April 28, 2020

Review shows diabetes increases mortality and severity of COVID-19, and ocular symptoms of SARS‐CoV‐2

By Denise Baez

NEW YORK -- April 28, 2020 -- In today’s DG Alert, we cover the association between diabetes and increased mortality and severity in coronavirus disease 2019 (COVID-19) pneumonia, and ocular symptoms of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2).

A systematic review and meta-analysis of 30 studies comprising 6,452 patients showed that diabetes was associated with mortality, severity, and acute respiratory distress syndrome (ARDS) in COVID-19, although the association was weaker in older patients and patients with hypertension. 

The findings were published in Diabetes & Metabolic Syndrome: Clinical Research & Reviews.

Ian Huang, MD, Universitas Pelita Harapan, Tangerang, Indonesia, and colleagues scrutinised original research articles (no reviews, letters or commentaries) of adults diagnosed with COVID-19 with information on diabetes and clinical grouping or outcome of the clinically validated definition of mortality, severe COVID-19, ARDS, intensive care unit (ICU), and disease progression. 

Meta-analysis showed that diabetes was associated with composite poor outcome (risk ratio [RR] = 2.38; 95% confidence interval [CI], 1.88-3.03; P< 0.001; I2: 62%), including mortality (RR = 2.12; 95% CI, 1.44-3.11; P< 0.001; I2: 72%), severe COVID-19 (RR = 2.45; 95% CI, 1.79-3.35; P< 0.001; I2: 45%), ARDS (RR = 4.64; 95% CI, 1.86-11.58; P = 0.001; I2: 9%), and disease progression (RR = 3.31; 95% CI, 1.08-10.14; P = 0.04; I2: 0%). 

Meta-regression showed that the association with composite poor outcome was influenced by age (P = 0.003) and hypertension (P< 0.001). 

Subgroup analysis showed that the association was weaker in studies with patients with a median age ≥55 years (RR 1.92) compared with patients aged <55 years (RR 3.48), and in prevalence of hypertension ≥25% (RR 1.93) compared with <25% (RR 3.06). Subgroup analysis on median age <55 years-old and prevalence of hypertension <25% showed strong association (RR 3.33).

Limitations of the study included that data on diabetic/hypertensive medications were lacking and could not be analysed. Because most of the reports were from China, the samples might overlap across the reports. 

Another study, published in Acta Ophthalmologica, showed that ocular symptoms are relatively common in COVID‐19 disease and may appear just before the onset of respiratory symptoms. 

Nan Hong, MD, First Affiliated Hospital, Hangzhou, China, and colleagues evaluated ocular symptoms and ocular tropism of SARS‐CoV‐2 in a group of 56 patients with COVID‐19.

Of the patients, 15 (27%) reported ocular symptoms in the course of COVID-19, including sore eyes, itching, foreign body sensation, tearing, redness, dry eyes, eye secretions and floaters. Of these patients, 6 (11%) presented with ocular symptoms before the onset of fever or respiratory symptoms, and of these, 4 reported the appearance of ocular symptoms 1 to 7 days before the onset of fever or respiratory symptoms, while the remaining 2 patients were uncertain about the temporal aspects of their reported ocular symptoms. 

Two patients (~4%) developed conjunctivitis on the left eye after hospitalization. Conjunctival swab sample from the left eye of one patient showed positive virus RNA detection using real-time reverse transcription-polymerase chain reaction assay. One subject reported a floater in the right eye after hospital discharge.

Of the patients, 15 (27%) had aggravated ocular symptoms, of which 6 (11%) had prodromal ocular symptoms before disease onset.

The differences in mean scores of the Ocular Surface Disease Index questionnaire and Salisbury Eye Evaluation Questionnaire between before and after onset of COVID‐19 were all significant (P< 0.05 for both).

“At a practical level, it should be noted that patients with undiagnosed COVID-19 might present at eye care facilities with ocular symptoms, bringing about occupational exposure to staff and, in particular, the attending eye care professional,” the authors wrote. 

SOURCE: Diabetes & Metabolic Syndrome: Clinical Research & Reviews, Acta Ophthalmologica