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Journal of Peking University (Health Sciences) ›› 2022, Vol. 54 ›› Issue (1): 153-160. doi: 10.19723/j.issn.1671-167X.2022.01.024

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Clinical characteristics of influenza pneumonia in the elderly and relationship between D-dimer and disease severity

LI Jia1,XU Yu2,WANG You-ya3,GAO Zhan-cheng3,△()   

  1. 1. Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
    2. Department of Pulmonary and Critical Care Medicine, Beijing Jishuitan Hospital, Beijing 100035, China
    3. Department of Pulmonary and Critical Care Medicine, Peking University People’s Hospital, Beijing 100044, China
  • Received:2020-07-31 Online:2022-02-18 Published:2022-02-21
  • Contact: Zhan-cheng GAO E-mail:zcgao@bjmu.edu.cn
  • Supported by:
    National Science and Technology Major Project for Control and Prevention of Major Infectious Diseases of China(2017ZX10103004)

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Abstract:

Objective: To clarify the clinical characteristics of influenza pneumonia in the elderly patients and the relationship between D-dimer and the severity of influenza pneumonia. Methods: In the study, 52 hospitalized patients older than 65 years with confirmed influenza pneumonia diagnosed in Peking University People’s Hospital on 5 consecutive influenza seasons from 2014 were retrospectively analyzed. General information, clinical symptoms, laboratory data, treatment methods and prognosis of the patients were collected. The relationship between D-dimer and pneumonia severity was analyzed, and receiver operating characteristic (ROC) curve was used to evaluate the predictive value of D-dimer. Results: Among the 52 patients, 31 were male (31/52, 59.6%), the average age was (77.1±7.4) years, and 19 of them (36.5%) were diagnosed with severe pneumonia. About 70% patients presenting with fever. In the severe group, the patients were more likely to complain of dyspnea than in the non-severe group (14/19, 73.7% vs. 10/33, 30.3%, P=0.004), severe pneumonia group had higher level of CURB-65 (confusion, urea, respiratory rate, blood pressure, and age>65), pneumonia severity index (PSI), C-reactive protein, urea nitrogen, lactate dehydrogenase, fasting glucose, and D-dimer (P value was 0.004, <0.001, <0.001, 0.003, 0.038, 0.018, and <0.001, respectively), albumin was lower than that in the non-severe group [(35.8±5.6) g/L vs. (38.9±3.5) g/L, t=-2.348, P=0.018]. There was a significant positive correlation between the D-dimer at the first admission and PSI score (r=0.540, 95%CI: 0.302 to 0.714, P<0.001), while a significant negative correlation with PaO2/FiO2 (r=-0.559, 95%CI: -0.726 to -0.330, P<0.001). Area under the curve of D-dimer was 0.765 (95%CI: 0.627 to 0.872). Area under the curve of PSI was 0.843 (95%CI: 0.716 to 0.929). There was no statistically significant difference in test efficacy between the two (Z=2.360, P=0.174). D-dimer level over 1 225 μg/L had a positive predict value for influenza pneumonia in hospital death with a sensitivity of 76.92% and a specificity of 74.36%. Conclusion: Influenza pneumonia in the elderly always has atypical symptoms, dyspnea is a prominent feature in severe cases, D-dimer level is associated with the severity of influenza pneumonia, and greater than 1 200 μg/L has a good predictive value for in-hospital death in the elderly.

Key words: Aged, Influenza, human, Pneumonia, D-dimer

CLC Number: 

  • R563.1

Table 1

Demographic data and clinical characteristics of elderly patients with influenza pneumonia"

Items Total Severe group Non-severe group Statistical value P
Year
October 1, 2014 to March 31, 2015 7 (13.5) 2 (10.5) 5 (15.2) 1.288 0.863
October 1, 2015 to March 31, 2016 7 (13.5) 2 (10.5) 5 (15.2)
October 1, 2016 to March 31, 2017 6 (11.5) 2 (10.5) 4 (12.1)
October 1, 2017 to March 31, 2018 17 (32.7) 8 (42.1) 9 (27.3)
October 1, 2018 to March 31, 2019 15 (28.8) 5 (26.3) 10 (30.3)
Gender (male) 31 (59.6) 12 (63.2) 19 (57.6) 0.156 0.693
Age/years 77.1±7.4 76.3±7.6 77.5±7.4 -0.544 0.589
65-70 12 (23.1) 5 (26.3) 7 (21.2) 0.360 0.853
71-80 21 (40.4) 8 (42.1) 13 (39.4)
80- 19 (36.5) 6 (31.6) 13 (39.4)
Smoking history 16 (30.8) 5 (26.3) 11 (33.3) 0.279 0.598
Drinking history 6 (11.5) 4 (21.4) 2 (6.1) 2.655 0.103
Coexisting diseases
None 7 (13.5) 2 (10.5) 5 (15.2) 0.298 0.862
1-2 25 (48.1) 9 (47.4) 16 (48.5)
3 and above 20 (38.5) 8 (42.1) 12 (36.4)
Category of coexisting diseases
Coronary heart disease 14 (26.9) 6 (31.6) 8 (24.2) 0.330 0.764
Hypertension 21 (40.4) 8 (42.1) 13 (39.4) 0.037 0.538
Pulmonary diseases 19 (36.5) 7 (36.8) 12 (36.4) 0.001 0.972
Diabetes 15 (28.8) 8 (42.1) 7 (21.2) 2.564 0.126
Chronic renal diseases 5 (9.6) 2 (10.5) 3 (9.1) 0.029 0.610
Chronic liver diseases 6 (11.5) 2 (10.5) 4 (12.1) 0.030 0.620
Cerebrovascular diseases 10 (19.2) 3 (15.8) 7 (21.2) 0.228 0.633
Immune disorders 5 (9.6) 0(0) 5 (15.2) - 0.145
Hematological diseases 10 (19.2) 4 (21.1) 6 (18.2) 0.064 0.800
Cancer 11 (21.2) 4 (21.0) 7 (21.2) 0.020 0.638
Clinical characteristics
Fever 36 (69.2) 13 (68.4) 23 (69.7) 0.009 0.924
Pharyngalgia 14 (26.9) 4 (21.1) 10 (30.3) 0.524 0.543
Cough 29 (55.8) 10 (52.6) 19 (57.6) 0.119 0.730
Expectoration 16 (30.8) 6 (31.6) 10 (30.3) 0.009 0.924
Chest discomfort 16 (30.8) 4 (21.1) 12 (36.4) 0.706 0.401
Dyspnea 24 (46.2) 14 (73.7) 10 (30.3) 1.327 0.004
Hemoptysis 3 (5.8) 0(0) 3 (9.1) - 0.291
Vomiting/diarrhea 7 (13.5) 2 (10.5) 5 (15.2) 0.221 0.638
Myodynia 9 (17.3) 2 (10.5) 7 (21.2) 0.962 0.458
Rigor 4 (7.7) 1 (5.3) 3 (9.1) 0.296 0.543
Fatigue 18 (34.6) 4 (21.1) 14 (42.4) 2.443 0.142
Confusion 7 (13.5) 3 (15.8) 4 (12.1) 0.139 0.697
Vital sign on admission
Temperature/℃ 37.2 (36.5, 38.6) 37.8 (36.9, 39.3) 37.0 (36.5, 38.4) -2.294 0.022
Heart rate/(beat/min) 93.6±18.2 103.7±17.1 87.8±16.4 3.315 0.002
Respiratory rate/(time/min) 20 (18, 22) 22 (20, 24) 18 (18, 20) -1.751 0.080
Systolic blood pressure/mmHg 126 (118, 140) 125 (115, 134) 130 (120, 143) -1.201 0.230
Diastolic blood pressure/mmHg 71 (68, 80) 70 (65, 84) 74 (69, 80) -0.326 0.774
Oxygen saturation/% 93 (91, 94) 92 (90, 93) 93 (92, 95) -2.534 0.011
Score on admission
CURB-65 2.0 (1.0, 3.0) 2.0 (1.0, 2.5) 3.0 (2.0, 4.0) -2.711 0.004
PSI 118 (92, 136) 107 (92, 129) 152 (104, 184) -4.108 <0.001

Table 2

Laboratory data within 24 h of admission in elderly patients with influenza pneumonia"

Laboratory data Reference range Severe group Non-severe group Statistical value P
Blood routine
WBC/(×109/L) 3.5-9.5 8.30 (6.83, 14.87) 8.80 (6.50, 11.58) -0.627 0.531
LY/(×109/L) 1.1-3.2 0.60 (0.40, 1.63) 0.92 (0.60, 1.60) -1.407 0.159
Hb/(g/L) 130-175 110.3±29.9 121.2±19.5 -1.600 0.116
PLT/(×109/L) 125-350 156.0 (98.0, 259.0) 179.0 (148.0, 219.5) -1.131 0.258
Biochemistry
AST/(U/L) 9-35 35.0 (16.0, 90.0) 28.0 (17.5, 52.0) -0.875 0.382
ALT/(U/L) 15-40 32.0 (17.0, 61.0) 31.0 (20.5, 57.5) -0.257 0.797
LDH/(U/L) 109-245 285.0 (199.0, 361.0) 176.0 (90.0, 251.0) -2.936 0.003
ALB/(g/L) 40-55 35.8±5.6 38.9±3.5 -2.348 0.018
BUN/(mmol/L) 2.8-7.2 8.8 (5.6, 11.4) 6.0 (4.6, 8.7) -2.072 0.038
CRE/(μmoI/L) 59-104 75.0 (51.0, 88.0) 77.0 (60.5, 89.0) -0.542 0.588
GLU/(mmol/L) 3.3-6.1 6.8 (5.6, 10.4) 5.5 (4.6, 7.0) -2.376 0.018
Aterial blood gas analysis
pH 7.35-7.45 7.47 (7.41, 7.48) 7.44 (7.38, 7.49) -1.276 0.202
PaO2/FiO2/mmHg 400-500 252.4±84.8 333.7±60.9 -4.004 <0.001
PaCO2/mmHg 35-45 35.2±8.5 41.6±10.8 -2.208 0.032
Lac/(mmol/L) <2.5 2.4 (1.8, 3.9) 2.0 (1.0, 3.1) -1.922 0.055
Coagulation function
PT/s 9.4-12.5 11.7 (11.0, 12.8) 12.0 (11.0, 12.9) -2.331 0.200
APTT/s 25.1-36.5 31.4±7.2 30.3±4.5 0.735 0.466
D-dimer/(μg/L) 0-243 908 (627, 1 398) 300 (193, 549) -4.380 <0.001
Inflammatory markers
CRP/(mg/L) 0-10 56.0 (37.8, 78.2) 19.5 (10.5, 37.6) -3.706 <0.001
PCT/(μg/L) <0.01 0.88 (0.16, 1.83) 0.22 (0.12, 0.99) -1.730 0.084
Myocardial injury markers
TnI greater than 2 fold 3/17 (17.6) 3/28 (10.7) 0.440 0.507
BNP greater than 2 fold 4/15 (26.7) 3/28 (10.7) 1.824 0.215

Table 3

Treatment, complications and outcomes of elderly patients with influenza pneumonia"

Items Total Severe group Non-severe group Statistical value P
Onset to admission/d 7.0 (2.3, 8.0) 7.0 (5.0, 9.0) 7.0 (2.5, 9.0) -0.459 0.646
Virus type 0.847 0.838
A/H1N1 17 (32.7) 7 (36.8) 10 (30.3)
A/H3N2 17 (32.7) 5 (26.3) 12 (36.4)
B 14 (26.9) 5 (26.3) 9 (27.3)
Mixed 4 (7.7) 2 (10.5) 2 (6.1)
Onset to antiviral treatment 0.239 0.135
≤48 h 13 (25.0) 7 (36.8) 6 (18.2)
>48 h 39 (75.0) 12 (63.3) 27 (81.8)
Antiviral drug 9.257 0.010
Oseltamivir 45 (86.5) 13 (68.4) 32 (97.0)
Oseltamivir plus Peramivir 4 (7.7) 4 (21.1) 0(0)
Unused 3 (5.8) 2 (10.5) 1 (3.0)
Co-infection
Bacterial 13 (25.0) 9 (47.4) 4 (12.1) 7.989 0.008
Fungus 3 (5.8) 2 (10.5) 1 (3.0) 0.249 0.618
Antibiotics before admission 45 (86.5) 16 (84.2) 29 (87.9) 0.139 0.709
Antibiotic during admission 0.368 0.947
Unused 3 (5.8) 1 (5.2) 2 (6.1)
1 19 (36.5) 7 (36.8) 12 (36.4)
2 26 (50.0) 9 (47.4) 17 (51.5)
≥3 4 (7.7) 2 (10.5) 2 (6.1)
Antifungal 6 (11.5) 3 (15.8) 3 (9.1) 0.530 0.467
Hormonotherapy 23 (44.2) 12 (63.2) 11 (33.3) 4.348 0.037
Respiratory support
Nasal catheter oxygen 48 (92.3) 19 (100.0) 29 (87.9) 2.495 0.114
Mask oxygen 10 (19.2) 3 (15.8) 7 (21.1) 0.228 0.633
Noninvasive ventilation 23 (44.2) 10 (52.6) 13 (39.4) 0.857 0.355
Invasive ventilation 9 (17.3) 9 (47.4) 0(0) - <0.001
Other support modes
CRRT 9 (17.3) 4 (21.1) 5 (15.2) 0.026 0.588
ECMO 3 (5.8) 3 (15.8) 0(0) - 0.044
Complications
ARDS 16 (30.8) 10 (52.6) 6 (18.2) 6.718 0.010
Pneumothorax 4 (7.7) 2 (10.5) 2 (6.1) 0.339 0.561
Shock 9 (17.3) 6 (31.6) 3 (9.1) 2.843 0.092
Acute kidney injury 12 (23.1) 6 (31.6) 6 (18.2) 1.219 0.270
Myocardial injury 6 (11.5) 3 (15.8) 3 (9.1) 0.077 0.782
Liver injury 9 (17.3) 5 (26.3) 4 (12.1) 1.697 0.193
DIC 10 (19.2) 7 (36.8) 3 (9.1) 4.325 0.038
Encephalopathy 3 (5.8) 2 (10.5) 1 (3.0) 0.249 0.618
ICU admission 20 (38.5) 12 (63.2) 8 (24.2) 7.715 0.005
Length of stay/d 13.5 (9.0, 20.0) 14.0 (11.0, 20.0) 10.0 (8.5, 20.0) -1.162 0.245
Death 13 (25.0) 9 (47.4) 4 (12.1) 7.989 0.008

Figure 1

The relation of D-dimer to PSI and PaO2/FiO2 PaO2/FiO2, oxygenation index; PSI, pneumonia severity index."

Figure 2

Receiver operator characteristic curve for D-dimer and PSI to predict in hospital death PSI, pneumonia severity index."

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