genetic sequence with SARS-CoV, which was named by the WHO as 2019- nCoV [3]. The World Health Organization (WHO) declares “Outbreak” as a Public Health emergency of international concern, on January 30, 2020. The International Committee on Taxonomy of Viruses (ICTV), a global authority for naming viruses, has referred to it as SARS-CoV -2. In Mexico, the first confirmed case was reported on February 28, 2020, John Hopkins University reports for Mexico City as of April 11, 2021; reports 2,278,420 cases and 209,212 deaths from COVID-19 [4].

In our Country (Mexico City), epidemiological surveillance is carried out with strict case definitions for identification: COVID-19 Case Operational Definitions [1]

Material and Methods

This is a prospective, cross-sectional, observational, single-center study of a series of patients with clinical data of upper and lower respiratory tract infection and a positive CRP for SARS-CoV-2, who requested telemedicine consultation to a first-rate clinic. Contact with a specialty in infectious diseases, attended from March 10, 2020 to January 31, 2021.

A mild to moderate COVID-19 case was considered to be patients who had a positive PCR test for SARS-2 CoV-2

plus the presence of symptoms; fever, dry cough, headache, odynophagia, dyspnoea, arthralgia, myalgia, odynophagia, shortness of breath, hyposmia, dysgeusia, dysphagia, asthenia, diarrhea, conjunctivitis, rash whether they present all the clinical data or incomplete and sign the informed consent Those patients who presented criteria for hospitalization, who did not sign informed consent, and another circumstance that prevented them from making a follow-up video call were excluded.

A pre-coded questionnaire was carried out, designed only for this study, the identification card was taken and the following variables were measured: sociodemographic characteristics date of the first consultation, sex, age in completed years, weight). Non-pathological personal history (probable transmission mechanism, family, public transport, work, unknown). Pathological personal history (comorbidities diabetes mellitus, arterial hypertension, previous pulmonary pathology, cancer, HIV, AIDS, asthma, allergy, obesity, disease cardiovascular disease, smoking, alcoholism) Current Condition Signs and symptoms (date of first symptom and date of first consultation, fever greater than 38°C, cough, headache, dyspnea, arthralgia, myalgia, odynophagia, shortness of breath, hyposmia, Dysgeusia, dysphagia , asthenia, diarrhea, conjunctivitis, rash, anxiety and depression)

Results

We found that during the period from March 10, 2020 to January 31, 2021, 106 patients with a positive PCR test for SARS-2 CoV-2 requested medical attention by telemedicine, of which 12 (11%) had signs and symptoms for entering hospital surveillance and treatment, 34 (30%) did not have laboratory studies, so they were eliminated, leaving 66 patients who met the criteria established for diagnosis, so they were included for the analysis.

In relation to the season, in the month of January 2021 “winter stage” was where more patients requested medical attention 28 (42%), followed by 15 (23%) in the month of December 2020 (see graph 1). From the date the symptoms began to the day they requested a consultation for COVID-19 was 6.5 days (range 1 to 12 days), The average age was 48 years with a range (10-80 years) 35 (53%) Corresponded females, 17 (26%) had type 2 diabetes mellitus, 15 (23%) with hypertension, 5 (7%) had Previous pulmonary disease, 3 (4%) had hypothyroidism, 16 (24%) had positive smoking, 14 (21%) Positive alcoholism, 26 (39%) had obesity, 11 (17%) were allergic (Table 1).

Discussion

Comparing the results of this study with other investigations was difficult, because there are few studies reported in outpatients with mild to moderate intensity COVID-19 in adult patients. In this study we describe the experience of a first contact clinic with a specialty in infectious diseases, in the south of Mexico City, the results provide the complete description of the clinical and epidemiological characteristics of the first wave of patients diagnosed with SARS- CoV-2 COVID-19, it was possible to identify the clinical, epidemiological, laboratory and imaging differences.

The treatment that was recommended for each subject is also described, individualizing each patient. These findings could be of use to first-contact clinicians According to the circulation of viruses in our country, SARS CoV-2 “COVID-19” circulated throughout the year, prevailing in the winter stage (1) as well as other respiratory viruses such as the influenza virus, virus respiratory syncytial that more cases are observed with the cold. Probably because in the cold season there is less social distance, there is less ventilation to keep heat in homes and workplaces and of course these are factors for more infections [7].

In general, the majority were women in their fifth decade of life, with comorbidities such as obesity, arterial hypertension and DM2, as the most prevalent, it was notorious that age and comorbidities added importance for the evolution of patients, especially when they are carriers of immune senescence in the cases of those over 60 years of age, or the immune system is immune compromised as is the case of patients with DM2 or when you have more than one comorbidity that persists, they have a pro-inflammatory state and attenuation of the innate immune response [8, 9].

Other comorbidities such as a history of smoking and positive alcoholism predominated in males, and are risk factors because they increase the development of a respiratory infection, alcohol affects different levels of the immune response from the cough reflex and epiglottic, which can cause aspiration risk and decrease chemotaxis and microbial activity and tobacco significantly increases gene expression of angiotensin converting enzyme 2, the binding receptor for severe acute respiratory syndrome coronavirus, which could explain the high susceptibility to COVID-19 in smokers. Furthermore, cigarette smoking is the leading cause of chronic obstructive pulmonary disease, which has been identified as an independent risk factor for severe cases of COVID-19 [10].

From the date on which symptoms began to the day they requested a consultation, it was 6.5 days, similar to that reported by Ortiz, et al. [11]. The most frequent symptoms were cough, headache, myalgia, asthenia) which contrasts with that reported by Ortiz, et al. [11]. The clinical manifestations depend on the viremia phase, where the virus passes from the mucous membranes, especially the nasal and larynx, and also enters the lungs through the respiratory tract and if it attacks other organs such as the digestive tract, kidney , heart, brain etc [8, 12, 13].

The dynamic profile of some laboratory tests related to the degree of inflammation were different in each patient, lymphopenia, and biomarkers such as C-reactive protein, ESR, Ferritin, Dimero D, were more frequent in patients with chronic comorbidities. Decreased vitamin D3 was found, and the deficiency is related to a high risk of infections due to the multiple functions in the body [14, 15].

To date, we do not have a targeted, effective and safe treatment to eliminate SARS-CoV-2, so the treatment for the patients in this study was individualized and established according to the different clinical scenarios and patient comorbidities. In general, in the absence of a specific treatment, we emphasize on improving the immune system, knowing that the immune system is a perfect system that combines a whole range of cells and mediators to provide protective immunity against infectious agents. Its intervention in early reactions (innate immunity) and later in (adaptive immunity) both very important for the defense against intracellular germs such as SARS-COV2, Pidotimod was prescribed as an immune modulator, in the acute phase with an 800mg tablet every 12hrs for 2 weeks, followed by a tablet every 24 hours for 4 more weeks, since the population that was treated had comorbidities that made them immune compromised, we favor Pidotimod because it stimulates the immune cells of the innate and adaptive response, studies Like that of Ferrario et al., they highlight it as a molecule capable of improving the response to inflammatory stimuli acting on different immunological pathways [8, 16], Ning Zhao et al, report the effectiveness in respiratory tract infections of viral origin [17]. Esposito S et al, reports it as an immunomodulator that can be given at the same time as an antibiotic with a good response [18], Claudio Ucciferri et al, and n a study in paucisymptomatic patients infected by SARS-CoV2, found and reported a significant reduction in systemic symptoms of the disease [19], other recent studies also recommend it [20, 21, 22]. The use of antibiotics was limited to patients who presented data compatible with community pneumonia with bacterial over aggregation, in which we covered the most frequent germ Streptococcus pneumoniae, the criteria was by laboratory and imaging and associated comorbidity. Initially prescribing amoxicillin as recommended by recent studies [23, 24, 25].

Conclusion

The new coronavirus SARS CoV-2 “COVID-19” has been epidemiologically presented throughout the year, so it is extremely important to be preventive with ourselves and our family environment and with patients, indicating immunization according to age, but in the case of adults and specifically for this disease, the anti-influenza vaccine and the vaccine against Streptococcus pneumoniae and obviously the vaccine for SARS-CoV2 that is being applied throughout the world, plus strengthening the immune system with immune modulars, this strategy should be Recommend especially to frail or elderly subjects due to immune senescence, to prevent the appearance and reduce the duration of viral or bacterial respiratory tract infections and anticipate the appearance of complications plus continue with good personal hygiene practices, use of masks and a tight mask, avoid places with a lot of people and keep a distance of 1.5 meters with other people, to prevent infection in this case by SARS-CoV2 and as physicians to control the source of infection, provide an early diagnosis, inform, isolate, generate supportive treatment and publish.