An Aberrant Right Subclavian Artery–Esophageal Fistula—A Fatal Complication of a Common Anomaly: A Case Report and Review of Literature

An aberrant right subclavian artery (ARSA), also called as arteria lusoria, is one of the most common aortic arch anomalies. ARSA–esophageal fistula is a rare, life-threatening complication, with only 37 cases reported in literature. We describe a case of a young girl who developed acute episode of massive hematemesis after the recovery from novel coronavirus disease 2019 (COVID-19) pneumonia. Computed tomography (CT) angiography showed ARSA with retroesophageal course and active contrast leak in esophagus. Digital subtraction angiography confirmed the site of active contrast extravasation from the ARSA. However, the patient succumbed to hypovolemic shock even before the endovascular or surgical interventions could be done.

An Aberrant Right Subclavian Artery-Esophageal Fistula-A Fatal Complication of a Common Anomaly: A Case Report and Review of Literature.

An aberrant right subclavian artery (ARSA), also called as arteria lusoria, is one of the most common aortic arch anomalies. ARSA-esophageal fistula is a rare, life-threatening complication, with only 37 cases reported in literature. We describe a case of a young girl who developed acute episode of massive hematemesis after the recovery from novel coronavirus disease 2019 (COVID-19) pneumonia. Computed tomography (CT) angiography showed ARSA with retroesophageal course and active contrast leak in esophagus. Digital subtraction angiography confirmed the site of active contrast extravasation from the ARSA. However, the patient succumbed to hypovolemic shock even before the endovascular or surgical interventions could be done.

Role of MRI in the Evaluation of Pulmonary Sequel Following COVID-19 Acute Respiratory Distress Syndrome (ARDS).

To evaluate the role of magnetic resonance imaging (MRI) chest as an alternative modality to CT chest for follow-up of patients recovered from severe COVID-19 acute respiratory distress syndrome (ARDS). A total of 25 subjects (16 [64%] men; mean age 54.84 years ± 12.35) who survived COVID-19 ARDS and fulfilled the inclusion criteria were enrolled prospectively. All the patients underwent CT and MRI chest (on the same day) at 6-weeks after discharge. MRI chest was acquired on 1.5T MRI using HASTE, BLADE, VIBE, STIR, and TRUFI sequences and evaluated for recognition of GGOs, consolidation, reticulations/septal thickening, parenchymal bands, and bronchial dilatation with CT chest as the gold standard. The differences were assessed by independent-sample t-test and Mann-Whitney U test. P-value of less than 0.05 was taken significant. There was a strong agreement (k = 0.8-1, P<0.01) between CT and MRI chest. On CT, the common manifestations were: GGOs (n=24, 96%), septal thickening/reticulations (n=24, 96%), bronchial dilatation (n=16, 64%), parenchymal bands (n=14, 56%), pleural thickening (n=8, 32%), consolidation (n=4, 16%) and crazy-paving (n=4, 16%). T2W HASTE, T2W BLADE, and T1 VIBE sequences showed 100% (95% CI, 40-100) sensitivity and 100% (95% CI, 3-100) specificity for detecting GGOs, septal thickening/reticulations, pleural thickening, consolidation, and crazy-paving. The overall sensitivity of MRI for detection of bronchial dilatation and parenchymal bands were 88.9% (95% CI, 77-100) and 92.9% (95% CI, 66-100), respectively; and specificity was 100% (95% CI, 29-100) for both findings. MRI chest, being radiation-free imaging modality can act as an alternative to CT chest in the evaluation of lung changes in patients recovered from COVID-19 pneumonia.

CT findings in sequel of COVID-19 pneumonia and its complications.

A significant number of patients after initial recovery from COVID-19 continue to experience lingering symptoms of the disease that may last for weeks or even months. Lungs being the most commonly affected organ by COVID-19, bear the major brunt of the disease and thus it is imperative to be aware of the evolution of the pulmonary parenchymal changes over time. CT chest is the imaging modality of choice to evaluate post-COVID lungs. Persistent ground-glass opacities, septal thickening, parenchymal bands, crazy-paving, traction bronchiectasis and consolidation constitute the commonly encountered imaging patterns seen on CT in post-COVID-19 lungs. Few vulnerable patients can develop lung fibrosis and show honeycombing on CT. Additionally, many complications like superadded infections (bacterial and fungal), pulmonary thromboembolism and pseudoaneurysm formation are also being reported. In the present pictorial review, we have tried to show the entire CT spectrum of sequelae of COVID-19 pneumonia and commonly associated infections and vascular complications.

Ultra-Low Dose CT Chest in Acute COVID-19 Pneumonia: A Pilot Study from India.

The rapid increase in the number of CT acquisitions during the COVID-19 pandemic raised concerns about increased radiation exposure to patients and the resultant radiation-induced health risks. It prompted researchers to explore newer CT techniques like ultra-low dose CT (ULDCT), which could improve patient safety. Our aim was to study the utility of ultra-low dose CT (ULDCT) chest in the evaluation of acute COVID-19 pneumonia with standard-dose CT (SDCT) chest as a reference standard. This was a prospective study approved by the institutional review board. 60 RT-PCR positive COVID-19 patients with valid indication for CT chest underwent SDCT and ULDCT. ULDCT and SDCT were compared in terms of objective (noise and signal-to-noise ratio) and subjective (noise, sharpness, artifacts and diagnostic confidence) image quality, various imaging patterns of COVID-19, CT severity score and effective radiation dose. The sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of ULDCT for detecting lung lesions were calculated by taking SDCT as a reference standard. The mean age of subjects was 47.2 ± 10.7 years, with 66.67% being men. 90% of ULDCT scans showed no/minimal noise and sharp images, while 93.33% had image quality of high diagnostic confidence. The major imaging findings detected by SDCT were GGOs (90%), consolidation (76.67%), septal thickening (60%), linear opacities (33.33%), crazy-paving pattern (33.33%), nodules (30%), pleural thickening (30%), lymphadenopathy (30%) and pleural effusion (23.33%). Sensitivity, specificity and diagnostic accuracy of ULDCT for detecting most of the imaging patterns were 100% (p < 0.001); except for GGOs (sensitivity: 92.59%, specificity: 100%, diagnostic accuracy: 93.33%), consolidation (sensitivity: 100%, specificity: 71.43%, diagnostic accuracy: 93.33%) and linear opacity (sensitivity: 90.00%, specificity: 100%, diagnostic accuracy: 96.67%). CT severity score (range: 15-25) showed 100% concordance on SDCT and ULDCT, while effective radiation dose was 4.93 ± 1.11 mSv and 0.26 ± 0.024 mSv, respectively. A dose reduction of 94.38 ± 1.7% was achieved with ULDCT. Compared to SDCT, ULDCT chest yielded images of reasonable and comparable diagnostic quality with the advantage of significantly reduced radiation dose; thus, it can be a good alternative to SDCT in the evaluation of COVID-19 pneumonia.

The Integral Role of Radiology in the Diagnosis and Management of COVID-19-Associated Mucormycosis Infections.

Recently, there has been a sudden surge in COVID-19-associated mucormycosis (CAM) infections. Rhino-oculo-cerebral and pulmonary mucormycosis are the two most common forms of CAM. Radiology plays an integral role in the management of CAM. Computed tomography (CT) determines gross bony and soft tissue involvement in COVID-19-associated rhino-oculo-cerebral mucormycosis, whereas magnetic resonance imaging helps in evaluation of the orbital and intracranial extension. Paranasal sinus soft tissue with extrasinus infiltration with or without bony destruction is suggestive of COVID-19-associated rhino-oculo-cerebral mucormycosis. High-resolution CT chest scan has shown to be helpful in the diagnosis of COVID-19-associated pulmonary mucormycosis. Consolidation and cavitation are the most common imaging features. Other CT abnormalities include the reverse-halo sign, pleural effusion, ground-glass opacities, pneumothorax, nodules, and pulmonary embolism. A high index of suspicion with appropriate imaging findings can lead to the early diagnosis of CAM and timely initiation of antifungal treatment and/or surgical debridement, which can be lifesaving.

Pulmonary embolism confounded with COVID-19 suspicion in a catatonic patient presenting to anesthesia for ECT: a case report.

Catatonic patients may develop deep vein thrombosis (DVT) and pulmonary embolism (PE) due to prolonged periods of immobility. These life-threatening conditions demand prompt recognition and management. We describe the case of a patient with catatonia who presented to anesthesia for electroconvulsive therapy (ECT) at the outset of the current coronavirus disease 2019 pandemic. She complained of breathing difficulty and was suspected to have COVID-19 infection. On further evaluation, she was found to have DVT and PE and required oxygen therapy and intensive care management. The diagnostic delay in our patient would have probably not occurred, had it not been for the existing pandemic situation.

Computed tomography chest in COVID-19: When & why?

Computed tomography (CT) of the chest plays an important role in the diagnosis and management of coronavirus disease 2019 (COVID-19), but it should not be used indiscriminately. This review provides indications of CT chest in COVID-19 suspect, positive and recovered patients based on the current scientific evidence and our personal experience. CT chest is not indicated as a routine screening modality due to its poor sensitivity and specificity. However, it is useful in a small subset of COVID-19 suspects who test negative on reverse transcription-polymerase chain reaction (RT-PCR) with normal/indeterminate chest X-ray (CXR) but have moderate-to-severe respiratory symptoms and high index of clinical suspicion. CT chest is not indicated in every RT-PCR-positive patient and should be done only in specific clinical scenarios, where it is expected to significantly contribute in the clinical management such as COVID-19 patients showing unexplained clinical deterioration and/or where other concurrent lung pathology or pulmonary thromboembolism needs exclusion. Serial CXR and point-of-care ultrasound are usually sufficient to evaluate the progression of COVID-19 pneumonia. CT chest is also indicated in COVID-19-positive patients with associated co-morbidities (age >65 yr, diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease, immune-compromise, etc.) who, despite having mild symptoms and normal/indeterminate CXR, record oxygen saturation of <93 per cent at rest while breathing room air or de-saturate on six-minute walk test. Finally, CT chest plays a crucial role to rule out lung fibrosis in patients recovered from COVID-19 infection who present with hypoxia/impaired lung function on follow up. In conclusion, though CT chest is an indispensable diagnostic tool in COVID-19, it should be used judiciously and only when specifically indicated.

Unraveling the mystery of Covid-19 cytokine storm: From skin to organ systems.

COVID-19 is a global pandemic that emerged from Wuhan, China. Besides pneumonia and acute respiratory distress syndrome, the disease leads to multisystem involvement in the form of myocarditis, arrhythmias, cardiac arrest, gastrointestinal symptoms, hypoxemic brain injury, acute liver, and renal function impairment. There are also reports of cutaneous lesions in form of urticarial and maculopapular rashes, chilblain like fingers and toes (covid feet), livedoid vasculopathy, and chicken-pox like or varicelliform vesicles. Clinically, many of these skin lesions are likely secondary to occlusion of small to medium blood vessels due to microthrombi formation or due to viral laden antigen-antibody immune complexes; and same explanation may hold true for possible hypoxemic injury simultaneously occurring in other vital organs like lungs, heart, brain, and kidneys. The histopathology, immunoflorescence and RT-PCR analysis of skin biopsies can provide useful insights for ascertaining the pathogenesis of this complex viral syndrome. Apparently, it is interplay of disarmed cellular immunity and over-activated humoral immunity that culminates in end-organ changes. The morbidity and mortality can be significantly reduced by upgrading the cellular immunity and downgrading the humoral response; along with prevention of hypoxemic and reperfusion injuries by using antivirals, immunomodulators, antioxidants, anti-platelets, and anticoagulants in judicious and phased manner.