DISCUSSION
Recently, COVID-19 infection, declared as a pandemic, has been
influencing many clinical practising and daily-life. Some hospitals have
been begun to serve for only COVID-19 infected patients except for
patients who had recourse to emergency service, hematology and oncology
clinics and also some elective surgical operations were delayed in our
country. In this study, we aimed to evaluate hematology consultation
requested in such a pandemic period.
In our study, we reported 82 patients during two months in the pandemic.
The mean age was 49,5 (18-83), which was consistent with James’s study
published in 2015.9
The risk of COVID-19 infection is higher in immunocomprimised patients
and cancer patients who received chemotherapy.7 In a
retrospective cohort, Fox et al. reported 55 patients with hematological
disorders and COVID-19 infection who were tested using PCR or diagnosed
with based on radiological findings.10 Only eight
patients was suspected with COVID-19 in our study, and the frequency of
suspicion in patients with the previously diagnosed hematological
disorder was 42,9%, which was higher significantly compare to patients
without previously diagnosed (p=0,018). On the other hand, the frequency
of suspicion of COVID-19 in in-patients was also higher than
outpatients, 19,4% and 2,2% (p=0,019), respectively. However, only two
of eight patients had PCR-positive. Interestingly, although a
significant difference to the frequency of suspicion of COVID-19 was not
found between patients new hematologic diagnosed and others, COVID-19
infection was diagnosed concomitant a new hematologic malignancy, CLL
and MCL, in both PCR-positive patients. These data show that the
findings of COVID-19 may be similar to findings of hematologic
malignancies.
In our study, patients previously diagnosed hematologic disorder were
not diagnosed with COVID-19 infection although He et al. reported that
as high as 10% of patients with hematologic malignancies were COVID-19
infected in a retrospective cohort.11 We explain this
paradox as follows. We evaluated only consultations and only the early
period of pandemic in this study. Additionally, in our university
hospital, during the pandemic, most of the clinics have been utilized as
a COVID-19 clinic and hematologist and some of the assistants in the
internal medicine have been worked in these clinics. Thereby, formal
consultation from some of the patients may not have requested.
Many clinics request hematology consultation in daily practice.
Gynecology is the most common clinic requested consultation in our
study. The most cause of these consultations was thrombocytopenia, one
of the common problems during pregnancy in 12 patients. In a
retrospective series, Parnas et al. reported that gestational
thrombocytopenia occurs 59% of the 199 pregnant
women.12 However, the frequency of gestational
thrombocytopenia in our study was 41%. The lower ratio may be due to a
low number of patients and some ethological tests in some patients
having not been completed yet. Causes of other consultations requested
from gynecology were anemia, splenomegaly and to discuss for using low
molecular weight heparin. Anemia and splenomegaly were found to be
associated with pregnancy as a result of the etiological evaluation.
As seen in Table 3, drug-related cytopenia is found as the most common
diagnosis. Of the 11 patients with cytopenia, six were neutropenic,
three were thrombocytopenic, and two were both. Because any patient had
not a deep level of cytopenia, a detailed evaluation was delayed to
period which after the pandemic and taking of the suspect drug was
discontinued only. These consultations were requested with the following
clinics: oncology, psychiatry, rheumatology and neurology. Oncology is
one of the clinics; the second common requested consultation in our
study. Thrombocytopenia, anemia, lymphadenopathy and leukocytosis were
causes of the consultation. Particularly drug related-thrombocytopenia
may be a significant reason to discontinue chemotherapy. Ten Berk et al.
reported that the frequency of chemotherapy-induced thrombocytopenia is
3% to 4% and patients received platelet transfusion are less than
3%.13 Severe thrombocytopenia is not usual in also
COVID-19 infection. It was reported that only 5% of patients had
thrombocyte lower than 100.000/µL, in a case series, in Wuhan, whereas
lymphopenia was the most common blood count abnormality in COVID-19
infection. Leukopenia may be determined in 33,7% of
patients.14-16 However, leukopenic and
thrombocytopenic patients had no symptoms and signs of COVID-19, so they
were not tested by PCR.
COVID-19 infection may lead to a hypercoagulable and dyscoagulable
situation, especially in patients with severe infection. Elevated
D-dimer levels and fibrinogen can be distinguished and
prognostic.17,18 Four patients with thromboembolic
disorder in our study had not suspicion of COVID-19. Thus, they were
researched for only their own disease.
The limitation of our study may be the absence of comparing between the
COVID-19 era and the pre-pandemic period and the existence of 12
patients whose evaluation has not been completed yet. However, our study
is crucial because, to our knowledge, there is not any study that has
investigated hematology consultation during the COVID-19 pandemic in the
literature.
Patients are referred to hematologist due to suspicion of hematologic
disease for various symptoms and findings in daily practice, although
many hematologic disorders are rare. Because of similarities in symptoms
and signs, COVID-19 related hematologic complications and applying to
hospital by non-COVID-19 causes; we think that hematology consultations
will continue, as long as the pandemic continues.