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We describe three postmortem open lung-biopsy findings among patients with COVID-19 pneumonia who were on anticoagulant therapy. The spectrum of histopathological findings included lung inflammation in the form of diffuse alveolar damage (DAD) in exudative and organizing phases, with or without pulmonary artery thrombosis in different stages of evolution. This spectrum of inflammation and thrombosis may be indicative of a natural history of severe COVID-19 pneumonia or demonstrative of variation in therapeutics.
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Abstract Cardiac masses represent a heterogeneous group, including secondary malignancies as the most common ones, followed by primary tumors, vegetations, and thrombi. Cardiac imaging techniques are essential for the non-invasive diagnosis of cardiac masses. Thrombi in a transplanted heart, especially in atria, are very common, but when they appear as multiple, they could be an early sign of rejection. We present the case of a cardiac transplant patient who presented with masses in both atria and the left ventricle, as well as symptoms of right heart failure. Various image techniques were useful in establishing the differential diagnoses and appropriate treatment.
Resumen Las masas intracardíacas representan un grupo variado, que incluye metástasis como las más frecuentes, seguidas de tumores primarios, vegetaciones y trombos. Los trombos intracavitarios en un paciente trasplantado, especialmente en la aurícula, son muy frecuentes, pero, si aparecen como masas múltiples, pueden ser un dato precoz de un posible rechazo. Se expone el caso de un paciente trasplantado cardíaco que se presenta con masas intracavitarias en ambas aurículas y en el ventrículo izquierdo y datos de insuficiencia cardíaca de predominio derecho. Gracias al uso de varias técnicas de imagen se estableció el diagnóstico diferencial de las mismas, y se instauró el tratamiento adecuado.
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Background & objectives: Autopsy study has been considered the gold standard method for studying the effects of any disease on the body. Since COVID-19 is a novel disease, autopsy is crucial to understand its pathophysiology. This study was conducted to analyze the microscopic and macroscopic findings of various organs in COVID-19 and to associate those findings with clinical observations and laboratory findings. Methods: Conventional invasive autopsies were performed on 33 patients with COVID-19 from September 7, 2020 to December 23, 2020. All the organs were removed by routine dissection techniques and preserved in 10 per cent formalin. The tissues were processed and stained according to standard practices using haematoxylin-eosin (H & E) and periodic acid-schiff (PAS) stain. Results: The study included 28 males and 5 females with a median age of 61 yr (range 30-90 yr). Massive pulmonary oedema and thrombi in the lungs were the characteristic features macroscopically. On microscopic examination, diffuse alveolar damage in the exudative/proliferative phase was found in 29 (87.88%) cases. Among the other notable microscopic findings were bronchopneumonia and lung abscesses due to secondary bacterial infection (n=17, 51.52%), acute tubular injury (n=21, 63.64%) and thrombi in the lungs, heart, and kidneys. Interpretation & conclusions: COVID-19 primarily affected the respiratory and the renal systems in the vast majority of severely affected patients in our study. We also found signs of hypercoagulability, as evidenced by widespread thrombi in multiple organs, along with a raised d-dimer level and a hyperinflammatory state manifested by elevated inflammatory markers. Our autopsy findings and altered laboratory investigations support
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Abstract A primary aortic mural thrombus (PAMT) is defined as a thrombus attached to the aortic wall in the absence of any atherosclerotic or aneurysmal disease of the aorta or any cardiac source of embolus. It is a rare entity that has high morbidity and mortality. There is no consensus on the ideal treatment of PAMT. The objective of this paper is to review the possibilities for treatment of mobile abdominal aortic mural thrombus. Endovascular therapy and open surgery appear to be the best options for treatment of mobile abdominal aortic mural thrombus. Thus, in patients with favorable anatomy, endovascular therapy is probably the treatment choice, while in those with unfavorable anatomy, open surgery is probably the best option for treatment of a mobile abdominal aortic thrombus. It is important to emphasize that anticoagulation alone can be used as a non-aggressive option and, if this fails, endovascular or surgical methods can then be employed.
Resumo O trombo mural aórtico primário é definido como um trombo aderido à parede aórtica na ausência de doença aterosclerótica e/ou aneurismática ou de fonte cardíaca de êmbolo. Trata-se de uma doença rara, porém causadora de alta morbimortalidade, e não há consenso acerca do seu tratamento. Este estudo objetivou revisar as possibilidades na presença de componente móvel. A terapia endovascular e a cirurgia aberta parecem ser as melhores opções, sendo a abordagem endovascular o tratamento de escolha para pacientes com anatomia favorável e a cirurgia aberta o tratamento de escolha para pacientes com anatomia desfavorável. No entanto, a anticoagulação sistêmica apresenta-se como método não invasivo para pacientes com alto risco cirúrgico e como possibilidade terapêutica na falha ou indisponibilidade de abordagem cirúrgica.
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Introducción: La parasitosis intestinal por Geohelmintiasis es una de las Enfermedades Infecciosas Desatendidas (OMS), que afecta a poblaciones vulnerables. Existen factores predisponentes como: condiciones precarias de vivienda, bajos ingresos económicos y nivel educativo deficiente. De los helmintos, el Ascaris lumbricoides es el más grande nematodo intestinal en humanos -alcanza hasta 40 centímetros-. La presentación clínica depende del grado de infestación variando desde anemia, astenia, pérdida de peso, hasta invasión interna de órganos blancos como hígado, pulmones, cerebro y corazón en casos extremos. Caso Clínico: Niña de 16 meses de edad, con historia de fiebre prolongada y expulsión espontánea de parásitos por orificio naturales, que llega al servicio de urgencias con síntomas de shock cardiorrespiratorio. Se realiza Ecocardiográfía visualizándose imágenes de cuerpos extraños en forma de cintas y con movimientos espontáneos, compatibles con parásitos de localización cardíaca (2 en aurícula y ventrículo derecho y 1 cabalgando las arterias pulmonares); en el seguimiento ecocardiográfico se constatan múltiples trombos a lo largo del parásito localizado en aurícula derecha y, que dada la gravedad del cuadro se determinó su extracción quirúrgica de urgencia. Se extrajeron 4 parásitos adultos,y, coágulos adherido a uno de ellos. Discusión: El estudio parasitológico y anatomopatológico concluyó que correspondían a hembras adultas de Ascaris lumbricoides. Alta al 8° día post-operatorio en buenas condiciones. Aunque este caso fue exitoso, las complicaciones cardiacas e infecciones sistémicas graves, son de alta morbi-mortalidad, que pueden evitarse con programas de desparasitación y reducción de carga parasitaria mediante mejoras en el saneamiento ambiental y educación sanitaria. A nuestro conocimiento este es el primer caso reportado en el mundo, de extracción de Ascaris Lumbricoides formas adultas del Corazón humano.
Introduction: Geohelminthiasis intestinal parasitosis is one of the neglected Infectious Diseases (WHO) that affects vulnerable populations. Predisposing factors are: poor housing conditions, low economic income and poor educational level. Of the helminths, Ascaris lumbricoides is the largest intestinal nematode in humans - it reaches up to 40 centimeters. The clinical presentation depends on the degree of infestation, which varies from anemia, asthenia, weight loss to internal invasion of organs such as liver, lungs, brain and the heart in severe cases. Case Report: A 16-month-old girl with a history of prolonged fever and spontaneous expulsion of parasites through a natural orifice, arrived at the emergency department with symptoms of cardiorespiratory shock. Echocardiography showed foreign bodies in the form of tapes and with spontaneous movements, compatible with cardiac parasites (2 in the atrium and right ventricle and 1 riding the pulmonary arteries); at echocardiographic follow-up, multiple thrombi were found along the parasite located in the right atrium and, given the severity of the condition, emergency surgical removal was performed 4 adult parasites were removed, with clots adhered to one of them. Discussion: The parasitological and pathological study concluded that the parasites were adult Ascaris lumbricoides females. The patient was discharged on the 8th post-operative day in good condition. Although this case was successful, the cardiac complications and serious systemic infections have a high morbidity and mortality, which can be avoided with deworming programs and reduction of parasite load through improvements in environmental sanitation and health education. To our knowledge, this is the first reported case of Ascaris Lumbricoides adult form extraction from the human heart in the world.
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Objective To review the role of extrahepatic bile duct resection in patients with hepatocellular carcinoma with bile duct tumor thrombi.Methods The Pubmed,Wan Fang and China Science and Technology Journal Database were reviewed systematically.Any case reports or studies involving treatment of hepatocellular carcinoma with bile duct tumor thrombi were included in this literature search.Two authors independently assessed the studies for inclusion and extracted the data.Univariate analysis was used to compare the baseline characteristics and the Kaplan-Meier method was used for analyzing survival and diseasefree survival outcomes.Results Using predetermined inclusion criteria,16 studies which included 170 patients entered into this study.All these patients underwent surgical resection of hepatocellular carcinoma and bile duct tumor thrombi.Based on the Satoh classification,45 patients were type Ⅰ,107 patients type Ⅱ and 18 patients type Ⅲ.Twenty-four patients underwent liver resection combined with extrahepatic bile duct resection.The remaining 146 patients underwent liver resection combined with thrombectomy.The 1-,3-,and 5-year survival rates of all the patients were 73.4％,41.5％ and 21.8％,and the corresponding recurrences free survival rates were 62.5％,29.2％ and 13.1％,respectively.On Kaplan-Meier analysis,there were no significant differences in the survival outcomes between the 2 groups of patients,(P ＞ 0.05).The 1-,3-,and 5-year survival rates of the extrahepatic bile duct resection group were 66.7％,41.7％ and 12.5％,and those of the thrombectomy group were 74.6％,41.3％ and 23.8％,respectively.On subgroup analysis (Satoh type Ⅱ and Ⅲ),no significant differences were observed between the two groups (P ＞0.05).The 1-,3-,and 5-year survival rates of the extrahepatic bile duct resection group were 65.2％,38.0％ and 13.0％,and those of the thrombectomy group were 72.8％,39.5％ and 20.9％,respectively.Conclusion Extrahepatic bile duct resection did not improve the overall survival of patients with hepatocellular carcinoma with bile duct tumor thrombi.
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No abstract available.
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Humans , Breast Neoplasms , Breast , Pulmonary Heart Disease , Thrombotic MicroangiopathiesABSTRACT
Free‑floating right heart thrombi are uncommon and need emergency treatment in view of their tendency to dislodge and cause pulmonary embolism. We report a successful surgical management of a patient who had large mobile right atrial thrombus, bilateral pulmonary thrombi, coronary artery disease, and postmyocardial infarction ventricular septal rupture (VSR). The patient underwent coronary angiography, inferior vena cava filter placement, removal of thrombi from the right atrium and pulmonary arteries, repair of VSR, and coronary artery bypass graft surgery in a hybrid operating room.
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Introducción: La incidencia de trombos cardíacos en recién nacidos (RN) ha aumentado con el uso de catéteres venosos centrales. La trombólisis con activador del plasminógeno tisular recombinante (rTPA) se ha utilizado como alternativa a la heparina en trombos gigantes con riesgo vital y de embolización. Nuestro objetivo fue describir la respuesta y las complicaciones relacionadas con el uso del rTPA en el manejo de trombos cardíacos con riesgo vital en RN. Pacientes y método: Estudio retrospectivo de 8 RN, 7 prematuros, con trombos cardíacos en los cuales se utilizó rTPA. Se analizó la edad gestacional y al diagnóstico, peso, sexo, enfermedades asociadas, hemograma, niveles de fibrinógeno, dímero D, tiempo parcial de tromboplastina activada y de protrombina, antes y al término de la infusión de rTPA. El diagnóstico del trombo se realizó por ecocardiografía doppler. La indicación de rTPA fue trombo mayor de 10 mm o que ocupara más del 50% de la cavidad donde se localizaba; aumento del tamaño a pesar del tratamiento con heparina, aspecto fragmentado y lobulado con riesgo embólico pulmonar o sistémico o que comprometiera la función valvular o cardíaca. Resultados: Cuatro hombres; peso promedio de 1.580 g. La principal enfermedad fue la sepsis (7/8), se usó catéter venoso central en todos, la vena cava superior fue la localización más frecuente, con tiempo promedio de instalación previo al diagnóstico de 12 días. En 7/8 RN los trombos se ubicaron en la aurícula derecha, con un tamaño entre 7 a 20 mm. Tres pacientes recibieron heparina de bajo peso molecular previo al uso de rTPA, se realizaron entre uno a 5 ciclos con rTPA. En 4 pacientes se logró resolución completa del trombo a los 3,5 días en promedio. No hubo embolia ni fallecidos. Cuatro pacientes presentaron hemorragia intracraneana grado I, sin secuelas en el seguimiento. Conclusión: Este estudio constituye la primera serie de neonatos tratados con rTPA en Chile, lográndose la resolución completa del trombo en un 50% de los RN y parcial en el resto, permitiendo con ello disminuir el riesgo vital secundario a este proceso patológico.
Introduction: The incidence of cardiac thrombi in newborns has increased with the use of central venous catheters. Thrombolysis with recombinant tissue plasminogen activator (rTPA) has been used as an alternative to heparin in life threatening giant thrombus and embolization. The aim of this study is to describe the response and complications related to the use of rTPA in the management of life- threatening cardiac thrombi in newborns. Patients and method: The medical records of 8 newborn were reviewed in a retrospective study, of whom 7 were preterm with cardiac thrombi, and rTPA was used in all of them. Results: The patients included 4 males with a mean weight of 1580 gr. The principal pathology was sepsis (7/8), all of them used venous central catheter. The superior vena cava was the most frequent location, with a mean time of installation before the diagnosis of 12 days. RN 7/8 thrombi were located in the right atrium with a size between 7 to 20 mm. Three patients received low molecular weight heparin prior to using rTPA. They received between 1 to 5 cycles with rTPA. In 4 patients complete resolution of the thrombus was achieved in a mean of 3.5 days. Four patients had intracranial haemorrhage grade I, without sequelae at follow-up. There were no deaths or embolism. Conclusion: This study is the first series of infants treated with rTPA in Chile, and where its use has quickly achieved complete resolution of the thrombus in 50% of cases, and partially in the others, thus reducing the secondary life-threatening risk of this disease.
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Humans , Male , Female , Infant, Newborn , Thrombosis/drug therapy , Tissue Plasminogen Activator/administration & dosage , Fibrinolytic Agents/administration & dosage , Heart Diseases/drug therapy , Time Factors , Heparin/administration & dosage , Thrombolytic Therapy/adverse effects , Chile , Retrospective Studies , Follow-Up Studies , Treatment Outcome , Tissue Plasminogen Activator/adverse effects , Tissue Plasminogen Activator/therapeutic use , Intracranial Hemorrhages/chemically induced , Intracranial Hemorrhages/epidemiology , Fibrinolytic Agents/adverse effects , Fibrinolytic Agents/therapeutic use , Central Venous Catheters , Heart Diseases/pathologyABSTRACT
Objective To evaluate the diagnostic value of intra-arterial thrombi under went susceptibility weighted imaging(SWI) in patients with acute ischemic stroke(AIS).Methods The MRI images of 133 patients with AIS was analyzed,included time of flight MR angiography(TOF-MRA )and SWI.The patients were divided into two groups according to the time between onset of symptoms and MR imaging (group A,interval time<24 h;group B,interval time 24-72 h).Two neuroradiologists who were blin-ded to the patients clinical information,documented the number and location of susceptibility vessel sign (SVS)in SWI and embolic occlusion or stenosis on TOF-MRA in AIS patients.Results The thrombus detection rate in group A was higher than that in group B.There was no significant difference in the overall detection rate of thrombi between SWI and TOF-MRA in all AIS patients,but the thrombi detection rate in M3 segement of middle cerebral artery(MCA)with SWI was higher than that with TOF-MRA in group A(P <0.05).Conclusion SWI performs a high diagnostic value for thrombus detection in AIS patients,especially for the thrombus detection of M3 segement in early period of AIS.
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Objective To analyze the clinical and pathological characteristics of 35 hepatocellular carcinoma (HCC) patients with bile duct tumor thrombi (BDTT),and to investigate the expressions of CD133,CD90,EpCAM,CK19,VEGF,and C-kit in the tumor tissues.Methods 35 HCC patients with BDTT out of 943 HCC patients who underwent surgical treatment were studied.The expressions of biomarkers in tissue specimens were determined by immunohistochemistry.35 HCC patients without BDTT were selected using the method of stratified sampling as a control group.Results In 19 of 35 patients,the diameters of the primary tumor were less than 5 cm (range 0 ～ 17 cm,average 6.9 ± 0.7 cm).When compared to the control group,most of the primary tumors were moderately to lowly differentiated (33/35,94％ vs 18/ 35,51％),had incomplete capsules (18/35,51％ vs 3/35,8％) and micro vascular invasion (29/35,83％ vs 7/35,20％).The positive expression rates of CD90,EpCAM,CK19,VEGF,CD133,and C-kit in the group of patients with HCC with BDTT and in the control group were 82.9％,77.1％,71.4％,85.7％,80.0％,80.0％ and 57.1％,54.3％,34.3％,65.7％,54.3％,51.4％,respectively.The 1-,2-,3-year postoperative survival rates of the HCC patients with BDTT were 69％,37％,20％ respectively which were worse than the HCC patients without BDTT (1-,2-,3-year postoperative survival rates were 88％,72％,62％ respectively,P ＜ 0.05).Conclusions The prognosis of HCC patients with BDTT was worse than HCC patients without BDTT.The expressions of liver stem cell biomarkers in the tumor specimens of the group of HCC patients with BDTT were higher than the control group.These findings prompt that this kind of HCC originate from liver stem ceils.
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Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment. The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.
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Humans , Angioplasty , Arteries , Compensation and Redress , Constriction, Pathologic , Embolism , Follow-Up Studies , Hemodynamics , Ischemia , Risk Factors , Stroke , Vertebral ArteryABSTRACT
Optical coherence tomography (OCT) is a new imaging technique capable of obtaining high-resolution intravascular images and has been used in interventional cardiology. However, an application of OCT in pulmonary arteries had seldom been documented. In this case, OCT imaging is performed in peripheral pulmonary arteries and shows mural red thrombi. Subsequently, the red thrombi are aspirated and confirmed by a histological examination. These findings suggest that OCT may be a useful tool to depict peripheral pulmonary artery thrombi.
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Adult , Humans , Male , Angiography , Pulmonary Artery/pathology , Pulmonary Embolism/diagnosis , Tomography, Optical Coherence/methods , Tomography, X-Ray ComputedABSTRACT
Objective To summarize the key points for diagnosis and differential diagnosis of hepatocellular carcinoma combined with bile duct tumor thrombi(HCCBDT), and analyze the common reasons for misdiagnosis. Methods A total of 392 patients with HCCBDT over a 18-year period were included in this study. The liable disease types of misdiagnoses were summarized and the main causes of preoperative misdiagnosis were analyzed. The patients were divided into two groups according to the time periods: Group A(from 1993 to 2001, 128 patients) and Group B(from 2002 to 2011, 264 patients). The misdiagnosis rates and types of misdiagnosed diseases were compared between the two groups. The key points of diagnosis and differential diagnosis of HCCBDT were summarized. Results The overall preoperative misdiagnosis rate was 16. 6% (65/392) in our patients. The misdiagnosis rate of Group B (9. 8%, 26/264) was significantly lower than that of Group A (30. 5%, 39/ 128) (P<0. 001). And 91. 7% (242/264) patients received ERCP/MRCP examination in Group B, which was significantly higher than that in the Group A(67. 9%, 87/128) (P<0. 001). The misdiagnosis rate of ERCP/MRCP(5. 5%, 18/329) was significantly lower than those of B-type ultrasound examination (26. 8%, 105/392) (P<0. 001) and CT/MRI scan(25. 0%, 98/392) (P<0. 001). The misdiagnosed diseases included hepatocellular carcinoma with hilar bile duct compression (4. 1%, 16/392), hilar bile duct adenoma/carcinoma (4. 3%, 17/392), distal bile duct adenoma/carcinoma (including ampullary adenoma/carcinoma) (2. 3%, 9/392), mucus-like bile duct adenoma/carcinoma (1. 0%, 4/392), metastatic liver cancer with bile duct tumor thrombi (1. 0%, 4/392), and bile duct stones (3. 8%, 15/392). The proportions of misdiagnosis as liver cancer with hilar bile duct compression in the Group A and Group B were 9. 4% (12/128) and 1. 5%(4/264), respectively, and those as bile duct stone were 7. 8% (10/128) and 1. 9% (5/264), respectively (P<0. 01). Conclusion More knowledge on the HCCBDT clinical features, effective imaging examination methods, and more efforts on differential diagnosis with the similar diseases can reduce misdiagnosis of HCCBDT.
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A 22-year old woman visited the LAMB Hospital, Parbatipur, Dinajpur, Bangladesh, in February 2010, with exertional dyspnea for three weeks. She had had a normal vaginal delivery four months ago; 2-dimensional echocardiogram showed severe left ventricular dysfunction and biventricular thrombi, which resolved without complications after anticoagulation. Biventricular thrombosis with peripartum cardiomyopathy is quite a rare finding, and its clinical course and proper management is not known. No such case has previously been reported in Bangladesh.
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A right atrial and inferior vena caval thrombus in a structurally normal heart is a very rare condition. We report a case of such a thrombus in a 66-year-old woman. She was admitted to our hospital with recent onset dyspnea. Based on echocardiography, we suspected that she had myxoma. We performed an excision of a mass, which was found, by pathologic examination, to be an organized mural thrombus.
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Aged , Female , Humans , Dyspnea , Echocardiography , Heart , Heart Atria , Myxoma , Thrombosis , Vena Cava, InferiorABSTRACT
BACKGROUND:Development of new coronary thrombolytic agents is hot in the market. A new drug, mutated recombinant tissue-type plasminogen activator (rtPAm), is the product of mutation of tPA by changing binding loci with plasminogen activator inhibitor (PAI)-1 to reduce the degradation. In vitro test has demonstrated that the activity of rtPAm is much higher than rtPA in the absence of PAI. The present study is to observe the efficacy of mutated recombinant tissue-type plasminogen activator (rtPAm) in coronary thrombolytic therapy. METHODS:A total of 30 adult beagles were equally divided into 5 groups after thrombi:vehicle group, urokinase group, rtPAm low-dose group, rtPAm medium-dose group, and rtPAm high-dose group. Thrombolytic effect and myocardial infarction were observed after thrombolytic therapy. RESULTS:In the urokinase group, time to reperfusion was (15.8±3.8) minutes. TIMI 2 flow was demonstrated in 4 beagles, TIMI 3 flow in 2, and re-occlusion in 4 after 90 minutes respectively. In the low-dose rtPAm group, time to reperfusion was (15±4.5) minutes; TIMI 2 flow was demonstrated in 2 beagles, TIMI 3 flow in 4, and re-occlusion in 2 after 90 minutes. In the high-dose rtPAm group, time to reperfusion was (7.5±2.6) minutes. None of the beagles showed re-occlusion after 90 minutes. The infarction areas were (2.1+0.9)％ in the medium-dose rtPAm group and (0.7+0.4)％ in the high-dose rtPAm group, which decreased significantly than those in the low-dose rtPAm group. The aggregation rate in the medium-dose and high-dose rtPAm groups decreased significantly than that in the urokinase group. CONCLUSION:rtPAm may serve as a thrombolytic agent with platelet-targeted fibrinolysis and antiplatelet aggregation activities.