**3. Results**

#### **3.1 Features of index cases (patients)**

Characteristics of a 75-year-old female patient who was reported as the first COVID-19 test positive patient in Rize on 13.03.2020, and a 69-year-old male patient who was positive on the tracheal aspirate COVID-19 test on 25.03.2020 were summarized as follows:

#### *3.1.1 The Index patient 1*

75 years-old, women. Place of birth and living: Rize province. The first-degree relative lives in Istanbul province. With the symptoms of fever, cough, shortness of breath, vomiting, chest pain, F.T was admitted to emergency service of Rize State Hospital on 10.03.2020 and she was hospitalized with diagnoses of primary hypertension (HT), congestive heart failure (CHF), acute sub-endocardial myocardial infarction (MI), non-ST elevated acute myocardial infarction (AMI), and acute renal failure (ARF). On 13.03.20, she was transferred to the RTEU Training and Research Hospital Cardiology service. On 13.03.2020, the patient's nasopharyngeal COVID-19 sampling was performed. The patient was started on hydroxychloroquine 2x400 mg loading and 2x200 mg/day maintenance doses (po), azithromycin 1x500 mg/ day (po), oseltamivir 2x30 mg/day (po), and piperacillin-tazobactam 4x3.375 g (1.5 flacon) iv treatment. On the date of 22.03.2020, she was transferred 1st stage coronary intensive care unit and intubated due to the deterioration in general condition, unconsciousness, hypotension, bradycardia, cyanosis, and decreased urine output.

Radiologically, there was no apparent opacity on the The posteroanterior (PA) chest X-ray dated 16.03.2020 (**Figure 1a**). Newly developed opacities in the right lung were noticeable on the control radiography dated 23.03.2020 (**Figure 1b**). In the IV contrast-free axial CT section dated 24.03.2020, ground-glass opacities (GGOs) were observed in the upper lobes, and an endobronchial intubation tube was present in the trachea (**Figure 1c**).

On 25.03.2020 and 29.03 2020, patient's endotracheal aspirate (ETA)-COVID-19 test resulted in positive. There was no overseas contact history. However, there was, a history of contact with the positive case (daughter), who was living in Istanbul and detected her positivity in RTEU hospital. Unfortunately, patient died on 30.03.2020.

While being followed up in the cardiology service and coronary intensive care unit, the staff working in these units was thought to have been transmitted.

#### *3.1.2 The Index patient 1 and the expanse GGOs on CT*

Radiologically, there was no apparent opacity on the PA chest X-ray dated 16.03.2020 (**Figure 1a**). Newly developed opacities in the right lung were noticeable on the control radiograph dated 23.03.2020 (**Figure 1b**). In the IV contrast-free axial CT section dated 24.03.2020, GGOs were observed in the upper lobes, and an endobronchial intubation tube was present in the trachea (**Figure 1c**).

#### **Figure 1.**

*(a–c) Radiologically, there was no apparent opacity on the PA chest X-ray dated 16.03.2020 (a). Newly developed opacities in the right lung were noticeable on the control radiograph dated 23.03.2020 (b). In the IV contrast-free axial CT section dated 24.03.2020, GGOs were observed in the upper lobes, and an endobronchial intubation tube was present in the trachea (c).*

#### *3.1.3 The Index patient 2*

69 years-old, male. On 16.03.2020, he was hospitalized to the Pulmonology clinic with the diagnoses of hyperlipidemia, essential (primary) hypertension (HT), atherosclerotic heart disease, pacemaker use, and myalgia. There were 20 packs per month of smoking history for 25 years. The patient, whose preliminary diagnosis of viral pneumonia was interned, had a history of cough and sputum for 2 months, and had a fever since the last 3 days, lymphopenia, higher levels of CRP and D-dimer. SO2 levels were around 80 receiving with 6 lt/min O2 support and his tachypnea continued.

With prediagnosis of COVID-19, the nasopharyngeal (NF)-COVID-19 test performed on the same day was negative and this negativity continued the second NF-COVID-19 test carried on 20.03.2020. Patients' endotracheal aspirate (ETA)- COVID-19 test examined on 24.03.2020 was also negative.

Radiological findings of the patient were the following; Peripheral groundglass areas were detected in the axial Pulmonary CT Angiography section dated *Demographic, Clinical and Radiological Features of Healthcare Workers and Two Index Cases… DOI: http://dx.doi.org/10.5772/intechopen.99148*

#### **Figure 2.**

*(a-c) Radiological findings of the patient was the following; peripheral GGOs were detected in the axial pulmonary CT angiography section dated 19.03.2020 (a). Reticulonodular opacities were present on the PA chest x-ray of the same date (b). Newly developed opacities were detected in both lung upper lobes on the control graph taken on 4.04.2020. Electrodes and pacemaker were displayed in the left pectoral region (c).*

19.03.2020 (**Figure 2a**). Reticulonodular opacities were present on the PA chest x-ray of the same date (**Figure 2b**). Newly developed opacities were detected in both lung upper lobes on the control graph taken on 4.04.2020 (**Figure 2c**).

On 25.03.2020, the patient's ETA COVID-19 test was found as positive and the case was recorded as the second COVID-19 case of Rize province. The patient diagnosed by COVID-19 via clinical and radiological imaging findings and was given hydroxychloroquine 2x400 mg loading and 2x200 mg/day maintenance doses (po), azithromycin 1x500 mg/day (po), oseltamivir 2x30 mg/day (po), piperacillin tazobactam 4x3.375 g (1.5 flacons) iv route. He, unfortunately, died on 10.04.2020.

While the patient was followed up by clinics of pulmonology and infectious diseases, it was thought that the personnel working in these units caught infection.

#### *3.1.4 The Index patient 2 and the expanse peripheral GGOs on CT*

Radiological findings of the patient was the following; Peripheral GGOs were detected in the axial Pulmonary CT Angiography section dated 19.03.2020 (**Figure 2a**). Reticulonodular opacities were present on the PA chest x-ray of the same date (**Figure 2b**). Newly developed opacities were detected in both lung upper lobes on the control graph taken on 4.04.2020. Electrodes and pacemaker were displayed in the left pectoral region (**Figure 2c**).

#### **3.2 Demographic and clinical features of health personnel**

COVID-19 positive health workers among them were 27 and 63% (n = 17) of them were women and 37% (n = 10) were men and the mean age was 33.2 ± 6.9 years. Of 55.6% (n = 15) cases were from Coronary ICU, 25.9% (n = 7) of them from Cardiology, and 18.5% (n = 5) of them from Infectious diseases clinic's personnel. Occupational distributions of cases were follows; 51.9% (n = 14) were nurses, 29.6% (n = 8) were doctors, 11.1% (n = 3) were cleaning staff and 7.4% (n = 2) were secretaries. Male doctors were found to be significantly higher than female doctors (70% vs. 5.9%, p < .001, Fisher's exact test, see (**Table 1**).

Clinically, patients with symptoms including at least one symptom were 74.1% (n = 20). None of the HCWs had comorbidity. While 63% of the cases (n = 17) had a mild clinical level, 29.6% (n = 8) were of moderate and 7.4% (n = 2) were severe. None of them had severe clinical outcome and acute respiratory distress syndrome



*Demographic, Clinical and Radiological Features of Healthcare Workers and Two Index Cases… DOI: http://dx.doi.org/10.5772/intechopen.99148*

*a Mean (standard deviation)*

*b Median (minimum-maximum)*

*\* Fisher's exact test*

*CT: computerized tomography.*

#### **Table 1.**

*Descriptives of health personnel infected with COVID-19 in terms of gender.*

(ARDS) requiring intensive care follow-up. While 40.7% (n = 11) of the cases knew COVID-contact, 59.3% (n = 16) did not. The hospitalization value (days) of the patients was in the range 0–15.

The findings were classified as severe (1–14 days), moderate (1–7 days), and mild (no hospitalization days) considering the duration of symptoms, length of hospital stay, and treatment practices. Milddefines, very close to asymptomatic patients who received only hydroxychloroquine therapy whereas moderate defines, symptomatic findings were evident, those who received hydroxychloroquine and azithromycin therapy followed in hospital and severe means, respiratory symptoms were severe, supportive therapy- receiving oxygen, hydroxychloroquine- azithromycin and favipiravir therapy.

While the CT findings of the HCW were normal in 74.1% (n = 20), the appearance of ground glass was found in 25.9% (n = 7), reversed halo or atoll sign was found in 7.4% (n = 2), consolidation was present in 3.7% of the cases (n = 1). Bilaterally involvement was detected in 7.4% of the cases (n = 2), peripheral and dorsal involvement in 25.9% of the cases (n = 7). The involvement of the middle and sub-zones was detected in 18.5% (n = 5) of the cases. Especially in the female gender, 76.5% (n = 13) of them had normal CT findings (see **Table 1**).

#### **3.3 Comparison of laboratory measurements**

The laboratory measurements of the patients in the first week of admission were compared with the test results when the patients were discharged from the hospital or re-admitted for control (second week). Laboratory measurements of HCWs were carried out at the first when they had symptoms and the second when they healed, and results were compared. A significant reduction was found between the mean PLT (238.3 vs. 204.3103 /μL; z = −2.858, p = .004), MPV (10.0 vs. 9.5 fL; z = −2.161, p = .031), CRP (2.9 vs. 1 g/dL; z = −2.490, p = .013), Hgb (13.5 vs. 13.1 g/dL; z = −2.300, p = .021), LDH (91.1 vs. 47.2 U/L; z = −4.542, p < .001), CK (77 vs. 60 U/L; z = −3.340, p = .001), CK-MB (0.8 vs. 0.5 mg/mL; z = −2.212, p = .027), troponin (all second examinations were < 3.2, z = −2.032, p = .042), ferritin (151.7 vs. 95 ng/mL; z = −2.822, p = .005) levels whereas a significant increase was found the mean albumin (43.8 vs. 44.4 g/L; z = −2.000, p = .046), K<sup>+</sup> (4.1 vs. 4.3 mmol/L; t(26) = −2.213, p = .036) and Na<sup>+</sup> (137.5 vs. 138.2 mmol/L; t(26) = −2.174, p = .039) levels. The D-dimer had increased in 2 poor-clinical findings of HCWs, but their mean values were within normal limits (see **Table 2**).


*a Mean (standard deviation)*

*b Median (minimum-maksimum)*

*N: normal reference range; WBC: White blood cell; NE: neutrophil; LY: lymphocyte; N/L: neutrophil/lymphocyte; PLT: platelet.*

#### **Table 2.**

*Comparison of the first and second values of laboratory measurements.*

*Demographic, Clinical and Radiological Features of Healthcare Workers and Two Index Cases… DOI: http://dx.doi.org/10.5772/intechopen.99148*

#### **3.4 Imaging findings**

## *3.4.1 The HCW with the worst clinical findings and the expanse GGOs on CT*

44 year old male patient, it was noteworthy that in the first examination (**Figure 3a**), the GGOs observed in the lower lobe of the left lung expanded in the control examination on iv non-contrasted axial CT images obtained with an interval of 4 days (**Figure 3b**). In the control evaluation in the ground glass area (**Figure 3c**) located in the left lobe lower lobe posterobasal segment, fibrous bands developed (**Figure 3d**).

#### *3.4.2 The HCW with good clinical findings and the halo sign on CT*

41 year old female patient, in the CT images of 31.03.2020 (**Figure 4a**) and 5.05.2020 (**Figure 4b**), the minimum-intensity-projection coronal cross-sectional CT images show different areas of involvement. Right lung lower lobe findings (**Figure 4a**) declined in control, but consolidation developed with a reverse halo sign in posterobasal (**Figure 4b**).

### *3.4.3 The HCW with asymptomatic clinical findings and the minimal peripheral GGOs on CT*

34-year-old female patient, peripheral small-sized GGOs are observed in the iv non-contrasted axial CT images obtained every 10 days apart (**Figure 5a**). The GGOswere diminished but new ground glass areas developed (**Figure 5b**).
