Aim. To determine the clinical features of moderate community-acquired pneumonia (CAP) associated with COVID-19 in patients without comorbidities compared to those with comorbid metabolic dysfunction-associated steatotic liver disease (MASLD).

Material and methods. A retrospective analysis was performed including 200 hospitalized patients with moderate CAP associated with SARS-CoV-2. Two groups (n = 100 each) were defined: Group 1 included patients with CAP without liver comorbidity and with normal body weight; Group 2 comprised patients with CAP and comorbid MASLD associated with being overweight or having class I–II obesity.

Results. Patients in Group 2 demonstrated a significantly higher prevalence of intense chest pain (1.7-fold), fever (1.7-fold), anosmia (2.3-fold), sore throat with odynophagia (2.0-fold), and progressive inspiratory dyspnea (1.7-fold) compared to Group 1 (p < 0.05). Systemic and gastrointestinal symptoms were also more frequent in Group 2, including myalgia (4.2-fold), asthenia and headache (both 1.6-fold), syncope (2.5-fold), nausea (2.3-fold), and diarrhea (3.9-fold) (p < 0.05). Hyperthermia >38.5 °C (1.6-fold), tachycardia >90/min (2.0-fold), tachypnea >25/min (2.2-fold), and oxygen saturation (SpO2) of 90–92 % (1.8-fold) were significantly more common in the comorbid group (p < 0.05). Laboratory findings in Group 2 revealed a higher incidence of leukopenia (52.0 % vs. 39.0 %), lymphopenia (77.0 % vs. 37.0 %, p < 0.05), and thrombocytopenia (61.0 % vs. 29.0 %, p < 0.05), alongside pronounced hyperfibrinogenemia and hyperferritinemia. Radiologically, Group 2 patients predominantly exhibited bilateral lung involvement (67.0 % vs. 38.0 %, p < 0.05), consolidation, ground-glass opacities, fibrotic changes, and pleuritis. Co-infections and superinfections were significantly more frequent in Group 2 (45.0 % vs. 18.0 %), with S. pneumoniae (27.0 %), K. pneumoniae (17.0 %), S. aureus (18.0 %), Aspergillus spp. (10.0 %), and Candida spp. (6.0 %) identified as the primary pathogens.

Conclusions. The presence of MASLD is associated with a more severe clinical course of COVID-19-related CAP. Patients with MASLD exhibit more pronounced respiratory and systemic manifestations, significant immune disturbances, higher rates of secondary co-infections, and more extensive bilateral radiological lung involvement (p < 0.05).