Not always COVID - pulmonary BCGosis as an unexpected cause of severe respiratory failure and massive ground glass opacities in the lungs

Introduction: Instillations with balcillus Calmette - Guerin (BCG) are established adjuvant therapy for superficial bladder cancer. Although generally safe and well tolerated, they may cause a range of different, local, and systemic complications. Case description: We present a patient treated with BCG instillations for three years, who was admitted to our hospital due to fever and progressive dyspnea. Blood test revealed elevated CRP and liver function tests. On CT scan massive bilateral ground glass opacities in the middle and lower parts of the lungs, parenchymal infiltrations, bronchial walls thickening, and hilar lymphadenopathy were visible. PCR test for SARS-CoV-2 as well as sputum, blood, and urine cultures were negative. Initial empiric antibiotic therapy was ineffective and respiratory failure progressed with the need of oxygen supplementation of 15l/min. Finally, positive cultures for M. tuberculosis ssp. bovis (BCG) were available from sputum and bronchoalveolar lavage fluid. Antituberculous treatment (rifampin, isoniazid, etambuthol) was implemented together with systemic corticosteroids resulting in the quick improvement of the patient's clinical condition. Due to hepatotoxicity and finally reported resistance of the BCG strain to isoniazid, it was replaced with levofloxacin with a good tolerance. Follow up CT scan showed partial resolution of the infiltrates. The patient was discharged home and continued treatment without further side effects. Conclusion(s): The diagnosis of BCG infection in the lungs must be taken into consideration in every patient treated with BCG instillations and symptoms of unexplained infection.

Pneumatocele as rare thoracic complication after recovering COVID-19 pneumonitis- a case series including literature review

Outbreak of coronavirus disease 2019 (COVID-19) with its overwhelming morbidity and mortality has created a significant challenge for health systems worldwide. Although peripheral ground-glass opacities are the most frequent radiologic feature of COVID-19 described in the literature, long term rare complications such as cavitations, pneumatocele, pneumothorax, empyema or hemothorax are occasionally reported. Pneumatoceles are defined as thin-walled air-filled cyst in the lung interstitium, caused by ischemia related damage of alveolar wall and check valve mechanism, which lead to air trapping. We describe a case series of eight patients, diagnosed with COVID-19, confirmed by the reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 of nasopharyngeal swab and complicated with pneumatocele and pneumothorax, the largest group at present. Among these patients seven were males, only one had a history of a previous lung disease, six had a smoking history. One out of these eight patients suffered from acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. During the hospitalization three patients received surgical intervention with resection of pneumatocele, others were successfully treated conservatively with antibiotic therapy. Reason for surgical intervention included non-resolving pneumothorax, superinfection of pneumatocele non responding to antibiotic therapy and hemothorax. According to our study not every pneumatocele requires surgical intervention. Conservative management or surgical approach in those complications should be decided individually.

Prolonged SARS-CoV-2 Infection and Organizing Pneumonia in a Patient with Follicular Lymphoma, Treated with Obinutuzumab-Challenging Recognition and Treatment.

A Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) led to a pandemic outbreak in 2019. COVID-19's course and its treatment in immunocompromised patients are uncertain. Furthermore, there is a possibility of protracted SARS-CoV-2 infection and the need for repeated antiviral treatment. Monoclonal antibodies against CD20, which are used, among other things, in the therapy of chronic lymphocytic leukaemia and follicular lymphoma, can induct immunosuppression. We present a case report of a patient with follicular lymphoma, treated with obinutuzumab, who was diagnosed with prolonged, ongoing SARS-CoV-2 infection and related organizing pneumonia. The recognition and the treatment were challenging which makes this case noteworthy. Antiviral therapy with several medications was administrated to our patient and their temporary, positive effect was observed. Moreover, high-dose intravenous immunoglobulin was applied, because slowly decreasing IgM and IgG levels were observed. The patient also received standard treatment of organizing pneumonia. We believe that such a complex approach can create an opportunity for recovery. Physicians should be conscious of the course and treatment possibilities facing similar cases.

Thromboprophylaxis in patients with COVID-19

For two years, the entire world has been grappling with the new challenge that is the COVID-19 pandemic. In December 2019 in China's largest province, Wuhan, Severe Acute Respiratory Syndrome- Coronavirus-2 (SARS-CoV-2), was detected in a patient with severe respiratory failure. Shortly after, infections were detected in all regions of the world. So far, 265 million infections have been confirmed around the world, and 5.2 million of those infected have died due to COVID-19. Infection with SARS-CoV-2 is associated with an increased risk of cardiovascular complications, especially thromboembolic complications. Low-molecular-weight-heparin presents a basic form of prophylaxis against thromboembolic complications in individuals who are ill with COVID-19. Controversy still exists regarding the optimal dose of LMWH depending on disease severity, this problem requires further randomized trials.