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.