This document discusses the importance of urologists being aware of the clinical presentation of COVID-19. It notes that some early cases of COVID-19 in Italy were initially attributed to urosepsis by internal medicine physicians due to fever in patients with urological devices. However, these cases were later determined to be pneumonia. The document emphasizes that the symptoms of COVID-19 can overlap with urosepsis, so urologists evaluating patients with fever should consider COVID-19 to avoid missed or delayed diagnoses and unnecessary exposure. Laboratory findings like procalcitonin levels can help differentiate between viral COVID-19 infection and bacterial urosepsis.

1. European Urology
COVID-19: importance of the awareness of clinical syndrome by urologists
--Manuscript Draft--
Manuscript Number: EURUROL-D-20-00385
Article Type: Letter to the Editor
Section/Category: Infections (INF)
Keywords: Coronavirus disease; urosepsis; procalcitonin
Corresponding Author: Bernardo Rocco, Professor
Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
Modena, ITALY
First Author: Bernardo Rocco, Professor
Order of Authors: Bernardo Rocco, Professor
Maria Chiara Sighinolfi
Cristina Mussini
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2. COVID-19: importance of the awareness of clinical syndrome by urologists
Maria Chiara Sighinolfi, Bernardo Rocco, Cristina Mussini
Maria Chiara Sighinolfi, MD, Phd, Urologists at the Department of Urology, University of Modena
and Reggio Emilia, Italy
Bernardo Rocco, Full Professor of Urology and Chief of the Department of Urology, University of
Modena and Reggio Emilia, Italy
Cristina Mussini, Full Professor of Infectious Diseases and Chief of the Department of Infectious
Diseases, University of Modena and Reggio Emilia, Italy
Word count: 446
Text
As of March 11, 2020, more than 10.500 cases of Coronavirus disease 2019 (COVID-19) and 827
deaths have been reported in Italy. On the same day, the disease has been considered a pandemic
from the WHO organization, and healthcare planning efforts are advised to face the upcoming
spread of COVID-19 worldwide.
From the experience of Wuhan, China, on 138 hospitalized patients with COVID-19, the most
common symptoms at onset of illness are fever (98,6%), fatigue (69,6%), dry cough (59,4%), myalgia
(34,8%), dyspnea (31,2%)1.
The knowledge of symptoms and their prevalence is of paramount importance for all physicians,
including ones from diverse backgrounds as surgeons, that are called to face COVID-19 disease in
their daily practice as well.
As far as the urology field is concerned, to date no certain direct impact of COVID-19 on urogenital
tissues has been reported1-4. However, urologists can be involved in the initial evaluation of patients
presenting with fever without other symptoms of COVID-19, often interpreted as urosepsis. The
attribution of fever to urinary infection could be supported by the possible presence of urological
devices, previously positioned to relief urinary obstruction.
Ureteral stenting and the positioning of a nephrostomic tube are common urological procedures
overcoming ureteral obstruction from stones or extrinsic compression5. Encrustation and super-
infections are frequent drawbacks of the indwelling devices, leading to an ultimate sepsis condition.
The severity of urosepsis depends mostly upon the host response: elderly patients, diabetics,
immunosuppressed and patients receiving cancer chemotherapy are mostly prone to a severe
presentation5. Fever or hypothermia, leukocytosis or leukopenia, tachycardia and tachypnoea are
signs of systemic inflammation of possible urological origin5.
The background of urosepsis development and its systemic symptoms may initially overlap the ones
typical of COVID-19; an immediate differentiation could prompt the treatment and avoid the
shortcoming of a missed or delayed COVID-19 diagnosis.
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3. Laboratory findings may be the driver of the diagnostic workup in this setting. Lymphopenia (70%),
prolonged prothrombin time (58%), elevated lactate dehydrogenase (40%) are typical of COVID-191-
3; opposite, procalcitonin rise may characterize the presence of urosepsis5.
Procalcitonin, the inactive pro-peptide of calcitonin, is undetectable in healthy humans5. European
Urological Guidelines state that levels could raise during severe generalized infections from
bacterial, parasitic and fungal origin, whereas procalcitonin levels are only moderately or no
increased in the case of viral infections5.
In conclusion, the possible overlap of COVID-19 clinical syndrome with different conditions – such
as urosepsis - should be recognized and deserves a proper investigation since the very beginning of
case presentation. The rapid diagnosis and isolation of COVID-19 cases - recognized to be public
health interventions slowing the spread6 - relies on the prompt preparation and knowledge of all
physicians to confront this unprecedented pandemic.
1. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y, Li Y,
Wang X, Peng Z. Clinical Characteristics of 138 Hospitalized Patients
With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China . JAMA February 7, 2020
2. Del Rio C, Malani PN. 2019 Novel Coronavirus—New insights on a rapid changing epidemic.
JAMA , February 28,2020
3. Del Rio C, Malani PN. 2019 Novel Coronavirus—Important Information for Clinicians.
February 5, 2020
4. Wu Z and McGoogan JM. Characteristics of and Important Lessons From
the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314
Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020.
PMID 32091533
5. European Urological Guidelines, 2019 Edition
6. Adalja A, Toner E, Inglesby TV. Priorities for the US Health Community Responding to COVID-
19. March 3, 2020

4. Dear Prof. Catto,
As COVID-19 is widely spreading in our Country (Italy), we would like to send you a brief advice to
make urologists aware of a possible presentation of COVID-19.
In the week preceding the spread in Italy, I have been personally called – as urologist – to visit
some cases of fever attributed to urinary infection by internal medicine physician; patients had
previously positioned urological devices such as ureteral stent or nephrostomic tubes.
At least two of those cases turned out to be finally pneumonia.
In these patients, I found leukocytes count to be normal (or below the range); procalcitonin
absent.
Unfortunately, I am not able to collect the consent from patients to publish their whole data
(otherwise difficult to be collected at this time), because of governments restrictions limiting
people circulation and/or worsening of their condition.
However, I believe that the take home message of the Letter could be clearly interpreted as well,
and I hope it may prevent urologists’ unprotected exposure to similar cases, namely fever only
supposed to derive from urinary tract.
Thank you for giving us the opportunity to consider our experience.
Maria Chiara Sighinolfi
All Authors have nothing to disclose.
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