Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : August | Volume : 16 | Issue : 8 | Page : EC41 - EC46 Full Version

Comparative Assessment of WBC Scattergram, Histogram and Platelet Indices in COVID-19 and Non COVID-19 Patients: A Cross-sectional Study


Published: August 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56018.16794
Nikhil, Subhashish Das, Raju Kalyani

1. Postgraduate, Department of Pathology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research (SDUAHER), Kolar, Karnataka, India. 2. Professor, Department of Pathology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research (SDUAHER), Kolar, Karnataka, India. 3. Professor, Department of Pathology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research (SDUAHER), Kolar, Karnataka, India.

Correspondence Address :
Subhashish Das,
Department of Pathology, Sri, Kolar, Karnataka, India.
E-mail: daspathology@gmail.com

Abstract

Introduction: Coronavirus Disease 2019 (COVID-19) is an extremely transmissible infectious disease. Detection of coronavirus by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) requires expert skills and moreover, it is not widely available in all the laboratories.

Aim: To evaluate Red Blood Cell (RBC), platelet histogram and White Blood Cell (WBC) scattergram graphic patterns and interpretation of corresponding parameters along with peripheral smear in 500 COVID-19 RT-PCR positive study cases (COVID-19) and to compare them with normal study controls (non COVID-19).

Materials and Methods: This was a laboratory-based observational study, conducted at a fully accredited National Accreditation Board for testing and calibration Laboratories’s (NABL) Central Diagnostic Research Laboratory, RL Jalapa Hospital Tamaka, Kolar, Karnataka, India from September 2020 to April 2021. RBC, platelet histogram, WBC scattergram graphic patterns with corresponding parameters were noted in RT-PCR COVID-19 positive patients and compared with controls using (Automated Haematology Analyser XN11500). Cases were further subcategorised into moderate and severe categories. For statistical analysis, Chi-square test or Fisher’s exact test, Independent t test was used for assessing qualitative and quantitative data respectively. Mean and standard deviation were depicted in box plots. Receiver Operating Characteristic (ROC) curve was used for predicting severity. A p-value <0.05 was considered statistically significant.

Results: Among 500 subjects, males were 359 and females 141 with the mean age 50.5 years. Present study showed a characteristic finding of “sandglass” effect in WBC scattergram which is described as discontinuous cluster of plasmacytoid lymphocytes. RBC histogram and parameters did not show any significant changes. In severe COVID-19 cases among WBC parameters most common finding was neutrophilia. Platelet Lymphocyte Ratio (PLR), Platelet Monocyte Ratio (PMR), Platelet Neutrophil Ratio (PNR) were statistically significant in severe COVID-19 cases (p-value <0.001) corresponding ROC curve for WBC and platelet showed WBC count and PLR as the significant parameter in severe COVID-19 positive cases.

Conclusion: Current study reported a specific and unique sandglass effect in WBC scattergram in severe COVID-19 subjects which can help the physicians for predicting the severity of disease and to prevent further progression of disease.

Keywords

Coronavirus Disease 2019, Haematological indices, Red blood cell

The adverse effects of coronavirus disease 2019 (COVID-19) pandemic have been more pronounced in the developing countries with poor socio-economic conditions with no universal health coverage facilities. Although molecular diagnostic methods such as RT-PCR is considered as a hallmark for the final diagnosis of COVID-19 infections, better diagnostic method which is more economical, readily accessible to the general population and can be easily performed in the laboratory without requirement of specially skilled manpower. Hence, author undertook this study based on WBC scattergram, histogram along with platelet indices in COVID-19 infected cases. Histogram, although a neglected part of automated hemogram, when interpreted scientifically can provide valuable clinical information both for diagnostic as well as for prognostic purposes (1). To the best of our knowledge, there is paucity of studies on the role of histogram evaluation and its clinicopathological correlation in COVID-19 infections. One study is done by Foldes D et al., (2) regarding the same concept. Our study is one such effort in that direction so as to evaluate if routine and cost effective investigations like Complete Blood Count (CBC) and its associated histogram could lead to a better and judicious allocation of financial and human resources for combating COVID-19 infections particularly in a resource constraint setup like ours.

The objectives of the study were to evaluate the graphic patterns of histogram, WBC scattergram, platelet indices in COVID-19 positive patients and further comparatively assess the difference of graphic patterns and platelet indices between moderate and severe COVID-19 cases and compare them with controls.

Material and Methods

This was a laboratory-based observational study, conducted at a fully accredited National Accreditation Board for testing and calibration Laboratories’s (NABL) Central Diagnostic Research Laboratory, RL Jalapa Hospital Tamaka, Kolar, Karnataka, India from September 2020 to April 2021. The study was approved by Institutional Ethical Committee IEC No. SDUMC/KLR/IEC/60/2021-22) and written informed consent was obtained from all the study participants.

Sample size calculation: Sample size is estimated using 95% confidence interval and an absolute error of 10%, comes to 500. Formula used for estimating sample size is as follows-

n=Z2 1-α/2 p(1-p) / d2

d=absolute precision 0.03, α/2=desired confidence interval 95%, p=expected proportion=0.6,Z2=level of confidence according to the standard normal distribution (for a level of confidence of 95%, Z=1.96).

p=estimated proportion of the population that presents the characteristic (when unknown p=0.5).
d=tolerated margin of error (the real proportion within 10%).

Utilising the above values sample size estimated to be around

When p=1/2 (0.5)
n=(z)2 / 4d2

To calculate with a 95% level of confidence and a margin of error of 10%, n=(1.96)2/4(0.05)2=500.13

Socio-demographic data of the all the study participants was collected from hospital records. Standard protocols were followed for collection of venous samples in EDTA (Ethylenediamine-tetraacetic acid) vial for estimation of CBC. While collecting blood samples, COVID-19 safety protocols were followed including utilization of Personal Protective Equipment (PPE). Following parameters were evaluated which included CBC, RBC and platelet histogram, WDF (WBC differential fluorescence) scattergram along with peripheral smear. All these parameters were analysed on five part fully Automated Hematologyanalyser (Sysmex XN 11500) which was daily calibrated as per NABL quality control standards. Various ratios were calculated from the haematological parameters.

Inclusion criteria: All healthy adult subjects without any clinical symptoms were taken as study controls. Study controls were all the above age of 18 years who tested negative for COVID-19 by RT-PCR without any clinical symptoms consistent with COVID-19 and all subjects above 18 years of age who tested positive on RT-PCR were considered as COVID-19 positive cases and categorised into mild, moderate and severe. Similar to study done by Osman J et al., mild categories data was not collected as these patients had undergone uneventful recoveries (3). As per Zhou F et al., protocol, 500 cases were further categorised into moderate (n=266) and severe (234).

• Moderate category subjects included who clinically presented with fever, sore throat, cough but not fulfilling the criteria of severe disease.
• Severe COVID-19 subjects included patients with respiratory rate of more than 30 times/min, oxygen saturation ≤ 90% in resting state or in respiratory failure in need of mechanical ventilation or in state of shock (4).

Exclusion criteria: Subjects with history of cardiovascular disease, haematological and thromboembolic disorders, history of any trauma and surgery in past six months, bedridden patients and pregnant females, patients on anticoagulants (as anticoagulants can alter the CBC parameters) were excluded from the study.

Procedure

The RBC parameters evaluated along with RBC histogram included Haemoglobin (Hb), RBC count (Red blood cell count), PCV (Packed Cell Volume), Mean Corpuscular Volume (MCV), Mean Corpuscular Haemoglobin (MCH), Mean Corpuscular Haemoglobin Concentration (MCHC) and RDW (Red cell Distribution Width). WBC parameters evaluated with WBC scattergram included WBC count, neutrophils, lymphocytes, eosinophil’s, basophils and monocytes. Platelet parameters evaluated with platelet histogram included platelet count, MPV (Mean Platelet Volume), Platelet Distribution Width (PDW), Platelet Large Cell Ratio (P-LCR), Plateletcrit (PCT). Ratios derived from these parameters mainly platelet indices PLR (Platelet-Lymphocyte Ratio), PMR (Platelet Monocyte Ratio), PNR (Platelet Neutrophil Ratio) were evaluated in both cases and controls.

Statistical Analysis

Data collected were entered into Microsoft excel data sheet and was analysed using Statistical Package for Social Sciences software (SPSS) version 22.0 (IBM SPSS Statistics, Somers NY, USA). Categorical data was represented in the form of frequencies and proportions. Chi-square test or Fisher’s exact test was used as test of significance for qualitative data. Continuous data was represented as mean and standard deviation demonstrated in the box plots. Independent t-test was used as test of significance to identify the mean difference between two quantitative variables. ROC curve was used to analyse the efficiency of various parameter in predicting severity. A test that predicts an outcome no better than chance has an area under the ROC curve of 0.5. An area under the ROC curve above 0.8 indicated fairly good prediction. For graphical representation of data Microsoft excels and Microsoft word was used to obtain various types of graphs. A p-value (Probability that the result is true) of 0.05 was considered as statistically significant.

Results

Demographic parameters of COVID-19 subjects

A total of 500 COVID-19 positive patients were included for the study while 500 patients served as controls. On basis of disease severity, subjects were divided into moderate (n=266) and severe (n=234) categories and the mean age of the patients was 50.5 years with more cases observed in males (n=359) as compared to females (n=141) with p-value of 0.725 which was not substantially significant. No significant difference was found between gender and severity (Table/Fig 1). In present study, maximum distribution of COVID-19 positive cases in the age group between 41-60 years was 236 (47.2%) followed by 61-80 years 120 (24%) followed by 21-40 years 110 (22%), 81-100 years 22 (4.4%) and ≤20 years 12 (2.4%) (Table/Fig 2). In moderate COVID-19 cases, out of 236 patients, 124 (52.5)% of the patients were in the age group of 41-60 years. Out of 120, 70 (58.3%) patients were in the age group of 61-80 years. Out of 110 patients, 72 (65.4%) patients were in the age group of 21-40 years.

Histogram and WBC scattergram

WBC differential fluorescence scattergram: One of the most significant finding of our study was the observation regarding “sandglass” effect which is described as discontinuous cluster of plasmacytoid lymphocytes represented by more than 4 dots in upper graduated column of scattergram depicted in (Table/Fig 3)a, (Table/Fig 3)e which is considered as a feature of COVID-19 infection as no other viral infective causes are known to demonstrate such kind of features in the scattergram. In current study, 68.3% (160/234) of the severe COVID-19 patients showed similar pattern of “sandglass effect” in WBC scattergram. Age and sex matched controls did not demonstrate sandglass effect as depicted in (Table/Fig 3)f. Lymphocyte with eccentric round nucleus and basophilic cytoplasm with perinuclear hof can be appreciated in above (Table/Fig 4).

RBC Histogram: RBC histogram represented a Gaussian or Bell shaped distribution in 95% of cases (Table/Fig 5)a with 3% of cases showed microcytic RBC’s (Table/Fig 5)b with curve deviated towards left and 2% of cases showed macrocytic RBC’s (Table/Fig 5)c with curve deviated towards the right in COVID-19 positive cases as reflected in the histogram.

Platelet Histogram: The normal platelet histogram curve starts and ends at the baseline and should lay between upper Platelet Discriminator (PU) and lower Platelet Discriminator (PL) (Table/Fig 5)d. In the present study, thrombocytopenia curve in platelet histogram was observed in 210 cases (42% of cases) (Table/Fig 5)e.

Haematological parameters of COVID-19 patients versus controls

Leucocytosis, neutrophilia, lymphopenia were characteristic findings noted in COVID-19 patients. On comparing COVID-19 patients (n=500) with controls (n=500), there was no substantial significant difference found in the RBC parameters and for WBC parameters statistical significant difference was found for WBC count, neutrophils, lymphocytes, eosinophil’s, monocytes (p-value <0.001) and for platelet parameters PLR, PMR and PNR were found to substantially significant between the two categories (p-value <0.001) (Table/Fig 6).

Hematologic parameters of COVID-19 patients based on severity of disease

COVID-19 patients were further classified into moderate and severe, statistically significant differences were observed in WBC count, neutrophils, lymphocytes, eosinophil’s, PLR, PMR, PNR. The ratios PLR, PMR and PNR were found to be increasing uniformly from moderate to severe categories (Table/Fig 6). Box plots demonstrating differences in platelet indices profile between moderate and severe categories of COVID-19 are depicted in (Table/Fig 7).

ROC curve for WBC parameters showed that neutrophils as depicted in (Table/Fig 8)a can be considered as crucial factor with Area Under Curve (Table/Fig 8)c (AUC: 0.967) to differentiate between moderate and severe cases. ROC curve for platelet parameters as depicted in (Table/Fig 8)b. PLR (AUC: 0.746) can be considered as a factor for distinguishing moderate and severe cases (Table/Fig 8)d.

Discussion

Male preponderance was seen in present study. Possible mechanisms for higher proportion of males being affected have been proposed, one is elevated expression of ACE-2 receptors (Angiotensin-converting enzyme-2 receptors) in males in comparison to females. Other is sex-based immunological differences driven by gender hormone and X chromosome. Major factor considered is lifestyle habits as high levels of smoking and drinking habits among males as compared to females. Irresponsible attitude of men towards basic preventive measures such as regular hand washing, use of sanitisers, wearing of face mask and lack of proper compliance regarding the need to strictly follow home isolation (5).

The present study is the first Indian study catering providing important insights into scattergram and histogram patterns induced by COVID-19 from the Indian perspective. The current study reported a specific “sandglass” effect on the WBC scattergram of COVID-19 positive patients. No mention of such observation of sandglass effect in COVID-19 has been documented in any of the Asian/or Southeast-Asian studies as per our review of literature. In sandglass pattern, plasmacytoid lymphocytes are represented by more than 4 dots in upper graduated column of scattergram (6),(7). This pattern was observed in severe COVID-19 cases corresponding to which plasmacytoid lymphocytes are reflected in the peripheral blood smears. Plasmacytoid lymphocytes are absent in healthy subjects and plasmacytoid lymphocytes have been reported in COVID-19 patients as demonstrated by the study done by Foldes D et al., (2) Further immunological exploration is needed to validate these findings. Although WDF scattergram did not show sandglass effect in controls whereas plasmacytoid lymphocytes were noted in controls. Present study demonstrates that WDF scattergram can be an effective screening method to detect severity in COVID-19 patients before higher level investigations are ordered as reflected in results of the current study where 68.3% of severe COVID-19 positive cases demonstrated sandglass effect and it is a simple, economical and non invasive diagnostic method. In COVID-19 associated lymphopenia, WDF scattergram analysis appears to be more accurate than peripheral blood smear and demonstration of plasmacytoid lymphocytes can be a useful alternative for hematology centres where WDF scattergram is not available (8),(9). “Sandglass effect ” on WDF can acts as a reliable tool in assisting physicians to pilot the medical management of suspected symptomatic COVID-19 subjects at the time of admission. WDF is of great diagnostic help particularly in a rural and resource constraint set up centre as ours where capital intensive and radiological interventions are not readily available and most of the patients belong to poor socio-economic background having variable non specific clinical presentation (3).

RBC Histogram, Normal RBC Histogram has two discriminators RBC Lower discriminator (RL) and RBC upper discriminator (RU). RL discriminator fluctuates between 25 and 75 fl. RU discriminator fluctuates between 200 and 250 fl (10). In the present study, RBC histogram and platelet histogram did not show major variations in graphic patterns when both cases and controls were assessed. COVID-19 is a multisystemic organ disease caused by SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2) (11). It is considered to be more contagious than previous SARS-CoV that occurred in 2003 and or MERS-CoV (Middle East Respiratory Syndrome Coronavirus) that occurred in 2012 (12),(13),]14]. SARS-CoV-2 essentially affects the lung, leading to Acute Respiratory Distress Syndrome (ARDS). The possible pathogenic mechanism considered is the virus attaches to the ACE-2 receptors and enters into alveolar epithelial cells stimulating a cytokine storm resulting in inflammatory response and ultimately resulting in damage to the tissues (15). These cytokines can induce significant alterations in the hematopoietic cells, mainly neutrophils and lymphocytes. WBC count and neutrophil counts were significantly higher in COVID-19 patients, especially in severe COVID-19 positive patients. Result of present study were similar to the study done by Chen N et al., (16), Ding X et al., (17).

The findings for male being more affected were identical to study done by Oscelik N et al., showing higher proportion of males being affected as compared to females (18). The probable reason for increased WBC count and neutrophil can be prolonged hypoxia in COVID-19 positive subjects stimulating release of granulocytes from bone marrow as a compensatory mechanism (19). Similar findings in ROC curve for WBC parameters which showed that neutrophils can be considered as vital factor to differentiate between moderate and severe cases. Lymphopenia was observed in the current study. Plausible mechanisms to explain lymphopenia, one is that virus results in lymphocyte death by targeting lymphocytes which express the ACE-2 receptor and other potential mechanism to be considered are cytokines (tumour especially Interleukin-6 (IL-6) which is a key interleukin released in COVID-19 disease can induce deficiency of lymphocytes (20). Study done by Guan WJ et al., (15) showed lymphopenia in 82.1% patients. In lung infection caused by virus, eosinophil’s have a tendency to get assembled in infected tissues to resist the virus infection therefore eosinopenia is noted (21).

Platelet count serve as a sensitive indicator for severity of disease. In present study, the difference between platelet counts between cases and controls were not statistically significant. Changes in platelet count might be due to viral invasion of hematopoietic cells or invasion of bone marrow stromal cells (22),(23). Normally the platelet curve is left skewed however, in case of thrombocytosis, curve is elevated and in case of thrombocytopenia, the curve is depressed from the normal. In case of multipeak platelet anisocytosis, multiple peaks are observed with PL and PU flags, PL flag appears when lower discriminator exceeds by >10% and PU flag appears when upper discriminator exceeds by >40% (24). In the present study platelet indices such as PLR,PMR,PNR were statistically significant. PLR, PMR were higher in severe cases and PNR was on lower side in severe cases and be utilised as biomarker for evaluation of the severity of infection. The results of current study were consistent with study done by Qu R et al., (25) and stated that PLR can be a novel marker for monitoring severity of disease in COVID-19 subjects. Similar findings noted in ROC curve for platelet parameters PLR (AUC: 0.746) can be considered as a factor for distinguishing moderate and severe cases.

Limitation(s)

Reported associations between hematological parameters, scattergram and histogram patterns and severity of disease cannot be concluded as it is a unicentric study. Large multicentre studies are required to overcome these limitations and further substantiate findings of the current study.

Conclusion

The most common hematological findings noted in COVID-19 patients in present study were leucocytosis, neutrophilia, lymphopenia, eosinopenia. PLR, PMR, PNR platelet indices can be considered as biomarkers for predicting severity in COVID-19 subjects. ROC curve depicted neutrophils and PLR can acts as important parameters to distinguish severe from moderate disease. A specific and unique pattern “sandglass effect” in severe COVID-19 subjects was reported. Current study provides vital insights regarding this topic which can help the physicians for predicting the severity of disease and clinicians can take efficacious treatment measures well in advance and prevent further progression of disease.

Declaration: The study has been presented in 62nd Annual Conference of Indian Society of Haematology and Blood Transfusion (ISHBT).

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DOI and Others

DOI: 10.7860/JCDR/2022/56018.16794

Date of Submission: Mar 04, 2022
Date of Peer Review: Apr 04, 2022
Date of Acceptance: May 31, 2022
Date of Publishing: Aug 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 10, 2022
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• iThenticate Software: Jun 14, 2022 (16%)

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