Respiratory and Non-Respiratory Symptom Duration and Its Association with Severity of Radiographic Edema in Patients with COVID-19

Abstract

Background: Symptoms of COVID-19 are often indistinguishable from other upper and/or viral lower respiratory tract infections, with some studies suggesting higher risk for severe disease and worse outcomes in certain symptom groups compared to others. We sought to evaluate the association of specific symptom/symptom groups and their duration with severity of radiographic edema - a clinical feature that has been independently associated with poor outcomes in patients with COVID-19. Methods: We collected CXRs, demographic and clinical data from patients with a naso- and/or oropharyngeal swab positive for SARS-CoV-2 PCR visiting the ED for COVID-19-related symptoms between March and September 2020 in a large, multi-hospital healthcare system. Two independent reviewers quantified radiographic edema using the Radiographic Assessment of Lung Edema (RALE) scoring system. We collected symptom duration based on the following groups: overall (total), dyspnea, cough, constitutional (fever, chills, malaise, myalgia), nausea and/or vomiting, and diarrhea. We assessed for correlation between radiographic edema and symptom duration as continuous variables using Pearson's R and based on symptom duration quartiles using one-way analysis of variance (ANOVA). Results: 433 symptomatic patients with available CXRs were identified (median age 54, 52% female). Inter-rate agreement for RALE score was excellent (interclass correlation coefficient = 0.89, 95% CI 0.87 - 0.92, p < 0.0001). Radiographic edema associations were as following (% of patients with symptom[s], Pearson's R and respective p-value;ANOVA p-value): total duration (r = 0.19, p < 0.001;p < 0.001), constitutional (84%, r = 0.23, p < 0.00;p < 0.001), dyspnea (55%, r = 0.14, p = 0.03;p = 0.1), cough (72%, r = 0.25, p < 0.001;p < 0.001), diarrhea (22%, r = 0.02, p = 0.83;p = 0.71) and nausea and/or vomiting (17%, r = 0.04, p = 0.71;p = 0.63). Conclusions: In a multi-center study of patients presenting to the ED with symptomatic COVID-19, severity of radiographic edema was associated with overall duration of symptoms, constitutional symptoms and cough but not with duration of dyspnea, diarrhea or nausea and/or vomiting.