ABSTRACT
Background and Aim: CoViD-19 patients with mild to severe ARDS, need to be treated with invasive or non-invasive ventilation (NIV);among those pneumomediastinum (PNM) is a frequent complication. The objective of our retrospective study is to identify predisposing factors and risk factors for PNM in a population admitted to Internal Medicine ward. Materials and Methods: We analyzed 304 CoViD patients from 17th October 2020 till 25th January 2021: 176 males (57.9%) and 128 females (42.1%), with a mean age of 69.6 years. During hospitalization, 129 patients (42.4%) needed NIV. Of these, 5 (3.8%) presented PNM. Results: PNM was associated with higher in-hospital stay (27±7 days vs 8±4 days) and in-hospital mortality (40% vs 16.7% p=0.04). Among NIV patients, higher inspiratory positive airway pressure (IPAP) and positive expiratory end pressure (PEEP), were associated with higher incidence of PNM at point-biserial correlation (p=0.042). There were no statistically significant differences between bilevel and CPAP (p=0.160) or according to pressure support (PS) ≥8 cmH2O (p=0.509) or days of ventilation (p=0,869). Conclusions: An increased lung frailty in CoViD-19 pneumonia could partially explain the incidence of barotrauma: however, the incidence is also related to a more aggressive ventilation, when higher pressure support are used. A gentle ventilatory approach aimed to avoid excessive high pressure should be pursued, supporting a gentle ventilation and permissive hypoxemia.
ABSTRACT
Background: Venous thromboembolism represents frequent complication of patients with severe CoViD-19 disease. The occurrence of venous thromboembolism is mainly in typical district, however several reports about atypical thrombosis are described. We report a case of isolated right endoventricular thrombosis in a patient with SARS-CoV-2 infection. Case Report: A 60-year-old man was admitted to our ward for severe respiratory failure in interstitial pneumonia. The nasopharyngeal swab for CoViD-19 resulted positive. Prophylaxis with LMWH were started associated to CPAP to maintain good gas exchange. During hospitalization a new onset AF was documented at the telemetry and an echocardiogram was performed showing a right endoventricular lesion of 1.8 cm adhering to the free wall. A CTpulmonary angiogram (CTPA) resulted negative for pulmonary embolism. Doppler ultrasound showed left popliteal thrombosis. A treatment with fondaparinux was started. After 10 days, an echocardiogram was repeated showing complete resolution of thrombosis. Another CTPA confirmed the absence of pulmonary embolism. The patient clinically improved and he was discharged with dabigatran. Conclusions: SARS-CoV-2 infection may cause hypercoagulability and inflammation leading to venous thromboembolism and this seems to be related with worse outcome of these patients. For this reason, to monitor the venous thrombosis complication is an important step in the assessment of patients with CoViD-19.
ABSTRACT
Background: Pyomysitis is a bacterial infection of skeletal muscle characterized by intramuscular abscess formation that arises in endemic areas (tropical) or in patients with immunocompromised condition such as HIV or Diabetes Mellitus. Staphylococcus aureus is the most common culprit, with rising proportion of MRSA. Description of the case: A 35-year-old man with history of diabetes mellitus in poor control was admitted to our ward with ketoacidotic state, fever, repiratory insufficiency and diffuse myalgia. After the prompt correction of DKA, Chest X-ray reveald bilateral interstitial pneumonia and nasopharyngeal swab for CoViD-19 resulted positive. He started dexamethasone, remdesivir and noninvasive ventilation with improvement of gas exchanges. A MRI revealed an intramuscular abscess on left paravertebral muscle and bedside ultrosound showed multiple muscolar abscesses (right rectus femoris, right gastrocnemius, left teres minor and left semitendinosus). Ultrasound assisted drainage was performed and liquid culture yielded MSSA, thus antibiogram guided treatment with linezolid plus sulphametoxazole/trimetroprim was started. Follow-up PET at two weeks demonstrated a dramatic reduction in the inflammations. Conclusions: Pyomyositis is a potentially severe but uncommon complication of poorly controlled diabetes that could be difficult to detect in the setting of a concomitant viral illness. Bedside ultrasound has a unique role in the diagnosis, in the surgical drainage and in the follow-up. The cornerstone of optimal antimicrobic therapy is antibiogram-guided due to the rising proportion of MRSA.
ABSTRACT
Background and Aim: Pneumomediastinum (PNM) is not an unfrequent complication in CoViD-19 patients and IL-6 is a laboratory index which can predict a worst outcome in these patients. We analysed the role of IL-6 and his association with the incidence of PNM. Materials and Methods: In our retrospective study, we analysed a population of 304 patients with SARS-CoV-2 infection admitted to an Internal Medicine ward from 17th October 2020 till 25th January 2021, including 176 males (57.9%) and 128 females (42.1%), with a mean age of 69.6 years. During hospitalization, 129 patients (42.4%) needed NIV. Of these, 5 (3.8%) presented a PNM. Results: Higher levels of interleukin-6 (IL-6) on admission were present in PNM patients than in the overall population (168.9±296.3 pg/mL vs 37.9±69.6 pg/mL, Student t-Test p<0.001) and NIV population (168.9±296.3 pg/mL vs 30.1±76.5 pg/mL, Student t-Test p=0.015): IL-6 levels are strongly associated with incidence of PNM. In recent literature, high levels of IL-6 are strictly associated with severity of CoViD- 19 disease and severity of respiratory failure, needing for NIV and/or invasive ventilation and death. Conclusions: In conclusion, PNM represents a severe and quite frequent complication in CoViD-19 patients treated with NIV. Before CoViD-19, the occurrence of PNM during NIV in Community Acquired Pneumonia was a rare complication. The detection of high levels of IL-6 must be a warning signal in ventilated patients, addressing the choice toward a more protective ventilation.