Th17 overexpression in severe COVID-19: a prospective observational study.

INTRODUCTION: The objective of the study was to determine T-cell subtypes, Natural Killer cell activity and cytokines in COVID-19 patients with mild to moderate disease and compare them between patients who had recovered and those who had progressed to severe disease. METHODS: Peripheral blood samples of COVID-19 patients were collected at the time of hospital admission and after one week. These samples were analysed for interleukins (IL-6, IL-17a) using chemiluminescence ELISA. The T-cell subsets (T naïve, T regulatory, Th17, Th1, Th2, CD8+ T cells] were studied using flow cytometry. Mild, moderate and severe COVID-19 are defined as per CDC guidelines. RESULTS: Nineteen COVID-19-positive patients were enrolled between June 2020 to December 2021. Nine had mild COVID-19 and 10 had moderate COVID-19 at recruitment. All mild cases recovered without progression to severe disease, while five patients from the moderate group progressed to severe disease. Overall, there is a decrease in lymphocyte count in patients with moderate-severe disease, but the ratio of Th17 [5.91 (2.69-12.01)] was higher compared to Th1 [1.12 (0.27-3.13)] and Th2[2.34 (2-3.5)]. The high baseline level of IL-6 observed in patients with moderate disease leads to the proliferation of more Th17 type of CD4+ T-cells(p=0.002) and suppression of Treg cells. A higher Th17 subset leads to neutrophilic inflammation in patients with severe COVID-19. CONCLUSION: Interpretation conclusions: Higher baseline IL-6 leads to depletion of regulatory T-cells, Th1 Th2 CD4 cells. IL-6 leads to the proliferation of Th17 type of CD4+ subsets in moderate COVID-19. Higher Th17 cells in moderate COVID-19 patients lead to the production of IL-17a, which may result in intense neutrophilic inflammatory response and cytokine storm.

A Combination of Inflammatory and Hematological Markers is Strongly Associated with the Risk of Death in Both Mild and Severe Initial Disease in Unvaccinated Individuals with COVID-19 Infection

Background Inflammatory and hematological markers are used extensively for early prognostication and monitoring in COVID-19. We aimed to determine whether routinely prescribed laboratory markers can predict adverse outcome at presentation in COVID-19. Methods This retrospective observational study was performed on 401 samples collected between July to December 2020 from COVID-19 positive subjects, admitted at All India Institute of Medical Sciences, Delhi, India. Clinical details and laboratory investigations within 3 days of COVID-19 positivity were obtained. Clinical outcomes were noted from patient medical records, till discharge or death. Laboratory parameters, with individually defined cut-offs, were used, either singly or in combination to distinguish survival and death for those having severe and non-severe disease at initial presentation. Findings Total Leukocyte count, Absolute neutrophil count, Neutrophil to Lymphocyte ratio, C-Reactive Protein (CRP), Interleukin-6 (IL-6), Lactate Dehydrogenase, Ferritin and Lymphocyte to CRP ratio (LCR) were significantly altered at presentation in severe COVID-19 as compared to non-severe cases;and, also in those who died due to COVID-19 compared to those who survived. A combination of four markers, CRP (≥3.9mg/dL);IL-6 (≥45.37pg/ml);Ferritin (≥373ng/mL);1/LCR ≥0.405 was found to strongly predict mortality in cases with non-severe presentation as also in severe cases. Conclusion and Interpretation The combination of routinely used markers, CRP, IL-6, Ferritin and 1/LCR can be used to predict adverse outcomes, even in those presenting with mild to moderate disease. This would identify subset of patients who would benefit from closer monitoring than usual for non-severe disease.

Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study.

Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.

"There is No Easy Way to Say This ": Communication Challenges in the COVID-19 Intensive Care Unit.

How to cite this article: Venkateswaran V, Soni KD, Trikha A. "There is No Easy Way to Say This…": Communication Challenges in the COVID-19 Intensive Care Unit. Indian J Crit Care Med 2023;27(1):79-81.

Clinical characteristics of COVID-19 patients who underwent tracheostomy and its effect on outcome: A retrospective observational study.

BACKGROUND: The exponential rise in Coronavirus disease 2019 (COVID-19) cases has resulted in an increased number of patients requiring prolonged ventilatory support and subsequent tracheostomy. With the limited availability of literature regarding the outcomes of COVID-19 patients with tracheostomy, we attempted to study the clinical characteristics and multiple parameters affecting the outcomes in these patients. AIM: To determine all-cause mortality following tracheostomy and its association with various risk factors in COVID-19 patients. METHODS: This retrospective study included 73 adult COVID-19 patients admitted to the ICU between 1 April, 2020 and 30 September, 2021 who underwent tracheostomy as a result of acute respiratory failure due to COVID-19. The data collected included demographics (age, sex), comorbidities, type of oxygen support at admission, severity of COVID-19, complications, and other parameters such as admission to tracheostomy, intubation to tracheostomy, ICU stay, hospital stay, and outcome. RESULTS: This study included 73 adult patients with an average age of 52 ± 16.67 years, of which 52% were men. The average time for admission to tracheostomy was 18.12 ± 12.98 days while intubation to tracheostomy was 11.97 ± 9 days. The mortality rate was 71.2% and 28.8% of patients were discharged alive. The mean duration of ICU and hospital stay was 25 ± 11 days and 28.21 ± 11.60 days, respectively. Greater age, severe COVID-19, mechanical ventilation, shock and acute kidney injury were associated with poor prognosis; however, early tracheostomy in intubated patients resulted in better outcomes. CONCLUSION: Patients with severe COVID-19 requiring mechanical ventilation have a poor prognosis but patients with early tracheostomy may benefit with no added risk. We recommend that the timing of tracheostomy be decided on a case-by-case basis and a well-designed randomised controlled trial should be performed to elucidate the potential benefit of early tracheostomy in such patients.

Association between Hypocalcemia and Outcome in COVID-19 Patients: A Retrospective Study.

Background Calcium has been shown to play a vital role in the pathophysiology of severe acute respiratory syndrome-coronavirus-2 and middle east respiratory syndrome coronavirus diseases, but less is known about hypocalcemia in coronavirus disease 2019 (COVID-19) patients and its association with the disease severity and the final outcome. Therefore, this study was conducted with an aim to assess clinical features in COVID-19 patients having hypocalcemia and to observe its impact on COVID-19 disease severity and the final outcome. Methods In this retrospective study, consecutive COVID-19 patients of all age groups were enrolled. Demographical, clinical, and laboratory details were collected and analyzed. On the basis of albumin-corrected calcium levels, patients were classified into normocalcemic ( n = 51) and hypocalcemic ( n = 110) groups. Death was the primary outcome. Results The mean age of patients in the hypocalcemic group was significantly lower ( p < 0.05). A significantly higher number of hypocalcemic patients had severe COVID-19 infection (92.73%; p < 0.01), had comorbidities (82.73%, p < 0.05), and required ventilator support (39.09%; p < 0.01) compared with normocalcemic patients. The mortality rate was significantly higher in the hypocalcemic patients (33.63%; p < 0.05). Hemoglobin ( p < 0.01), hematocrit ( p < 0.01), and red cell count ( p < 0.01) were significantly lower with higher levels of absolute neutrophil count (ANC; p < 0.05) and neutrophil-to-lymphocyte ratio (NLR; p < 0.01) in the hypocalcemic patients. Albumin-corrected calcium levels had a significant positive correlation with hemoglobin levels, hematocrit, red cell count, total protein, albumin, and albumin-to-globulin ratio and a significant negative correlation with ANC and NLR. Conclusion The disease severity, ventilator requirement, and mortality were considerably higher in hypocalcemic COVID-19 patients.

Ultracellular Imaging of Bronchoalveolar Lavage from Young COVID-19 Patients with Comorbidities Showed Greater SARS-COV-2 Infection but Lesser Ultrastructural Damage Than the Older Patients.

In this study, we examined the cellular infectivity and ultrastructural changes due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the various cells of bronchoalveolar fluid (BALF) from intubated patients of different age groups (≥60 years and <60 years) and with common comorbidities such as diabetes, liver and kidney diseases, and malignancies. BALF of 79 patients (38 cases >60 and 41 cases <60 years) were studied by light microscopy, immunofluorescence, scanning, and transmission electron microscopy to evaluate the ultrastructural changes in the ciliated epithelium, type II pneumocytes, macrophages, neutrophils, eosinophils, lymphocytes, and anucleated granulocytes. This study demonstrated relatively a greater infection and better preservation of subcellular structures in these cells from BALF of younger patients (<60 years compared with the older patients (≥60 years). The different cells of BALF from the patients without comorbidities showed higher viral load compared with the patients with comorbidities. Diabetic patients showed maximum ultrastructural damage in BALF cells in the comorbid group. This study highlights the comparative effect of SARS-CoV-2 infection on the different airway and inflammatory cells of BALF at the subcellular levels among older and younger patients and in patients with comorbid conditions.

COVID-19 infection in patients with haematological disease - A tertiary centre experience from north India.

This retrospective study was aimed to understand the clinical, laboratory, radiological parameters and the outcome of COVID-19 patients with underlying haematological disease. All patients with known haematological disease admitted with COVID-19-positive status from April to August 2020 in the COVID-19 facility of a tertiary care centre in north India, were included. Their medical records were analyzed for outcome and mortality risk factors. Fifty four patients, 37 males, were included in the study. Of these, 36 patients had haematological malignancy and 18 had benign disorder. Fever (95.5%), cough (59.2%) and dyspnoea (31.4%) were the most common symptoms. Nine patients had severe disease at diagnosis, mostly malignant disorders. Overall mortality rate was 37.0 per cent, with high mortality seen in patients with aplastic anaemia (50.0%), acute myeloid (46.7%) and lymphoblastic leukaemia (40.0%). On univariate analysis, Eastern Cooperative Oncology Group performance status >2 [odd ratio (OR) 11.6], COVID-19 severity (OR 8.2), dyspnoea (OR 5.7) and blood product transfusion (OR 6.4) were the predictors of mortality. However, the presence of moderate or severe COVID-19 (OR 16.6, confidence interval 3.8-72.8) was found significant on multivariate analysis. The results showed that patients with haematological malignancies and aplastic anaemia might be at increased risk of getting severe COVID-19 infection and mortality as compared to the general population.

Clinical profile of ChAdOx1 nCoV-19- and BBV152-vaccinated individuals among hospitalized COVID-19 patients: a pair-matched study.

Background: COVID-19 infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-vaccinated individuals are of clinical concern, especially in those requiring hospitalization. Such real-world data on ChAdOx1 nCoV-19- and BBV152-vaccinated individuals are scarce. Hence, there is an urgent need to understand their clinical profile and outcomes. Methods: A 1:1 pair-matched study was performed among vaccinated and unvaccinated COVID-19 patients admitted between March 2021 and June 2021 at a tertiary care centre in New Delhi, India. The vaccinated group (received at least one dose of ChAdOx1 nCoV-19 or BBV152) was prospectively followed till discharge or death and matched [for age (±10 years), sex, baseline disease severity and comorbidities] with a retrospective group of unvaccinated patients admitted during the study period. Paired analysis was done to look for clinical outcomes between the two groups. Results: The study included a total of 210 patients, with 105 in each of the vaccinated and unvaccinated groups. In the vaccinated group, 47 (44.8%) and 58 (55.2%) patients had received ChAdOx1 nCoV-19 and BBV152, respectively. However, 73 patients had received one dose and 32 had received two doses of the vaccine. Disease severity was mild in 36.2%, moderate in 31.4% and severe in 32.4%. Two mortalities were reported out of 19 fully vaccinated individuals. All-cause mortality in the vaccinated group was 8.6% (9/105), which was significantly lower than the matched unvaccinated group mortality of 21.9% (23/105), p = 0.007. Vaccination increased the chances of survival (OR = 3.8, 95% CI: 1.42-10.18) compared to the unvaccinated group. Conclusion: In the second wave of the pandemic predominated by delta variant of SARS CoV-2, vaccination reduced all-cause mortality among hospitalized patients, although the results are only preliminary.

Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials.

Introduction: Vitamin D deficiency is an amendable risk factor linked to increase in mortality in critically ill patients. The aim of this systematic review was to evaluate if vitamin D supplementation reduced the mortality, and length of stay (LOS) in intensive care units (ICU) and hospitals in critically ill adults including coronavirus disease-2019 (COVID-2019) patients. Materials and methods: We searched the literature using the PubMed, Web of Science, Cochrane and Embase databases until January 13, 2022, for RCTs comparing vitamin D administration to placebo or no treatment in ICUs. The fixed-effect model was used for the primary outcome (all-cause mortality) and the random effect model for secondary objectives (LOS in ICU, hospital, mechanical ventilation). Subgroup analysis included ICU types and high vs low risk of bias. Sensitivity analysis compared severe COVID-19 vs no COVID disease. Results: Eleven RCTs (2,328 patients) were included in the analysis. Pooled analysis of these RCTs, showed no significant difference in all-cause mortality between the vitamin D and placebo groups [odds ratio (OR) 0.93, p = 0.47]. Inclusion of COVID-positive patients did not change the results (OR 0.91, p = 0.37). No significant difference was observed between the vitamin D and placebo groups in LOS in ICU (p = 0.34); hospital (p = 0.40) and mechanical ventilation duration (p = 0.7). In the subgroup analysis, there was no improvement in mortality in medical ICU (p = 0.36) or surgical ICU (p = 0.03). Neither low risk of bias (p = 0.41) nor high risk of bias (p = 0.39) reduced mortality. Conclusion: Vitamin D supplementation in the critically ill did not have statistically significant benefits on clinical outcomes in terms of overall mortality, duration of mechanical ventilation, and LOS in ICU and hospital. How to cite this article: Kaur M, Soni KD, Trikha A. Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022;26(7):853-862.

Managing Traumatic Brain Injury During the Coronavirus Disease 2019 Pandemic-A Case-Matched Controlled Analysis of Immediate Outcomes.

OBJECTIVE: The primary objective of this study was to evaluate the outcome of patients with traumatic brain injury (TBI) during the coronavirus disease 2019 (COVID-19) pandemic and to compare their outcome with case-matched controls from the prepandemic phase. METHODS: This is a retrospective case-control study in which all patients with TBI admitted during COVID-19 pandemic phase (Arm A) from March 24, 2020 to November 30, 2020 were matched with age and Glasgow Coma Scale score-matched controls from the patients admitted before March 2020 (Arm B). RESULTS: The total number of patients matched in each arm was 118. The length of hospital stay (8 days vs. 5 days; P < 0.001), transit time from emergency room to operation room (150 minutes vs. 97 minutes; P = 0.271), anesthesia induction time (75 minutes vs. 45 minutes; P = 0.002), and operative duration (275 minutes vs. 180 minutes; P = 0.002) were longer in arm A. Although the incidence of fever and pneumonia was significantly higher in arm A than in arm B (50% vs. 26.3%, P < 0.001 and 27.1% vs. 1.7%, P < 0.001, respectively), outcome (Glasgow Outcome Scale-Extended) and mortality (18.6% vs. 14.4% respectively; P = 0.42) were similar in both the groups. CONCLUSIONS: The outcome of the patients managed for TBI during the COVID-19 pandemic was similar to matched patients with TBI managed at our center before the onset of the COVID-19 pandemic. This finding suggests that the guidelines followed during the COVID-19 pandemic were effective in dealing with patients with TBI. This model can serve as a guide for any future pandemic waves for effective management of patients with TBI without compromising their outcome.

Is it a challenging task to work with personal protective equipment in a COVID-19 ICU: Findings from a hospital-based cross-sectional study from north India.

Introduction: Amidst the coronavirus disease 2019 (COVID-19) pandemic, the use of personal protective equipment (PPE) is mandatory for healthcare workers to remain protected against infection. The present study was undertaken to evaluate challenges faced by the healthcare workers while using level 3 PPE. Methods: This hospital-based study was conducted among resident doctors selected by convenience sampling method using a pretested, semi-structured, self-administered questionnaire after getting informed consent from the participants to collect data on the somatic, psychological, and technical problems faced while working in PPE. Bivariate and multivariable logistic regression was done between outcome variables and other independent variables to check for the association. Results: Of the total, 252 resident doctors completed the survey, their age ranged from 22 to 36 years with 140 (55.6%) males and 112 (44.4%) females. One-twenty-nine (51.2%) residents were trained to work in ICU, 73 (29%) participants used PPE ≤10 times and the rest 179 (71%) used PPE more than 10 times. The difficulties faced were as follows: visual impairment (n = 244, 96.8%), headache (n = 226, 89.6%), breathing difficulty (n = 216, 85.7%), hearing impairment (n = 201, 79.8%), sweating (n = 242, 96%), and fear of being infected (n = 156,61.9%). Two-thirty-six (93.6%) participants felt that overall work quality reduced due to PPE. Headache, hunger, urge to micturate, anxiety, sleep disturbances, and need to change the timing of medication or diet were higher with increased duration of work with PPE. Conclusion: A longer duration of work is associated with headache, hunger, anxiety, and sleep disturbances. More research has to be done to improve the PPE to reduce problems like visual impairment, skin irritation, sweating, and breathing difficulty.

Alveolar Arterial Gradient and Respiratory Index in Predicting the Outcome of COVID-19 Patients; a Retrospective Cross-Sectional Study.

Introduction: Alveolar arterial (A-a) oxygen gradient and respiratory index can be of immense help for the critical care physician in clinical decision making. This study aimed to evaluate the potential application of A-a oxygen gradient and respiratory index in predicting the survival of COVID-19 patients in intensive care unit (ICU). Method: This is a retrospective cross-sectional study involving 215 adult patients with COVID-19 disease, admitted to the ICU between 1st April 2020 and 30 June 2021. Details regarding demographic variables, comorbidities, laboratory and arterial blood gas (ABG) findings were recorded. Alveolar-arterial gradient and respiratory index were calculated and tested as predictors of survival. Result: The mean age of the patients was 51.92 years (65.6 % male). Hypertension was the most common comorbidity and oxygen via non-rebreathing mask was the most common modality used at the time of ICU admission. Mortality was 28.37% and average length of stay was 12.84 days. Patients who died were older (p=0.02), mostly male (p=0.017), had at least one comorbidity (p<0.001), and higher heart rate and respiratory rate (<0.001 and p=0.03, respectively), lower pH on arterial blood gas (ABG) (p=0.002), higher FiO2 requirement (p<0.001), and increased A-a oxygen gradient on admission compared to survivors. According to receiver operating characteristic (ROC) curve analysis, A-a oxygen gradient and respiratory index were not sensitive or specific in predicting mortality in the studied patient subset. Conclusion: A-a oxygen gradient and respiratory index calculated at time of admission to ICU in patients with COVID-19 were poor predictors of survival.

SARS-CoV-2 Rapid Antigen Detection in Respiratory and Nonrespiratory Specimens in COVID-19 Patients.

Rapid antigen testing for coronavirus disease 2019 (COVID-19) available at present provides immediate results at low cost with less expertise and without any need of sophisticated infrastructure. Most of these test kits available are for nasopharyngeal samples. This is a novel study to detect the presence of COVID antigen in samples other than throat and oropharyngeal. Various samples received from patients admitted in the COVID-19 dedicated center were tested for the presence of antigen. Same procedure was followed as done for the nasopharyngeal sample. A total of 150 samples were tested, which included ascitic fluid, pleural fluid, drain fluid, bile, bronchoalveolar lavage, cerebrospinal fluid, endotracheal tube aspirate, sputum, tissue, and urine. Out of 150, 11 (7.33%) were positive and 138 (92.66%) were negative for the antigen test. The COVID-19 antigen test kit, though designed for nasopharyngeal samples, was able to detect the presence of antigen in other clinical samples.

Poor Respiratory Health Following Relapsing SARS-CoV-2 Infection in Children with Cystic Fibrosis.

Children with cystic fibrosis (CF) constitute a high-risk group for COVID-19 with underlying chronic lung disease. COVID-19 severity varying from mild infection to need of intensive care has been described in children with CF. Two children with significant underlying pulmonary morbidity are described here, who developed severe disease following SARS-CoV-2 infection. Case 1 (a 9-y-old boy) had pneumonia with respiratory failure requiring noninvasive ventilation support. He had delayed clearance of SARS-CoV-2, with recurrence of symptomatic disease with short asymptomatic period in between. He was also diagnosed with CF-related diabetes and allergic bronchopulmonary aspergillosis during the second episode. Case 2 (an 18-mo-old boy) had two episodes of SARS-CoV-2-related severe lower respiratory infection within a period of 2 mo, requiring high-flow nasal oxygen support. Both children had 3rd pulmonary exacerbation but SARS-CoV-2 was not detected in respiratory secretions. To conclude, children with CF with underlying pulmonary morbidity, can develop severe COVID-19 and prolonged SARS-CoV-2 shedding.

Epidemiology and clinical characteristics of COVID- 19 patients requiring critical care in a Tertiary care teaching hospital.

BACKGROUND AND AIMS: We describe the epidemiological and clinical characteristics, and 28 day outcome of critically ill COVID-19 patients admitted to a tertiary care centre in India. MATERIAL AND METHODS: We included 60 adult critically ill COVID-19 patients in this prospective observational study, admitted to the intensive care unit (ICU) after obtaining ethics committee approval and informed consent. Demographics, clinical data, and treatment outcome at 28 days were assessed. RESULTS: Demographic characteristics of the COVID-19 patients reveal that compared to the survivors, the non-survivors were significantly older [57.5 vs. 47.5 years], had more comorbid disease [Charlson's comorbidity index 4 vs. 2], higher Apache II scores [19 vs. 8.5], and had significantly higher percentage of smokers. Diabetes mellitus and hypertension were the most common comorbidities. Dyspnea, fever, and cough were the most common presenting symptoms. Total leucocyte count as well as blood lactate level were significantly higher in non-survivors. Around 47% patients had severe ARDS, and 60% patients required invasive mechanical ventilation. 28 day ICU mortality was 50%, with a mortality of 75% in patients receiving invasive mechanical ventilation. Mortality was higher in males than females (57% vs. 33%). Acute kidney injury and septic shock were the most common non-pulmonary complications during ICU stay. Incidence of liver dysfunction, septic shock, and vasopressor use was significantly higher in the non-survivors. CONCLUSION: This study demonstrates a high 28 day mortality in severe COVID-19 patients. Further well designed prospective studies with larger sample size are needed to identify the risk factors associated with poor outcome in such patients.

Proteinaceous Lung With COVID-19: The Mimicker

Pulmonary alveolar proteinosis (PAP) is a syndrome, in which surfactants get deposited slowly in alveoli, blocking the airway exchange. PAP severity also varies from mild to severe, presenting with dyspnea, cough, hemoptysis with or without fever. The radiological findings are ground-glass opacities along with septal thickening (Crazy Paving), consolidations, and less commonly air bronchograms. COVID-19 is a viral infection caused by SARS COV2 primarily affecting the lungs and causing atypical viral pneumonia. The clinical picture of the disease varies from a milder form of fever, dry cough with or without expectoration, to severe disease-causing respiratory distress, pneumonia, acute respiratory distress syndrome (ARDS), and even death. Radiologically, the findings of COVID-19 are similar to PAP. So, PAP mimics the COVID-19, posing a differential challenge, though our patient was a known case of PAP. Therefore, for proper management of the disease, it is important to differentiate it from other pathologies. In this case report, we describe a patient who was a known case of autoimmune pulmonary alveolar proteinosis. She presented with acute exacerbation in the emergency department and tested positive for COVID-19. We followed a systematic approach consisting of clinical, laboratory, radiologic parameters to differentiate the cause of this exacerbation.

Clinical Profile and Outcome of Critically Ill COVID-19 Patients With Malignancy Admitted in Intensive Care Unit of a Tertiary COVID Center, India.

Introduction There is a dearth of literature describing the clinical profile of coronavirus disease 2019 (COVID-19) in patients with malignancy. Patients with associated malignancy can have a more severe course of the disease. The aim was to study clinical course and outcome of critically ill patients admitted in ICU with associated malignancy. Methods The study was a single-center, retrospective, study conducted at a tertiary care hospital. Patients with active or recent malignancy on follow-up and with confirmed COVID-19 infection who were admitted to the Intensive care unit of COVID-19 dedicated hospital between November 1, 2020 to January 15, 2021 were included. Demographic data, clinical features, clinical course and outcome were retrieved from the hospital electronic medical records. Results A total of 24 patients with malignancy and COVID-19 were admitted to the ICU of COVID-19 center. There were 20 patients with solid organ malignancy and four patients with hematological malignancy. The most common malignancy was breast carcinoma in six (25 %) patients. Fifty percent of the patients were diagnosed with malignancy within the previous six months. Among the presenting symptoms, 13 (54.1%) patients presented with symptoms of severe acute respiratory infection (SARI), eight (33.3%) patients presented with altered sensorium, and three (12.5%) with pain abdomen. Regarding the severity of COVID-19, six (25%) patients had moderate COVID-19 and 18 (75%) had severe COVID-19. Out of 24 patients, six survived and 18 died, the mortality being 75%. The most common cause of death was sepsis with multiorgan dysfunction syndrome (MODS) in 10 (42.6 %) patients followed by severe acute respiratory distress syndrome (ARDS) and neurological cause in four (16.6 %) patients each. When survivors were compared with non-survivors, advanced age and presence of altered sensorium were more in non-survivors. Conclusion Severe COVID-19 and advanced malignancy is a sinister combination that has high mortality. These patients require close monitoring and aggressive care. Presence of altered sensorium and advanced age predicts poorer outcome.