COVID-19 Pneumonia through a lens of surgeon and physician: An experience study in Basrah City

The pandemic of SARS-CoV-2 virus represented the major disaster in the world in this century. It impacted all fields in the life and in all countries in the world. Imaging techniques play an important role in supporting the diagnosis, grading, severity, guiding treatment, diagnosing complications, and assessing the response to treatment. More than 500 patients confirmed diagnosis with COVID-19 were consulted at private clinics in Basrah, Iraq from December 2019 till April 2021. Chest X-ray is generally the first-line imaging test in patients with suspected or confirmed COVID-19 due to its usefulness, availability and low cost for our locality peoples. The chest X-ray may be normal in mild cases of disease. The most common findings are airspace opacities, which may be consolidations or, less frequently, ground-glass opacities. Males were 70% whereas females constituted 30% of the sample. Above 50 years was the age of the majority of patients. The mean age was 50.7±12.88 years. Smoker patients were 60%. Approximately, 49% of patients were obese, 20% overweight, and 31% with normal weight. Comorbidities were recorded in 62% of patients. In relation to marital status, 35% married, 23% divorce, 17% widowed, and 25% single. About 24% of patients were employer, 45% had no jobs, 25% were housewives, and only 6% were students. CXR play an important role in the management of patients with suspected or confirmed COVID-19. COVID-19 pneumonia is characterized by the presence of ground-glass opacities and/or consolidations, which are typically bilateral and peripheral.


Introduction
COVID-19 is a newly emerged disease, it caused by a single stranded RNA genome. The disease has led to a public-health emergency. As a result, WHO has announced corona virus disease as a pandemic at December 2019 [1]. There were more than 182 million cases recorded, and 3.9 million deaths till July 2021 [2]. Serious cases, COVID-19 can be complicated by acute respiratory distress syndrome (ARDS), cardiac injury, septic shock, sepsis, acute infection of kidney and multi-organ failure [3]. The main pathology beyond that is resulted from direct cytopathic effect of the virus on pneumocytes, the late is due to a profuse inflammatory reaction similar to bacterial sepsis such as (Hemophagocytic lymphohystiocytosis) [3]. During the early phase the innate immune response occur, and if it fail to control the disease, mild symptoms will appear as a result of viral cytopathic effect and innate immune response. Subsequently, this will enhance the adaptive immune response. In other term, the inflammatory cytokines will significantly increase causing tissue damage and clinical deterioration. Patients may exhibit a clinical phenomenon, when patients suddenly deteriorate after a period of stability and improvement [4]. Symptoms of disease including all body system such as fever, myalgia and headache. Upper respiratory symptoms are rhinorrhea, sore throat. Lower respiratory symptoms are dyspnea, chest tightness, cough and sputum. Gastrointestinal symptoms are nausea, vomiting, and diarrhea. CNS and CVS also involvement [5]. Chest x-ray play an important role in initial detection of COVID-19. Peripheral and basal patchy ground glass opacification, high number of patches or diffuse opacification are the main features noticed of the severity of the disease [6].
Here, we showed a number of chest x-ray photography of several COVID-19 patients, diagnosed in our private clinic, to introduced the real picture about the size of this disaster.

Study design and setting
More than 500 patients confirmed diagnosis with COVID-19 were consulted at private clinics in Basrah, Iraq from December 2019 till April 2021. All patients in this study were diagnosed according to the WHO procedure [2].

Data collection
Clinical data were collected in private clinic and patients' data were reviewed. Those including demographic information and CXR findings.

Investigation
WBC count tends to be normal, Lymphopenia can appear in 80%, mild thrombocytopenia also can be found, Platelet count < 100 may be associated with poor prognosis. Generally D-Dimer commonly elevated (>0.28ng/L) testing. DIC may develop over time and associated with poor prognosis. IL6 elevated (>24.3), C-reactive protein, it's an important marker to pursue the disease severity, prognosis and mortality. Positive PCR for other Viruses doesn't mean patient isn't infected with COVID-19. Additionally, PCR can diagnose four Coronaviruses which cause mild illnesses. Nowadays, the standard test for the detection of SARS-CoV-2 is reverse transcription-polymerase chain reaction (RT-PCR), usually done on a sample of nasopharyngeal or respiratory secretions. RT-PCR is believed to be highly specific, but its sensitivity can range from 60-70% to 95-97%, so false negatives are a real clinical problem, especially in the early stages. Sensitivity varies by time elapsed since exposure to SARS-CoV-2. The rate of false negatives is 100% on the first day after exposure, then decreases to 38% on the day of onset of symptoms and drops to 20%, its lowest level, on the third day of symptoms [7]. Atypical (uncommon): These include lobar consolidation, lung nodules or masses, miliary pattern, cavitation and pleural effusion, reported in only 3% of patients and more typical of advanced disease Chest X-ray is generally the first-line imaging test in patients with suspected or confirmed COVID-19 due to its usefulness, availability and low cost for our locality peoples. The chest X-ray may be normal in mild cases of disease [8,9]. The most common findings are airspace opacities, which may be consolidations or, less frequently, ground-glass opacities [8]. CXR findings have been divided into four categories [10][11][12][13] (Table 1).

Results
The demographic of 500 patients were illustrated in Table 2. Males were 70% whereas females constituted 30% of the sample. Above 50 years was the age of the majority of patients. The mean age was 50.7±12.88 years. Smoker patients were 60%. Approximately, 49% of patients were obese, 20% overweight, and 31% with normal weight. Comorbidities were recorded in 62% of patients. In relation to marital status, 35% married, 23% divorce, 17% widowed, and 25% single. About 24% of patients were employer, 45% had no jobs, 25% were housewives, and only 6% were students. ( Table 2). CXR findings were showed in figures 2.

Conclusion
CXR play an important role in the management of patients with suspected or confirmed COVID-19. COVID-19 pneumonia is characterized by the presence of ground-glass opacities and/or consolidations, which are typically bilateral and peripheral. As regards clinical course, reparative changes appear from the second week of the disease, characterized by subpleural lines, greater subpleural distortion and bronchial dilations.

Acknowledgments
Thank you for Dr. Rasha Alsaad for their helping.

Disclosure of conflict of interest
There was no conflict of interest to be declared.

Statement of informed consent
Informed consent was obtained from all individual participants included in the study.