The impact of COVID-19 on TB in Iran: an illustrative study

The COVID-19 pandemic has caused significant disruptions in TB services across the globe. Like many other countries, TB case notifications decreased during the pandemic in Iran. In this paper, we describe two cases of concomitant COVID-19 and TB infection whose diagnosis of pulmonary TB was delayed amid the pandemic. We depict how atypical imaging findings may guide physicians to pulmonary TB diagnosis and discuss strategies to maximize TB case detection.

The impact of COVID-19 on TB in Iran: An illustrative study.

The COVID-19 pandemic has caused significant disruptions in TB services across the globe. Like many other countries, TB case notifications decreased during the pandemic in Iran. In this paper, we describe two cases of concomitant COVID-19 and TB infection whose diagnosis of pulmonary TB was delayed amid the pandemic. We depict how atypical imaging findings may guide physicians to pulmonary TB diagnosis and discuss strategies to maximize TB case detection.

Feasibility of telemedicine in the management strategy of patients with lymphoma amid the COVID-19 pandemic in Spain, a prospective study.

BACKGROUND: In March 14, 2020, the state of alarm and was declared in Spain due to the spread of the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). Beyond this date, the coronavirus disease 2019 (COVID-19) in the country changed the practice of oncologic care. OBJECTIVE: Since recurrent hospital visits were potential risk factors for contagion, the aims of this prospective observational study was to analyze the consequences of COVID-19 pandemic in the health care of patients with lymphoma. METHODS: All data were obtained from the electronic medical record (EMR). Variables such as age, sex, matter of the visit, use of patient's portal, changes in management, impact in clinical trials and suffering from COVID-19 contagion were recorded. RESULTS: 290 patients were attended in the lymphoma clinic accomplishing 437 appointments. The median age was 66 years (range 18-94) and 157 (54.13%) were male. Of them, 214 patients (73.79%) had only 1 visit to the clinic. Only 23 patients (7.93%) didn't have access to patient's portal. Amid the COVID-19 pandemic, 78 patients (26.89%) remained in active treatment, 35 patients (12.06%) suffered from delayed in their treatments and 6 patients (2.06%) suffered from treatment discontinuation. During the follow-up, only 8 patients (2.75%) suffered from COVID-19 (7 cases with confirmed PCR test and 1 case with clinical suspicion). Despite the implementation of telemedicine strategies to avoid visit to hospital, 66 patients (22.75%) had in-person visits to the lymphoma clinic. Patients who attended in-person consultation were younger than those who preferred telemedicine consultation (62 vs 66 years) and had less use of patient's portal (7.58% vs 9%), although these differences didn't reach statistical significance. Patients who atttended in-person visits used to have only 1 visit to hospital (43.93% vs 82.58%, P<.0001). Regarding the matter of in-person consultation, more patients were on active treatment in comparison with those using telemedicine resources (56.06% vs 18.30%, P<.0001). Patients with preference for telemedicine strategies had more surveillance visits (65.62% vs 36.36%, P<.0001). With regards of treatment modifications, more treatment delays (12.94% vs 9.09%) and more definite treatment discontinuations (2.67% vs 0%) were seen in patients using telemedicine resources when compared to patients attending in-person visits, although these differences didn't reach statistical significance. Regarding the type of therapy, patients attending in-person visits were more likely to receive an intravenous treatment rather than those on telemedicine (62.16% vs 40.47%, P<.0001). CONCLUSIONS: Telemedicine such as patient's portal are feasible strategies in the management of patients with lymphoma during the COVID-19 pandemic, with a reduction of in-person visits to hospital and a very low contagion rate.

Bronchial wall necrosis secondary to mucormycosis following SARS-Cov2 infection: A case report.

Coronavirus 2019 infection (COVID-19) has a broad spectrum of clinical complications, some unrecognized. Herein, a case of a diabetic patient with multiple episodes of hemoptysis 2 months following her recovery from SARS-CoV-2 infection is reported. The initial computed tomography (CT scan) revealed the left lower lobe collapsed secondary to bronchial narrowing and obliteration. Bronchoscopy was performed, indicating necrotic endobronchial tissue, which was confirmed histopathologically as invasive mucormycosis. Bronchial necrosis due to mucormycosis is an unusual presentation of COVID-19-associated pulmonary mucormycosis. The accurate diagnosis could be challenging as it can resemble other pathologies such as malignancies. Therefore, it is crucial to identify this fatal complication in patients with prolonged COVID-19 and lung collapse.

National Research Institute of Tuberculosis and Lung Disease (NRITLD) Protocol for the Treatment of Patients with COVID-19.

More than a year after the onset of the coronavirus disease pandemic in 2019, the disease remains a major global health issue. During this time, health organizations worldwide have tried to provide integrated treatment guidelines to control coronavirus disease 2019 (COVID-19) at different levels. However, due to the novel nature of the disease and the emergence of new variants, medical teams' updating medical information and drug prescribing guidelines should be given special attention. This version is an updated instruction of the National Research Institute of Tuberculosis and Lung Disease (NRITLD) in collaboration with a group of specialists from Masih Daneshvari Hospital in Tehran, Iran, which is provided to update the information of caring clinicians for the treatment and care of COVID-19 hospitalized patients.

Development and validation of a predictive model of in-hospital mortality in COVID-19 patients.

We retrospectively evaluated 2879 hospitalized COVID-19 patients from four hospitals to evaluate the ability of demographic data, medical history, and on-admission laboratory parameters to predict in-hospital mortality. Association of previously published risk factors (age, gender, arterial hypertension, diabetes mellitus, smoking habit, obesity, renal failure, cardiovascular/ pulmonary diseases, serum ferritin, lymphocyte count, APTT, PT, fibrinogen, D-dimer, and platelet count) with death was tested by a multivariate logistic regression, and a predictive model was created, with further validation in an independent sample. A total of 2070 hospitalized COVID-19 patients were finally included in the multivariable analysis. Age 61-70 years (p<0.001; OR: 7.69; 95%CI: 2.93 to 20.14), age 71-80 years (p<0.001; OR: 14.99; 95%CI: 5.88 to 38.22), age >80 years (p<0.001; OR: 36.78; 95%CI: 14.42 to 93.85), male gender (p<0.001; OR: 1.84; 95%CI: 1.31 to 2.58), D-dimer levels >2 ULN (p = 0.003; OR: 1.79; 95%CI: 1.22 to 2.62), and prolonged PT (p<0.001; OR: 2.18; 95%CI: 1.49 to 3.18) were independently associated with increased in-hospital mortality. A predictive model performed with these parameters showed an AUC of 0.81 in the development cohort (n = 1270) [sensitivity of 95.83%, specificity of 41.46%, negative predictive value of 98.01%, and positive predictive value of 24.85%]. These results were then validated in an independent data sample (n = 800). Our predictive model of in-hospital mortality of COVID-19 patients has been developed, calibrated and validated. The model (MRS-COVID) included age, male gender, and on-admission coagulopathy markers as positively correlated factors with fatal outcome.

Case Report: COVID-19-associated Rhinosinusitis Mucormycosis Caused by Rhizopus arrhizus: A Rare but Potentially Fatal Infection Occurring After Treatment with Corticosteroids.

COVID-19 first emerged in Wuhan, China, in December 2019. Since that time, the frequency of bacterial and fungal coinfections has been continuously increasing. Although invasive pulmonary aspergillosis is being increasingly recognized in association with COVID-19, there is limited information regarding COVID-19-associated mucormycosis. We describe a 50-year-old woman with uncontrolled diabetes who received systemic corticosteroids and remdesevir during her admission for COVID-19. A few days after discharge, the patient was readmitted because of facial swelling and numbness, and a diagnosis of COVID-19-associated rhinosinusitis mucormycosis caused by Rhizopus arrhizus (formerly called Rhizopus oryzae) was confirmed with sequencing of the internal transcribed spacer region of the ribosomal DNA. This report aimed to address the importance of short-term follow-up for COVID-19 patients who have received systemic corticosteroids, particularly those with predisposing conditions, because early detection and prompt, aggressive treatment are essential for the management of invasive fungal infections.

Radiological and Laboratory Findings of Patients with COVID-19 Infection at the Time of Admission.

BACKGROUND & OBJECTIVE: Diagnosis of coronavirus disease 2019 (COVID-19) can be challenging, especially when the real-time quantitative reverse transcription polymerase chain reaction (RT-PCR) is not available or it is negative. In this study, we evaluated imaging and laboratory findings in a group of patients with a multidisciplinary diagnosis of COVID-19 pneumonia. METHODS: A total of 163 patients with a clinical diagnosis of COVID-19 pneumonia admitted to a specialised respiratory centre in Tehran, Iran were enrolled in this study. The distribution and characteristics of presenting radiological and laboratory findings were evaluated and the relationship to the outcome was investigated. RESULTS: RT-PCR was positive in 92 patients. The diagnosis of COVID-19 in RT-PCR negative patients was made on clinical and radiological features (n=71) and 24 (14.7%) patients died of disease. The common computed tomography (CT) scan findings included ground-glass (94%) and consolidating opacification (12%), mainly in the lower lobes (90%). Peripheral and central lung changes were observed in 90% and 52% of patients, respectively. Lymphopenia, positive CRP, and raised LDH were present in 32%, 65%, and 96% of cases, respectively. A raised LDH of >500U/L was the best predictor of death in these patients (R2=0.6623; OR=24.4). Other markers of outcome included male gender, age (>50 years), lymphopenia, and severe CXR changes. CONCLUSION: Diagnosis of COVID-19 can be challenging, and a multidisciplinary approach is often needed. Whilst RT-PCR is still the standard diagnostic test, a negative test should be interpreted with caution. Blood tests and imaging can be useful in the diagnosis, monitoring, and risk assessment in patients with COVID-19.

Concurrent chronic lymphocytic leukemia and COVID-19: A comprehensive review of epidemiological, diagnostic, and therapeutic challenges.

A comprehensive review of the literature on chronic lymphocytic leukemia (CLL) patients and recommendations regarding the evaluation and treatment of these patients was conducted. The overall prevalence of CLL and COVID-19 concurrence was found to be 0.6% (95%CI: 0.5% to 0.7%). Diagnostic interaction between CLL and COVID-19 remains a major challenge. Also, CLL patients have a lower rate of anti-SARS-CoV-2 IgG development. Evidences show the unacceptable therapeutic outcome in these patients. Although the CLL-COVID-19 occurrence is associated with adverse clinical consequences, no general and standard agreement has yet been presented for the management and treatment of this disease.

Comparative evaluation of SARS-CoV-2 IgG assays against nucleocapsid and spike antigens.

BACKGROUND: There are few studies to compare antibody response against anti-spike (S) and anti- nucleoprotein (N) SARS-CoV-2. OBJECTIVE: The aim of this study was to evaluate the IgG antibody production against S and N antigens of the virus and their correlation with the time and severity of the disease. METHODS: The IgG antibodies against S and N antigens of SARS-CoV-2 in serum specimens of 72 symptomatic patients who tested real-time reverse transcription polymerase chain reaction positive for SARS-CoV-2 were detected using the ELISA technique. Different antibody response was compared and the correlation with the time from disease onset and the severity was evaluated. RESULTS: Forty-eight of 72 (67%) patients tested positive for anti-SARS-CoV-2 antibodies, while 24 (33%) did not have detectable antibodies. Comparison of antibody levels for N and S antibodies showed that they correlate with each other well (r= 0.81; P< 0.001). However, sensitivity of anti-S SARS-CoV-2 IgG and anti-N SARS-CoV-2 IgG was 30% and 60%, during the first 7 days after symptom onset (r= 0.53; P= 0.111), but increased to 73% and 68% at more than 1-week post symptom onset (r= 0.89, P= 0.111), respectively. Cases with positive IgG response showed a decreased CD8+ T cells percentage compared to the negative IgG groups (26 ± 14 vs. 58 ± 32, p= 0.066 in anti-N IgG group and 28 ± 15 vs. 60 ± 45, p= 0.004 in anti-S IgG group, respectively). CONCLUSION: Nearly one-third of the confirmed COVID-19 patients had negative serology results. Lower percent positivity at early time points after symptom onset (less than 1 week) was seen using anti-S SARS-COV-2 IgG kit compare to the anti-N SARS-CoV-2 IgG; therefore, clinicians should interpret negative serology results of especially anti-S SARS-CoV-2 IgG with caution.

Prevalence, Risk Factors and Outcomes Associated with Acute Kidney Injury in Patients Hospitalized for COVID-19: A Comparative Study between Diabetic and Nondiabetic Patients.

BACKGROUND: The risk factors for acute kidney injury (AKI) development in patients with diabetes hospitalized for COVID-19 have not been fully studied yet. In this study, we aimed to estimate the rate of AKI among the hospitalized population with COVID-19 and to identify the risk factors associated with AKI among patients with diabetes. Material and Methods. This retrospective cohort study included 254 patients (127 with diabetes and 127 without diabetes) who were admitted for COVID-19 to a tertiary hospital in Tehran, Iran, between February and May 2020. Clinical characteristics and outcomes, radiological findings, and laboratory data, including data on AKI, hematuria, and proteinuria were recorded and analyzed. RESULTS: Of 254 patients, 142 (55.9%) were male and the mean (± SD) age was 65.7 years (±12.5). In total, 58 patients (22.8%) developed AKI during hospitalization, of whom 36 patients had diabetes (p = 0.04); most patients (74.1%) had stage 1 or 2 AKI. Also, 8 patients (13.8%) required renal replacement therapy (RRT) after developing AKI. Regardless of diabetes status, patients who developed AKI had significantly higher mortality rates compared with patients who did not develop AKI (p = 0.02). Hematuria and proteinuria were observed in 38.1% and 55% of patients, respectively. Multivariate analysis showed that invasive mechanical ventilation, proteinuria, HBA1c level, history of cardiovascular disease, and use of statins were independent risk factors for AKI development in patients with diabetes. CONCLUSION: Results of this study showed that AKI develops in a considerable percentage of patients with COVID-19, especially in those with diabetes, and is significantly associated with mortality.

Diffuse alveolar damage and thrombotic microangiopathy are the main histopathological findings in lung tissue biopsy samples of COVID-19 patients.

BACKGROUND: Since the outbreak of the novel coronavirus disease-2019 (COVID-19) in December 2019, limited studies have investigated the histopathologic findings of patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). MATERIAL AND METHODS: This study was conducted on 31 deceased patients who were hospitalized for COVID-19 in a tertiary hospital in Tehran, Iran. A total of 52 postmortem tissue biopsy samples were obtained from the lungs and liver of decedents. Clinical characteristics, laboratory data, and microscopic features were evaluated. Reverse transcription polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 was performed on specimens obtained from nasopharyngeal swabs and tissue biopsies. RESULTS: The median age of deceased patients was 66 years (range, 30-87 years) and 25 decedents (81 %) were male. The average interval from symptom onset to death was 13 days (range, 6-34 days). On histopathologic examination of the lung specimens, diffuse alveolar damage and thrombotic microangiopathy were the most common findings (80 % and 60 %, respectively). Liver specimens mainly showed macrovesicular steatosis, portal lymphoplasmacytic inflammation and passive congestion. No definitive viral inclusions were observed in any of the specimens. In addition, 92 % of lung tissue samples tested positive for SARS-CoV-2 by RT-PCR. CONCLUSIONS: Further studies are needed to investigate whether SARS-CoV-2 causes direct cytopathic changes in various organs of the human body.

Clinical efficacy of convalescent plasma for treatment of COVID-19 infections: Results of a multicenter clinical study.

Since Dec. 2019 the new coronavirus (SARS-CoV-2) has infected millions and claimed life of several hundred thousand worldwide. However, so far no approved vaccine or drug therapy is available for treatment of virus infection. Convalescent plasma has been considered a potential modality for COVID-19 infection. One hundred eighty-nine COVID-19 positive patients including 115 patients in plasma therapy group and 74 patients in control group, registered in the hospitals with confirmed COVID-19 infection, entered this multi-center clinical study. Comparison of outcomes including all-cause mortality, total hospitalization days and patients' need for intubation between the two patient groups shows that total of 98 (98.2 %) of patients who received convalescent plasma were discharged from hospital which is substantially higher compared to 56 (78.7 %) patients in control group. Length of hospitalization days was significantly lower (9.54 days) in convalescent plasma group compared with that of control group (12.88 days). Only 8 patients (7%) in convalescent plasma group required intubation while that was 20 % in control group. This clinical study provides strong evidence to support the efficacy of convalescent plasma therapy in COVID-19 patients and recommends this treatment for management of these patients. Clinical efficacy, immediate availability and potential cost effectiveness could be considered as main advantages of convalescent plasma therapy.