Imaging profile after treatment with Tocilizumab in COVID-19: a case series.

INTRODUCTION- COVID-19 is a pandemic disease, mainly affecting the respiratory tract, triggering an inflammatory cascade complicated by multiorgan failure up to death. Among the tested medications for this disease, tocilizumab appears to act directly on the inflammatory cascade, improving COVID-19 outcomes. For this reason, we have tested the efficacy of tocilizumab on lung damage using chest computed tomography (CT). CASE Presentation: The study was conducted on twenty-one hospitalised COVID-19 patients between March-June 2020. Patients were divided into 2 groups according to the therapies administered (TCZ group= treatment with tocilizumab and NTZ group= other therapies). At admission, TCZ group presented worse laboratory test values, respiratory profile (PaO2/FiO2 ratio: 145.37±38.16 mmHg vs 257.9±95.3 mmHg of NTZ group, P<0.01) and radiological signs (multifocal opacity at chest-X-ray: 88% vs 23% of NTZ group, P<0.01). After performing chest CT at the clinical recovery, the scans of the 2 groups were compared and we observed that some features (e.g., ground glass opacity, consolidation and parenchymal bands) were less marked in the TCZ group. CONCLUSION- In our study, patients treated with tocilizumab presented a worse overall clinical and radiological profile at admission, but the control CT showed a similar imaging profile to patients treated with standard therapy. Based on this evidence, we may suggest that tocilizumab plays an important role in COVID-19 patients reducing lung inflammation.

Real life experience of molnupiravir as a treatment of SARS-CoV-2 infection in vaccinated and unvaccinated patients: a letter on its effectiveness at preventing hospitalization.

BACKGROUND: The SARS-CoV-2 pandemic has prompted clinicians to develop an early and effective treatment of viral infections. To date, vaccines, monoclonal antibodies, and antivirals are the cornerstone of therapy for SARS-CoV-2. AIFA approved the prescription of molnupiravir on 30/12/2021. Molnupiravir is a prodrug that causes the accumulation of errors in the viral genome. METHODS: We prescribed molnupiravir to a total of 74 patients in a range between 26 and 96 years old and followed-up them for 30 days. 10 patients affected by idiopathic pulmonary fibrosis (IPF) were treated. RESULTS: The follow-up showed that all of the treated patients presented a regression of symptoms. No patients were hospitalized and/or showed sequelae after the infection by SARS-CoV-2, even though the examined population was older and with more co-morbidities than other patients treated with different antivirals. CONCLUSION: Molnupiravir is safe and well-tolerated by patients with high-risk of progression to severe COVID. No patients were hospitalized or showed sequelae, including all patients affected by IPF.

Chylothorax found in a patient with COVID-19.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its clinical spectrum ranges from mild to moderate or severe illness. A 78-year-old male was presented at emergency department with dyspnoea, dry cough and severe asthenia. The nasopharyngeal swab by real-time polymerase chain reaction confirmed a SARS-CoV-2 infection. The x-ray and the thoracic ultrasound revealed right pleural effusion. A diagnostic-therapeutic thoracentesis drained fluid identified as chylothorax. Subsequently, the patient underwent a chest computed tomography which showed the radiological hallmarks of COVID-19 and in the following weeks he underwent a chest magnetic resonance imaging to obtain a better view of mediastinal and lymphatic structures, which showed a partial thrombosis affecting the origin of superior vena cava and the distal tract of the right subclavian vein. For this reason, anticoagulant therapy was optimized and in the following weeks the patient was discharged for clinical and radiological improvement. This case demonstrates chylothorax as a possible and uncommon complication of COVID-19.

Impact of smoking, COPD and comorbidities on the mortality of COVID-19 patients.

The prognosis of the coronavirus disease 2019 (COVID-19) patients is variable and depends on several factors. Current data about the impact of chronic obstructive pulmonary disease (COPD) and smoking on the clinical course of COVID-19 are still controversial. This study evaluated the prevalence and the prognosis of COPD patients and smokers in a cohort of 521 patients admitted to four intermediate Respiratory Intensive Care Units (Puglia, Italy) with respiratory failure due to COVID-19 pneumonia. The prevalence of COPD and current smokers was 14% and 13%, respectively. COPD patients had a higher 30-day all-cause mortality than non-COPD patients. Former smokers compared to never smokers and current smokers had higher 30-day all-cause mortality. COPD patients and former smokers had more comorbidities. This study described the prevalence and the outcomes of COPD patients and smokers in a homogenous cohort of COVID-19 patients. The study showed that the prevalence of COPD and current smokers was not high, suggesting that they were not at increased risk of getting the infection. However, when SARS-CoV-2 infection occurred, COPD patients and former smokers were those with the highest all-cause mortality, which seemed to be mainly related to the presence of comorbidities and not to COPD and smoking itself.

COVID-19 Pneumonia: The Great Ultrasonography Mimicker.

The pandemic spread of the new severe acute respiratory syndrome coronavirus 2 has raised the necessity to identify an appropriate imaging method for early diagnosis of coronavirus disease 2019 (COVID-19). Chest computed tomography (CT) has been regarded as the mainstay of imaging evaluation for pulmonary involvement in the early phase of the pandemic. However, due to the poor specificity of the radiological pattern and the disruption of radiology centers' functionality linked to an excessive demand for exams, the American College of Radiology has advised against CT use for screening purposes. Lung ultrasound (LUS) is a point-of-care imaging tool that is quickly available and easy to disinfect. These advantages have determined a "pandemic" increase of its use for early detection of COVID-19 pneumonia in emergency departments. However, LUS findings in COVID-19 patients are even less specific than those detectable on CT scans. The scope of this perspective article is to discuss the great number of diseases and pathologic conditions that may mimic COVID-19 pneumonia on LUS examination.

Lung Ultrasound in the Diagnosis of COVID-19 Pneumonia: Not Always and Not Only What Is COVID-19 "Glitters".

Background: In the current coronavirus disease-2019 (COVID-19) pandemic, lung ultrasound (LUS) has been extensively employed to evaluate lung involvement and proposed as a useful screening tool for early diagnosis in the emergency department (ED), prehospitalization triage, and treatment monitoring of COVID-19 pneumonia. However, the actual effectiveness of LUS in characterizing lung involvement in COVID-19 is still unclear. Our aim was to evaluate LUS diagnostic performance in assessing or ruling out COVID-19 pneumonia when compared with chest CT (gold standard) in a population of SARS-CoV-2-infected patients. Methods: A total of 260 consecutive RT-PCR confirmed SARS-CoV-2-infected patients were included in the study. All the patients underwent both chest CT scan and concurrent LUS at admission, within the first 6-12 h of hospital stay. Results: Chest CT scan was considered positive when showing a "typical" or "indeterminate" pattern for COVID-19, according to the RSNA classification system. Disease prevalence for COVID-19 pneumonia was 90.77%. LUS demonstrated a sensitivity of 56.78% in detecting lung alteration. The concordance rate for the assessment of abnormalities by both methods increased in the case of peripheral distribution and middle-lower lung location of lesions and in cases of more severe lung involvement. A total of nine patients had a "false-positive" LUS examination. Alternative diagnosis included chronic heart disease (six cases), bronchiectasis (two cases), and subpleural emphysema (one case). LUS specificity was 62.50%. Collateral findings indicative of overlapping conditions at chest CT were recorded also in patients with COVID-19 pneumonia and appeared distributed with increasing frequency passing from the group with mild disease (17 cases) to that with severe disease (40 cases). Conclusions: LUS does not seem to be an adequate tool for screening purposes in the ED, due to the risk of missing some lesions and/or to underestimate the actual extent of the disease. Furthermore, the not specificity of LUS implies the possibility to erroneously classify pre-existing or overlapping conditions as COVID-19 pneumonia. It seems more safe to integrate a positive LUS examination with clinical, epidemiological, laboratory, and radiologic findings to suggest a "virosis." Viral testing confirmation is always required.

Low Sensitivity of Admission Lung US Compared to Chest CT for Diagnosis of Lung Involvement in a Cohort of 82 Patients with COVID-19 Pneumonia.

Background and Objectives: The potential role of lung ultrasound (LUS) in characterizing lung involvement in Coronavirus disease 2019 (COVID-19) is still debated. The aim of the study was to estimate sensitivity of admission LUS for the detection of SARS-CoV-2 lung involvement using Chest-CT (Computed Tomography) as reference standard in order to assess LUS usefulness in ruling out COVID-19 pneumonia in the Emergency Department (ED). Methods: Eighty-two patients with confirmed COVID-19 and signs of lung involvement on Chest-CT were consecutively admitted to our hospital and recruited in the study. Chest-CT and LUS examination were concurrently performed within the first 6-12h from admission. Sensitivity of LUS was calculated using CT findings as a reference standard. Results: Global LUS sensitivity in detecting COVID-19 pulmonary lesions was 52%. LUS sensitivity ranged from 8% in case of focal and sporadic ground-glass opacities (mild disease), to 52% for a crazy-paving pattern (moderate disease) and up to 100% in case of extensive subpleural consolidations (severe disease), although LUS was not always able to detect all the consolidations assessed at Chest-CT. LUS sensitivity was higher in detecting a typical Chest-CT pattern (60%) and abnormalities showing a middle-lower zone predominance (79%). Conclusions: As admission LUS may result falsely negative in most cases, it should not be considered as a reliable imaging tool in ruling out COVID-19 pneumonia in patients presenting in ED. It may at least represent an expanded clinical evaluation that needs integration with other diagnostic tests (e.g., nasopharyngeal swab, Chest-CT).

Surgical mask and N95 in healthcare workers of Covid-19 departments: clinical and social aspects.

Introdution. In order to prevent or slow down the transmission of COVID-19, various public health measures have been introduced, including social distancing, environmental disinfection and the use of personal protective equipment (PPE). In this perspective, the clinical practice of healthcare professionals has changed dramatically. As a matter of fact, the use of surgical masks and N95 has significantly worsened the job performance of workers who deal directly with COVID-19 disease. METHODS: The study included 116 health workers employed in the pulmonology, intensive care and infectious diseases departments of Bari and Foggia Hospital, directly involved in the healthcare of patients affected by COVID-19. Between May 1, 2020 and May 31, 2020, each participant completed an online questionnaire aimed to investigate the impact of the COVID-19 pandemic on workers' lifestyle changes and job performances. We compared the results based on the type of mask used by each participant (surgical mask vs N95). RESULTS: Although disturbances related to the use of the mask arose earlier in subjects who wore the N95 (p = 0.0094), healthcare workers that wore surgical masks reported a statistically higher average score for a greater number of disorders. CONCLUSIONS: This is the first study that compares the effects of the two most used PPE on the quality of life of health workers and which highlights the greater discomfort caused by surgical masks. This result brings to light a serious social problem, being surgical masks widely used in everyday life by ordinary people and non-healthcare workers.

Real Time PCR and Culture-Based Virus Isolation Test in Clinically Recovered Patients: Is the Subject Still Infectious for SARS-CoV2?

BACKGROUND: The highly variable manifestation of the COVID-19 disease, from completely asymptomatic to fatal, is both a clinical and a public health issue. The criteria for discharge of hospitalized patients have been based so far on the negative result of Real-Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) tests, but the persistence of viral fragments may exceed that of the integral virus by weeks. The aim of our study was to verify the clearance of the virus at viral culture in patients hospitalized for COVID-19 that have clinically recovered but are still positive on nasopharyngeal swab. METHODS: The study was conducted in hospitalized patients with positive RT-PCR on nasopharyngeal swab. Patients included were from asymptomatic to severe cases and performed nasopharyngeal control swabbing on day 14 for asymptomatic patient or at least three days after remission of symptoms. RT-PCR positive specimens were sent to a biosafety level 3 laboratory for viral culture. RESULTS: We performed a combined analysis of RT-PCR and a highly sensitive in vitro culture from 84 samples of hospitalized patients. The average age was 46 ± 20.29, and 40.5% of the subjects had radiologically confirmed pneumonia, with average PaO2 of 72.35 ± 12.12and P/F ratio of 315 ± 83.15. Ct values for the N gene were lower in the first swab than in the control one (p < 0.001). The samples from 83 patients were negative at viral culture, and RT-PCR on the respective supernatants always confirmed the absence of viral growth. CONCLUSIONS: Our preliminary results demonstrate that patients clinically recovered for at least three days show the viral clearance at viral culture, and presumably they continued to not be contagious.

Tocilizumab and liver injury in patients with COVID-19.

Current mortality rate in patients with COVID-19 disease is about 2%, whereas 5% of patients require admission to the intensive care unit. It is assumed that interleukin (IL)-6 may be involved in the pathogenesis of severe COVID-19 infections; therefore, in the absence of a specific antiviral therapy, some authors have suggested that tocilizumab - a drug used to block the signal transduction pathway of IL-6 - could have beneficial effects in the management of severe COVID-19 disease. However, mild-to-moderate elevation in transaminases and drug-induced liver injury have been observed in patients treated with tocilizumab. We present seven cases of patients with elevated liver enzymes [up to five times the upper limit of normal (ULN)] at baseline who received tocilizumab for life-threatening COVID-19 disease. All patients had no history of liver or pulmonary disease and were admitted for acute hypoxemic respiratory failure, dyspnea and fever due to COVID-19 bilateral pneumonia. IL-6 was available in six patients, and was significantly increased particularly in those with severe impairment of lung function. All patients received tocilizumab (8 mg/kg/day) for two consecutive days because of lack of improvement after hydroxychloroquine, azithromycin and lopinavir/ritonavir treatment. After tocilizumab administration, clinical condition rapidly improved and liver function test normalized within 3 weeks of treatment. Tocilizumab may be effective for the treatment of severe COVID-19 disease, even in patients with elevated liver function tests. Further studies are needed to evaluate the impact of tocilizumab use on liver function tests in patients with pre-existing chronic liver disease.