ORIGINAL ARTICLE

Effect of serum total testosterone and its relationship with other laboratoryparameters on the prognosis of coronavirus disease 2019 (COVID-19) inSARS-CoV-2 infected male patients: a cohort study

Selahittin Cayana, Mustafa U!guzb, Barıs Saylamc and Erdem Akbaya

aDepartment of Urology, University of Mersin School of Medicine, Mersin, Turkey; bDepartment of Infectious diseases, Mersin CityEducational and Research Hospital, Mersin, Turkey; cDepartment of Urology, Mersin City Educational and Research Hospital,Mersin, Turkey

ABSTRACTObjective: To investigate effect of serum total testosterone and its relationship with otherlaboratory parameters on the prognosis of coronavirus disease 2019 (COVID-19) in severe acuterespiratory syndrome coronavirus 2 (SARS-CoV-2) infected male patients.Methods: This prospective cohort study included 221 consecutive male patients (>18 years old)with laboratory confirmed SARS-CoV-2 who had been hospitalized due to COVID-19. Thepatients were divided into 3 groups: Asymptomatic patients (n: 46), symptomatic patients whowere hospitalized in the internal medicine unit (IMU) (n: 129), and patients who were hospital-ized in the intensive care unit (ICU) (n: 46).Results: As serum total testosterone level at baseline decreases, probability (%) to be in the ICUsignificantly increases (p¼ 0.001). As serum total testosterone level at baseline decreases, prob-ability (%) of mortality significantly increases (p¼ 0.002). In the patients who had pre-COVID-19serum gonadal hormones test (n: 24), serum total testosterone level significantly decreased frompre-COVID-19 level of 458±198ng/dl to 315±120ng/ml at the time of COVID-19 in thepatients (p¼ 0.003).Conclusions: COVID-19 might deteriorate serum testosterone level in SARS-CoV-2 infected malepatients. Low serum total testosterone level at baseline has a significant increased risk for theICU and mortality in patients with COVID-19.

ARTICLE HISTORYReceived 9 July 2020Accepted 6 August 2020Published online 17 July2020

KEYWORDSSARS-CoV-2; COVID-19;testosterone; gonadalhormones; risk factors;prognosis; morbid-ity; mortality

Introduction

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) causing coronavirus disease 2019(COVID-19) is a systemic disease, affecting respiratory,cardiovascular, gastrointestinal, neurologic and uro-genital systems. It may mainly cause acute respiratorydistress syndrome, leading to relatively high risk ofdeath [1,2]. Since the World Health Organization hasdeclared the disease as pandemics, globally as of 29July 2020, a total of 16,558,289 SARS-CoV-2 cases havebeen confirmed, and 656,093 people died due toCOVID-19 (https://covid19.who.int).

The mortality rate due to COVID-19 has beenranged from 0.9% in patients without comorbidities to10.5% in patients with co-morbid diseases (https://covid19.who.int). Higher mortality rate related toSARS-CoV-2 has led clinicians to investigate newerparameters that might predict prognosis of COVID-19.

Male sex has been reported as a worse clinical out-come than women in some studies, suggesting thepresence of a male-related susceptibility in COVID-19.In addition, global average life expectancy has beenreported as 5.1 years less for men than for women [3].

Testosterone is the principal male sex hormone,and decreases on average by 0.8–2% per year afterthe age of 40 years. The prevalence of male hypo-gonadism has been ranged from 2.1 to 9.5% in menaged 40–70 years [4–6]. Its rate significantly increases,ranging 10–80% in several morbid diseases [4–6]. Malelate-onset hypogonadism has been reported as a riskfactor for diabetes, chronic obstructive pulmonary dis-ease, metabolic syndrome, dyslipidemia, thromboticand cardiovascular disease, leading to increased mor-tality in the general population [6–10]. The prevalenceof hypogonadism in age hospitalized male patientshas been reported as 53.3% [7]. Low levels of testos-terone have been found as an association with higher

CONTACT Selahittin Cayan selcayan@mersin.edu.tr Andrology Section, Department of Urology, University of Mersin School of Medicine, Mersin,33343, Turkey! 2020 Informa UK Limited, trading as Taylor & Francis Group

THE AGING MALEhttps://doi.org/10.1080/13685538.2020.1807930

rates of infection-related hospitalization and all-causemortality in male hemodialysis and intensive care unitpatients [6,7,11,12]. In a double blind, placebo con-trolled, randomized study, testosterone replacementtherapy provided improvement in peak oxygen con-sumption in elderly patients with chronic heart fail-ure [13].

Angiotensin-converting enzyme 2 (ACE2) is primar-ily expressed in the adult type Leydig and Sertoli cells,and has an important role in lung protection [14,15].Therefore, viral binding to the ACE2 receptor maydecrease its expression causing deterioration in a lungprotective pathway, and might affect testosterone pro-duction, leading to increases in pro-inflammatory cyto-kines in SARS-CoV-2 infected patients [16]. Very fewstudies have investigated the relationship betweentestosterone and mortality with the contradictoryresults in patients with COVID-19 with a small samplesize and short follow-up period [12,17].

Our hypothesis was whether serum testosteroneand other gonadal hormones might play an importantrole on the prognosis of COVID-19 in male patients.Therefore, the aim of this cohort study was to investi-gate effect of serum testosterone and its relationshipwith other laboratory parameters on the prognosis ofCOVID-19 in SARS-CoV-2 infected male patients.

Materials and methods

Patients and data collection

During an interval between 20 April and 8 May 2020,3766 consecutive people were tested for COVID-19 in2 hospitals (Mersin City Educational and ResearchHospital and University of Mersin School of MedicineHospital) in Mersin province, Turkey. Of those, SARS-CoV-2 was detected in 438 (11.63%). Therefore, 438consecutive patients with laboratory confirmed SARS-CoV-2 were hospitalized due to COVID-19. Of thepatients, 418 were adults (221 males and 197 females,>18 years old), and 20 were children (11 boys and 9girls). Therefore, the study included 221 consecutivemale patients (>18 years old) with laboratory con-firmed SARS-CoV-2 who had been hospitalized due toCOVID-19. At the beginning, all the 221 male patientswith laboratory confirmed SARS-CoV-2 were hospital-ized in the internal medicine unit to monitor and com-plete a detailed clinical history, complete physicalexamination, laboratory and radiological imaging stud-ies. Of the patients, 46 were asymptomatic on thesecond or third day of the admission, and thesepatients were discharged from the hospital. The rest175 patients were symptomatic and remained

hospitalized. Therefore, all the adult male patientswere divided into three groups: Asymptomaticpatients (n: 46), symptomatic patients who were hos-pitalized in the internal medicine unit (IMU) (n: 129),and patients who were hospitalized in the intensivecare unit (ICU) (n: 46).

All data were prospectively collected. A detailedclinical history, complete physical examination, labora-tory and radiological imaging studies were performedin every patient. All data of the patients were checkedand reviewed by the two physicians (BS and MU). Alldeaths during hospitalization were recorded. Thestudy was approved by the local ethics committee,consisting of the members from the Turkish Ministryof Health and University of Mersin School of Medicine(2020/#378). An informed consent was taken from allpatients, included in the study.

Demographic characteristics, co-morbidities, labora-tory results, radiological and computer tomographic(CT) scan findings, admission to the ICU, days in theICU and duration of hospital stay were recorded inevery patient. Charlson’s comorbidity index (CCI)which predicts 10-year survival in patients with mul-tiple comorbidities were measured in all patients [18].

The criteria for discharge were absence of fever forat least 2–3 days, substantial improvement in bothlungs on the chest CT scan, clinical remission ofrespiratory symptoms, and two throat-swab samplesnegative for SARS-CoV-2 RNA, obtained at least24 h apart.

Of the patients, 24 had measurement of total tes-tosterone level at any time with any reason in the lastone year before COVID-19 pandemics, and had thesecond measurement at the time of diagnosis ofCOVID-19. In the patients who had pre-COVID-19serum gonadal hormones test (n: 24), the total testos-terone level was compared from pre-COVID-19 to thetime of COVID-19.

Laboratory evaluation

All laboratory tests were performed on the first daythe patients were admitted to the hospitals, and thesevalues were used for the statistical calculations.Considering the circadian rhythm of testosteronerelease, venous serum samples were obtained in themorning (7–11 a.m.) to determine serum follicle stimu-lating hormone (FSH), luteinizing hormone (LH), pro-lactin, estradiol (E2) and total testosterone levels inevery patient, on the first day of the admission to thehospital. These hormones were measured by a chemi-luminescence immunoassay (Siemens Healthcare

2 S. ÇAYAN ET AL.

Diagnostics Inc, Laboratory Diagnostics, Advia CentaurXPT, Erlangen, Germany, produced in Ireland). Otherlaboratory biochemical tests, taken from venous blood,included blood count, coagulation profile, C-reactiveprotein (CRP), D-dimer, procalcitonin, total white bloodcells (WBC), neutrophils, lymphocytes, platelets, cre-atinine, alanine transaminase (ALT), aspartate-trans-aminase (AST), lactate dehydrogenase (LDH), ferritin,troponin, fibrinogen and albumin. Blood sample analy-ses were performed in the central laboratory of thetwo hospitals with commercially available kits whichare used for the clinical practice of the hospitals.

Definitions of criteria for diagnosis of COVID-19

Pharyngeal and/or nose swab positivity of SARS-CoV-2infection was confirmed using real-time PCR. Feverwas defined as axillary temperature of at least 37.3 "C.

On chest computer tomographic (CT) scan (GEHealthcare Optima CT660, Chicago, IL, USA), positiveradiological findings, related to SARS-CoV-2 infectionwere considered in the presence of any finding orfindings such as bilateral or unilateral opacities with orwithout pleural effusion, multiple ground-glass opacity(accompanied or not by septal thickening) and paren-chymal consolidation in the lungs of thepatients [1,2,19].

One or more of clinical symptoms, related toCOVID-19, such as fever, cough with or without spu-tum, muscle aches and/or fatigue, dyspnea, headache,sore throat and gastrointestinal symptoms were con-sidered as positive clinical symptom(s). Asymptomaticsituation was considered as no any clinical symptomin the presence of positive SARS-CoV-2 infection.

Definition of criteria for diagnosis ofhypogonadism

Hypogonadism was considered as the presence ofserum total testosterone level of <300 ng/dl [4,20].

Testing for SARS-CoV-2

Real-time reverse transcription polymerase chain reac-tion (RT-PCR) assay nucleic acid amplification test wasused to directly with Bio-Speedy COVID-19 RT-qPCR kitBS-SY-WCOR-305-1000; version 2003261000SK-MK fordetecting SARS-CoV-2 RNA. This method’s sensitivitywas 99.4%, and the specificity was 99%.

For detecting SARS-CoV-2 RNA, nasopharyngealspecimens were collected from suspected patients,and placed into the collection tube. Materials were

sent to the laboratory immediately. Total RNA wasextracted about two hours for respiratory sample RNAisolation kit (Wuhan, China). A cycle threshold valueless than 37 was defined as a positive result, and cyclethreshold value 40 or more was defined as a negativetest. The cycle threshold value within 37–40 wasdefined as needed a retest.

Assessment of sexual functions

In the asymptomatic patients (n: 46), sexual functionswere assessed using the nationally validated inter-national index of erectile function-erectile functiondomain (IIEF-EF) questionnaire, including 6 questions(based on a total score of 30) [21]. The IIEF-EF score of# 26 was considered as normal sexual function, andthe IIEF-EF score of <26 was considered as the pres-ence of erectile dysfunction. The aging male symptom(AMS) questionnaire was used to assess testosteronedeficiency symptoms. In addition, presence of sexuallibido was assessed face to face, and the answer wasrecorded as “yes” or “no.”

Statistical analysis

For statistical analyses SPSSVR (Statistical Package forthe Social Sciences Inc, Chicago, IL, USA) version 21.0package program was employed, and p values lessthan 0.05 was considered to be statistically significant.Descriptive statistics for continuous variables wereexpressed, and also tabulated as mean± standarddeviation, and for categorical variables as frequencies,and percentages (%).

T-test and Mann–Whitney U tests were used tocompare duration of hospitalization betweenthe groups.

One-way ANOVA test was used to compare meanage, BMI, CCI score and serum gonadal hormonesincluding FSH, LH, total testosterone, prolactin andestradiol levels among the groups, and the Post Hoctests were used to compare the serum gonadal hor-mone mean values between the groups. The Pearson’scorrelation test was used for the association betweenmean total testosterone and other clinical and labora-tory findings.

Probability (%) to be in the ICU and mortality dur-ing hospitalization were calculated using Linear andlogarithmic equations. Multivariate and univariateanalyses were used to investigate all the parametersthat might predict to be in the ICU and mortality. TheOdds ratio with 95% confidence interval (CI) was used

THE AGING MALE 3

to predict prognosis of COVID-19, such as probabilityto be in the ICU and mortality during hospitalization.

The chi-square test was used to compare mortalityrates between the genders. Paired t test was used tocompare serum total testosterone level from pre-COVID-19 to the time of COVID-19 in the patients whohad pre-COVID-19 serum gonadal hormones test.

Results

Of the 438 consecutive patients with laboratory con-firmed SARS-CoV-2 who had been hospitalized due toCOVID-19, the gender representation was male in 232(53%) and female in 206 (47%). The mean age of theadult male patients was 45.07±18.28 years (range:19–88). The mean age of the adult female patients was44.04±18.8 years (range: 19–98). The mean age of thechildren was 8.02±5.6 years (range 0–18) (9.86±5.09 forboys and 6.77±5.69 for girls). Of the 438 consecutivepatients, death was observed in 11 of the male adultpatients (4.97%) and 7 of the female patients (3.55%),revealing no significance between the two genders(p> 0.05). However, none died in the children group.

The mainly symptoms were fever in 95 (43%), andrespiratory symptoms such as cough, sputum and dys-pnea in 94 (42.5%), and other symptoms such as myal-gia, fatigue, diarrhea, nausea or vomiting in 102 (46.1%).Chest CT scans showed positive findings in 125 (56.6%)of the patients. The mean BMI was 23.77±3.45 (range:18.17–33.03). The CCI score was 0 in 125 (56.6%), 1 in16 (7.2%) and # 2 in 80 (36.2%) of the patients.

Table 1 shows mean age, BMI and CCI score ofthe patients according to the groups. As shown in thetable, significant differences were observed in themean age (p¼ 0.000) and CCI score (p¼ 0.000), how-ever, no significant differences in BMI (p¼ 0.676)among the 3 groups.

Hypogonadism was observed in 113 (51.1%) of themale patients. Of the hypogonadal patients, serumtotal testosterone level was between 200 and$ 300 ng/dl in 62 patients, between 100 and $ 200 ng/dl in 25 patients and $ 100 ng/dl in 26 patients. Of theeugonadal patients, serum total testosterone level wasbetween 300 and $ 400 ng/dl in 51 patients, between400 and $ 500 ng/dl in 26 patients, 500 and $ 600 ng/dl in 22 patients and # 600 ng/dl in 9 patients.

Among the 46 patients with COVID-19 who stayedin the ICU, 11 (23.9%) remained staying in the ICU(intubated: 8), and 35 (76.1%) were taken to the IMU.Of the patients in the ICU, 11 (23.9%) died at the endof the study. Of the symptomatic patients who weredischarged from the IMU, the mean hospital stay was5.84 ± 4.09 days (range 1–24). Of the patients whostayed in the ICU, the mean duration was11.24 ± 6.54 days (3–32), revealing significant differencebetween the IMU and ICU groups (p¼ 0.000). Themortality was observed in 11 (4.97%) of all patients.

Of the 46 male patients with COVID-19 who wereasymptomatic, 30 (65.2%) had loss of libido. In thisgroup, the mean IIEF-EF score was 18.85 ± 9.96 (1–30),and the mean AMS score was 22.18 ± 2.97 (17–61).

Table 2 shows laboratory findings of all patientswith COVID-19. Table 3 shows serum gonadal hor-mone levels of the patients according to groups in theCOVID-19 patients. As shown in Figure 1, mean totaltestosterone decreased, and mean gonadotropins (FSHand LH) increased, as the severity of the COVID-19increased. The mean total testosterone level was sig-nificantly lower in the ICU group than in the asymp-tomatic group (p¼ 0.006). In addition, the mean totaltestosterone level was significantly lower in the ICUgroup than in the IMU group (p¼ 0.017). The meanFSH level was significantly higher in the ICU groupthan in the asymptomatic group (p¼ 0.02).

Table 4 shows comparison of mean total testosteronelevels in the presence of various findings and parametersin the COVID-19 patients. The mean total testosteronelevel was significantly lower in the presence of CCI scoreof # 2 than in the presence of CCI score of 0 and 1(p¼ 0.001). The patients in the ICU group showed signifi-cantly lower mean total testosterone level than thepatients who were not in the ICU (p¼ 0.001). The patientswho died showed significantly lower mean total testoster-one than the patients who were alive (p¼ 0.001). Thepatients with D-dimer level of # 1mg/ml showed signifi-cantly lower mean total testosterone level than thepatients with D dimer level of <1mg/ml (p¼ 0.009).

The Pearson correlation analysis showed thatincreased age (r¼% 0.236, p¼ 0.000), increased levelsof D-dimer (r¼% 0.213, p¼ 0.003), LH (r¼ 0.171,p¼ 0.01), CRP (r¼% 0.144, p¼ 0.003) and procalcitonin

Table 1. Mean age, BMI and CCI score of the patients according to the groups.Asymptomatic group

(n: 46) mean ± SD (range)IMU group

(n: 129) mean ± SD (range)ICU group

(n: 46) mean ± SD (range)p Value

(ANOVA test)

Age (year) 34.83 ± 12.51 (19–79) 44.54 ± 17.63 (19–88) 56.8 ± 18.57 (19–88) 0.000BMI 23.87 ± 3.6 (18.17–30.89) 23.62 ± 3.6 (18.17–33.03) 24.18 ± 2.83 (19.01–30.89 0.676CCI score 0.46 ± 1.09 (0–4) 1.35 ± 1.95 (0–11) 1.33 ± 1.99 (0–10) 0.000

4 S. ÇAYAN ET AL.

(r¼ % 0.225, p¼ 0.000) were the parameters that might

predict lower total testosterone level.Figure 2 shows probability (%) to be in the ICU dur-

ing hospitalization in the COVID-19 patients. Of the 46patients in the ICU group, 35 (76%) had serum totaltestosterone level of <300 ng/dl, while 21 (45.6%) hadserum total testosterone level of <200 ng/dl. As serumtotal testosterone level at baseline decreases, probabil-ity (%) to be in the ICU during hospitalization signifi-cantly increases (p¼ 0.001 for linear equation and0.000 for logarithmic equation).

Figure 3 shows probability (%) of mortality duringhospitalization in the COVID-19 patients. Of the 11deaths, 10 (90.9%) had serum total testosterone levelof <300 ng/dl, while 8 (72.7%) had serum total testos-terone level of <200 ng/dl at baseline. As serum totaltestosterone level at baseline decreased, probability(%) of mortality significantly increased (p¼ 0.002 forlinear equation and 0.000 for logarithmic equation).

On the multivariate analysis of the demographic

and clinical characteristics and laboratory findings thatmight predict to be in the ICU in the COVID-19patients, presence of D-dimer # 1mg/l was the onlyhighly significant predictor for the ICU in the COVID-19 patients (OR: 7.309, 95% CI: 1.241–43.058). On theunivariate analysis, older age (OR: 1.046), longer hospi-talization (OR: 1.225), lower albumin level (OR: 0.631),lower total testosterone level (OR: 0.996), presence offever (OR: 2.236), positive chest CT findings (OR:3.005), presence of D-dimer # 1mg/l (OR: 14.065) andpresence of CCI # 2 (OR: 2.318) were the highly signifi-cant predictors for the ICU in the COVID-19 patients.

On the multivariate analysis of the demographicand clinical characteristics and laboratory findings thatmight predict mortality in the COVID-19 patients, noparameter was significant predictor for the mortality.However, on the univariate analysis, longer hospitaliza-tion (OR: 1.118), lower albumin level (OR: 2.188), lower

Table 2. Laboratory findings of all male patients with COVID-19.Parameters Mean Standard Deviation Minimum Maximum

FSH (mIU/ml) 6.639 3.39 1.34 18.21LH (mIU/ml) 5.679 2.38 1.19 12.01Total testosterone (ng/dl) 308 164 18 931Prolactin (pg/ml) 9.749 4.75 1.91 33.60Estradiol (pg/ml) 25.85 9.90 11.79 65.76Albumin (mg/l) 3.569 0.78968 2.00 7.14White blood cell (WBC) 9199 4181.80 2990 26,000Neutrophil (/l) 6119 4037.50 1680 22,000Creatinine (mmol/ml) 1.07 0.78 0.32 5.86Alanine aminotransferase (ALT) (U/l) 39.70 35.41 4 271Aspartate aminotransferase (AST) (U/l) 47.02 43.75 5 256C-reactive protein (CRP) (mg/l) 295.93 323.32 104 2452Lactate dehydrogenase (LDH) (mU/l) 15.80 36.36 0.10 238Procalcitonin (mg/l) 0.88 2.90 0.10 25.48D-dimer (mg/l) 0.968 1.23 0.02 7.16Ferritin (mg/l) 168.04 287.46 0.02 1681Troponin (ng/ml) 71.38 237.04 0.10 2377Fibrinogen (g/l) 407.92 208.08 34 1026

Table 3. Serum gonadal hormone levels of the COVID-19 patients according to groups.

Gonadal hormonesAsymptomatic group(n: 46) (mean ± SD)

IMU group(n: 129) (mean ± SD)

ICU group (n: 46)(mean ± SD) p Value (Post Hoc)&

FSH (mIU/ml) 5.26 ± 2.68 6.67 ± 3.22 8.41 ± 4.38 Asymptomatic vs IMU: 0.222Asymptomatic vs ICU: 0.02IIMU vs ICU: 0.176

LH (mIU/ml) 5.31 ± 2.38 5.73 ± 2.22 5.97 ± 3.17 Asymptomatic vs IMU: 0.758Asymptomatic vs ICU: 0.699IIMU vs ICU: 0.935

Total testosterone (ng/ml) 346 ± 140 318 ± 156 241 ± 191 Asymptomatic vs IMU: 0.563Asymptomatic vs ICU: 0.006IIMU vs ICU: 0.017

Prolactin (pg/ml) 8.71 ± 3.80 9.81 ± 3.96 11.05 ± 8.65 Asymptomatic vs IMU: 0.625Asymptomatic vs ICU: 0.346IIMU vs ICU: 0.662

Estradiol (pg/ml) 26.18 ± 7.31 25.71 ± 9.70 26.1 ± 14.32 Asymptomatic vs IMU: 0.982Asymptomatic vs ICU: 1.000IIMU vs ICU: 0.991

&Tukey HSD.

THE AGING MALE 5

total testosterone level (OR: 1.008), presence of fever(OR: 6.488), presence of D-dimer # 1mg/l (OR: 15.750)were the highly significant predictors for the mortalityin the COVID-19 patients.

In the patients who had pre-COVID-19 serumgonadal hormones test (n: 24), serum total testoster-one level significantly decreased from pre-COVID-19

level of 458 ± 198 ng/dl to 315 ± 120 ng/ml at the timeof COVID-19 in the patients (p¼ 0.003).

Discussion

Some risk factors in multivariate analyses have beenreported about staying in the ICU and the mortality

Figure 1. Mean serum gonadal hormone levels of the COVID-19 patients according to the groups: (A) FSH, (B) LH, (C) total testos-terone, (D) prolactin and (E) estradiol.

6 S. ÇAYAN ET AL.

for adult patients with COVID-19. Pathophysiologicmechanisms that might be associated with the deadof patients with COVID-19 include increasing the neu-trophil count, D-dimer, blood urea and creatinine lev-els and decreasing in lymphocyte counts [1].Neutrophilia may be related to cytokine storm inducedby virus invasion, coagulation activation might berelated to sustained inflammatory response, and acutekidney injury might be related to direct effects of thevirus, hypoxia and shock [1]. In the present study,logistic regression analysis showed that older age, lon-ger hospitalization, lower albumin level, lower totaltestosterone level, presence of fever, positive chest CTfindings, presence of D-dimer # 1mg/l and presenceof CCI # 2 were the highly significant predictors forthe ICU in the COVID-19 patients. In addition, longer

Table 4. Comparison of mean total testosterone levels in thepresence of various findings and parameters in the COVID-19 patients.

Presence Mean (ng/dl) Standard deviation p Value

Symptoms þ 344.78 140.02 0.058– 298.18 168.91

Fever þ 290.36 179.59 0.179– 321.10 150.810

Respiratory findings þ 306.46 167.88 0.912– 308.93 161.93

Chest CT findings þ 294.69 169.94 0.173– 325.05 155.41

CCI score # 2 257.45 161.88 0.0010 and 1 336.50 158.93

ICU þ 239.94 187.88 0.001– 326.73 152.18

Intubation þ 195.13 183.14 0.048– 312.11 162.31

Death þ 158.45 151.68 0.001– 315.70 161.29

D-dimer (mg/l) # 1 224.33 215.08 0.009<1 343.10 141.67

Figure 2. Probability (%) to be in the ICU during hospitalization in the COVID-19 patients.

THE AGING MALE 7

hospitalization, lower albumin level, lower total testos-terone level, presence of fever, presence of D-dimer# 1mg/l were the highly significant predictors for themortality in the COVID-19 patients.

Sex specific differences in disease severity ofCOVID-19 have been studied in various diseasesincluding cardiovascular diseases and infectious agents[22,23]. The incidence of COVID-19 has ranged from54 to 69% of the males from the study population[1,22,23]. In addition, in a prospective cohort study,the incidence of age-standardized all-cause mortalitywas found as significantly higher in men than in thewomen (7.4 per 1000 person-years for men and 4.5per 1000 person-years for women [23]. There aresome studies reporting that MERS-COV and SARS-COVhave infected more men than women [24,25]. In amice study, Channappanavar et al. [25] showed thatmale mice were more susceptible to SARS-CoV

infection, compared with age-matched females. In ameta-analysis consisting of 10 studies with 1994patients, Li et al. [22] reported COVID-19 patients’ clin-ical characteristics, discharge rate and fatality, andthey found that the male took a significantly largerpercentage in the gender distribution of COVID-19patients (60%) with the fatality rate of 5%. Nakashimaet al. [11] reported the association between serum tes-tosterone levels and adverse clinical outcomes such asevents and all-cause mortality in male dialysis patients,and they found that infection related hospitalizationwas more frequent in the lower testosterone tertilethan in the higher testosterone tertile. In addition, all-cause mortality was significantly greater in the lowertestosterone tertile than in the higher testosterone ter-tile. In the present study, we did not observe signifi-cant sex related difference in mortality rate betweenadult men (4.97%) and women (3.55%), although the

Figure 3. Probability (%) of mortality during hospitalization in the COVID-19 patients.

8 S. ÇAYAN ET AL.

rate was slightly higher in the males than inthe females.

Late-onset hypogonadism or testosterone defi-ciency may result in significant detriment to quality oflife, and adversely affect the function of multipleorgan systems [4]. In a systematic review and meta-analysis, consisting of the 21 studies, Araujo et al. [6]demonstrated that difference in the means of the topand bottom third of the standard normal distributionin total testosterone was associated with 35 and 25%increased risk of all-cause and cardiovascular diseasemortality, respectively. Iglesias et al. [7] reported theprevalence of hypogonadism as 53.3% in 150 maleaged # 65 years hospitalized patients for acute dis-eases. The main cause of hospitalization was respira-tory tract infection in 23.7% of in hypogonadalpatients. They also found significant associationbetween low serum total testosterone level and mor-tality during hospital stay. In a study, supporting thetheory of higher mortality in hypogonadal men,exogenous testosterone treatment was associatedwith decreased mortality compared with no testoster-one treatment [26]. Prevalence of hypogonadism inmen with chronic obstructive pulmonary diseaseranges from 22 to 69% and has been associated withseveral other systemic conditions including osteopor-osis, depression and muscle weakness [9].Hypogonadism associated systemic diseases havebeen more prevalent in obese patients. Iglesias et al.[7] demonstrated that patients with low/normalweight (BMI < 25 kg/m2) who died during hospitaliza-tion showed significant lower testosterone level thanthose who survived. In the present study, hypogonad-ism (serum total testosterone level of <300 ng/dl) wasobserved in 51.1% of the male patients.

Testosterone is associated with the immune systemof respiratory organs, and low levels of testosteronemight increase the risk of respiratory infections. Themetallopeptidase, Angiotensin-converting enzyme 2(ACE2) is a constitutive product of adult type Leydigand Sertoli cells, and has an important role in lungprotection [14,15]. ACE2 is activated and down-regu-lated by the spike protein of the virus and allows thepenetration of SARS-CoV-2 into the epithelial respira-tory cells and myocardium [27]. Therefore, viral bind-ing to the ACE2 receptor may decrease its expressioncausing deterioration in a lung protective pathway,and might affect testosterone production, leading toincreases in pro-inflammatory cytokines in SARS-CoV-2infected patients [16]. Measuring testosterone levelsmay be recommended at the time of COVID-19 diag-nosis. There are also contradictory studies suggesting

that the hyperandrogenic phenotype could explainthe COVID-19 positivity in those few young males withsevere SARS-CoV-2 infection [20], possibly with shorterAR CAG lengths, who are greater risk of developingprostate cancer because higher receptor transcriptionactivity [28]. Montopoli et al. [17] demonstrated thatcancer patients have an increased risk of SARS-CoV-2infections than non-cancer patients. They included 118patients with prostate cancer, and demonstrated thatpatients receiving androgen deprivation therapy (n: 4)had a significantly lower risk of SARS-CoV-2 infectioncompared to patients who did not receive androgendeprivation therapy (n: 114). However, they had only 4patients under androgen deprivation therapy, andattempted to compare those 4 patients with 114patients who did not receive androgen deprivationtherapy [17].

Rastrelli et al. [12] included 31 consecutive malepatients with COVID-19 who recovered in the ICU of ahospital in Italy. They demonstrated that lower base-line levels of total testosterone and calculated free tes-tosterone levels predicted poor prognosis andmortality in the SARS-CoV-2 infected patients whoadmitted to intensive care unit. They also found thatboth total testosterone and calculated free testoster-one levels showed a negative significant correlationwith the neutrophil count, LDH and procalcitonin, buta positive association with the lymphocyte count. Inaddition, total testosterone was also negatively associ-ated with CRP and ferritin levels. However, the num-ber of patients included in their study was limited,clinical findings of the patients were not included, andthey included only patients in the ICU, and wereunable to compare those findings with the SARS-CoV-2 infected patients who were asymptomatic or symp-tomatic who were in the IMU, not in the ICU. In ourstudy, of the 46 patients in the ICU group, 76% hadserum total testosterone level of <300 ng/dl, while45.6% had serum total testosterone level of <200 ng/dl. As serum total testosterone level at baselinedecreased, probability (%) to be in the ICU during hos-pitalization significantly increased. In addition, of the11 deaths in our study, 10 (90.9%) had serum totaltestosterone level of <300 ng/dl, while 8 (72.7%) hadserum total testosterone level of <200 ng/dl at base-line. As serum total testosterone level at baselinedecreased, probability (%) of mortality significantlyincreased. In the present study, we did not includemeasurement of free testosterone level, because theAmerican Urological Association (AUA) guidelines donot recommend routine use of free testosterone meas-urements in clinical decision making [19].

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As the limitation of the study, we did not include acontrol group, consisting of the patients other thanCOVID-19. However, during the COVID-19 pandemics,it is very hard to include patients without COVID-19 inthe IMU and ICU at the same period. Therefore, wedid not want to use historical control group at the dif-ferent time period (for example before COVID-19period). In addition, checking the concentration ofACE2 would be worth in the COVID-19 patient popula-tion to investigate relationship with the total testoster-one level. Unfortunately, we were unable to check thismeasurement. These could be aim of other studies inthe future.

Conclusions

For the first time, our data suggest that COVID-19might deteriorate serum testosterone level in SARS-CoV-2 infected male patients. Low serum total testos-terone level at baseline has a significant increased riskfor the ICU and mortality in patients with COVID-19.Future studies related to testosterone treatment inthis population would discover possible improvementin clinical outcomes with the testosterone treatmentin SARS-CoV-2 infected hypogonadal male patients.

Disclosure statement

The authors report no declarations of interest.

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