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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: CT Chest is considered as one of the important modalities for the diagnosis and assessment of progression of COVID-19 disease. We conducted a study highlighting salient features of CT chest in patients with COVID-19 in a tertiary care center in Karachi, Pakistan. METHODS: This was a cross-sectional study done at Aga khan university from April 2020 to December 2020. Adult patients who had a positive COVID-19 PCR and underwent CT scan chest were included in the study. Five hundred and eighteen patients who underwent CT scan chest were selected for screening. One hundred and twelve patients who were positive for COVID-19 PCR were selected for review. Two patients were later excluded as they had chronic changes on CT scan due to underlying comorbidities. RESULTS: Among the study cohort of 110 patients, 70 (63.7 %) were males and 40 (36.4 %) were females with a mean age of 56.5 ± 14.8 years (range 46-67 years). Out of 110 patients, 79 underwent high-resolution CT (HRCT) scan and 31 underwent contrast-enhanced CT chest. The most common abnormality seen on CT was ground-glass opacities (79%), followed by consolidation (62%), crazy paving pattern (32%), vascular enlargement sign (27%) and fibrotic-like features or reticulations (21%). Furthermore, air bronchogram sign was seen in 21%, pleural effusion was seen in 8% and lymphadenopathy in 7% of patients. CONCLUSIONS: CT scan chest is a key tool of investigation in the diagnosis of COVID-19 disease. Studies from across the world have identified specific CT scan patterns that can aid in the diagnosis of the disease. This is a study from a low to middle-income country that describes the spectrum of radiological features found in COVID-19 and has also focused on certain atypical features associated with COVID-19. CLINICAL IMPLICATIONS: Certain radiological features like ground-glass opacities and consolidation are a known features of COVID-19. This study emphasizes on the most frequent radiological features of COVID seen in a tertiary care hospital in Pakistan. Chest CT imaging has a high negative predictive value and high sensitivity for diagnosing COVID-19 and can be considered as an alternative primary screening tool for COVID-19 in epidemic areas. Moreover, a negative RT-PCR test and a positive CT chest finding can suggest COVID-19. Hence as a clinician and radiologist, one should be aware of all the spectrum of radiological features so that early diagnosis and management can be facilitated. DISCLOSURES: No relevant relationships by Safia Awan, source=Web Response No relevant relationships by Kulsoom Fatima, source=Web Response no disclosure on file for Basit Salam;No relevant relationships by Aqusa Zahid, source=Web Response No relevant relationships by Syed Muhammad Zubair, source=Web Response No relevant relationships by Ali Zubairi, source=Web Response
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TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pneumocystis carinii pneumonia (PCP) is an AIDS-defining illness, associated with significant morbidity and mortality. It is also found in patients with other immunosuppressive conditions such as organ transplant and malignancies (1). We present 4 cases of PCP in post-COVID 19 patients. All cases were HIV negative. CASE PRESENTATION: Case 1: A 30-year old female was admitted with a 1-month history of worsening shortness of breath (SOB) and productive cough. She had no known co-morbids and no history of corticosteroid use. Her oxygen saturation (SpO2) was 85% and respiratory rate (RR) was 35 breaths/minute (BPM). Chest examination revealed bibasilar crackles and CT scan showed bilateral (B/L) ground-glass haziness along with interlobular septal thickening. Patient's COVID-19 test was negative however her antibodies were reactive. Bronchoalveolar lavage (BAL) came back positive for PCP. Patient was managed with co-trimoxazole 48 hourly and prednisolone 25 mg BID.Case 2: A 70-year old male was admitted with high grade fever and SOB for 4 days. He was a known hypertensive, with a history of severe COVID-19 pneumonia 1.5 months back for which he was managed with IV tocilizumab and dexamethasone. His SpO2 was 63% and RR was 73 BPM. Chest examination revealed unilateral (U/L) reduced breath sounds. Chest X-ray showed U/L consolidation and sputum for PCP tested positive. Patient was shifted to the ICU and intubated for respiratory failure. He expired after 4 days of ICU stay.Case 3: A 71-year old male was admitted with SOB for 3 days. He was a known diabetic and hypertensive, with a history of severe COVID-19 pneumonia 1.5 months back, for which he was treated with IV tocilizumab and corticosteroids. His SpO2 was 93% and RR was 28 BPM. Chest examination revealed bibasilar crackles. His CT scan revealed B/L ground-glass haziness, and BAL was positive for PCP. Patient was managed with co-trimoxazole 8 hourly and prednisolone 20 mg BID.Case 4: A 28-year old female was electively admitted for induction chemotherapy. She was a known case of Acute Myeloid Leukemia with a history of COVID-19 infection 1 month back for which she was managed at home. During her hospital stay, she developed persistent cough and febrile neutropenia. Chest examination revealed bibasilar crackles and CT scan showed B/L ground-glass haze. BAL was positive for PCP. She was managed with co-trimoxazole 8 hourly and prednisolone 20 mg BID. DISCUSSION: A number of infectious sequelae have been described in post-COVID 19 patients. Few case reports of concurrent PCP and COVID-19 infection exist in literature (2), however there is only 1 case report of PCP as a post-COVID 19 sequela (3). CONCLUSIONS: This case series highlights the importance of being vigilant for infectious sequelae associated with SARS-CoV-2. REFERENCE #1: Schmidt, J.J., Lueck, C., Ziesing, S. et al. Clinical course, treatment and outcome of Pneumocystis pneumonia in immunocompromised adults: a retrospective analysis over 17 years. Crit Care 22, 307 (2018). REFERENCE #2: Bhat P, Noval M, Doub JB, Heil E. Concurrent COVID-19 and Pneumocystis jirovecii pneumonia in a severely immunocompromised 25-year-old patient. International Journal of Infectious Diseases. 2020 Oct 1;99:119-21. REFERENCE #3: Viceconte G, Buonomo AR, Lanzardo A, Pinchera B, Zappulo E, Scotto R, Schiano Moriello N, Vargas M, Iacovazzo C, Servillo G, Gentile I. Pneumocystis jirovecii pneumonia in an immunocompetent patient recovered from COVID-19. Infectious Diseases. 2021 May 4;53(5):382-5. DISCLOSURES: No relevant relationships by Maaha Ayub, source=Web Response No relevant relationships by Mustafa Bin Ali Zubairi, source=Web Response No relevant relationships by Ali Zubairi, source=Web Response
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INTRODUCTION: Since its first reported from Wuhan in December 2019, the clinical symptoms of COVID-19 and its complications are still evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema and pneumomediastinum. We report the case series of 10 patients of COVID-19, with subcutaneous emphysema along with pneumomediastinum. METHODS: All patients were admitted to the critical care area from April to June 2020 at Aga Khan University Hospital, Karachi, Pakistan. Electronic records and medical files reviewed for the patient's baseline characteristics, days of ventilation before subcutaneous emphysema, treatment given for COVID-19, cytokine release syndrome (CRS) grade, and with in-hospital mortality. RESULTS: The mean (±SD) age of the patients was 59±8 years (range, 23-97). The majority of them were men (80%), and common symptoms were dyspnea (100%), fever (80%), and cough (80%). None of them had underlying lung disorder. Six patients had hypertension, and five had diabetes. All patients had acute respiratory distress syndrome (ARDS) on admission, with a median PaO2/FiO2 ratio of 122.5. Eight patients with CRS grade III were being managed in high dependency units at the time of development of subcutaneous emphysema, and two with CRS grade IV were treated in ICU. The median duration of assisted ventilation before the development of subcutaneous emphysema was 7 days (interquartile range, 5-10 days). The highest PEEP for invasively ventilated patients was 10, while the CPAP ranged from 12-16, in non-invasive ventilation patients. Eventually, all required intubation. Chest tubes thoracostomy was done in five patients. All received corticosteroids, 6 received tocilizumab, and 7 received convalescent plasma therapy. Seven patients died during their hospital stay. Obstructive shock with tension pneumothorax was the cause of death in 1 patient, while four died of septic shock. Two patients had their ventilator withdrawn due to multiorgan dysfunction syndrome. CONCLUSIONS: High risk COVID-19 patients requiring positive pressure ventilation can develop subcutaneous emphysema and pneumomediastinum. One has to be vigilant about lung-protective ventilator strategies for the management of hypoxia in COVID -19 patients.
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Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5-10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8-25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients.