Pulmonary infarct in post COVID-19 period, complicated with spontaneous pneumothorax - case report

Introduction: Lung cavitation is a rare finding in COVID-19 patients (1, 2). The aim of this presentation is to report a rare case of cavitary aseptic pulmonary infarct in post-COVID-19 period that is complicated with spontaneous pneumothorax. Case presentation: A 63-year old woman was presented with acute onset of chest pain and on 35th day of COVID19 infection. Chest X-Ray established right-sided total pneumothorax and tube thoracostomy was performed. Due to the persistent air leak computed tomography was performed on the 4th day of thoracostomy. Areas of lung consolidation with a cavitary mass with maximum diameter of 34 mm in the upper lobe were established (fig.1). The woman was scheduled for thoracoscopy and multiple petechiae on the lung surface with necrotic area (bronchopleural fistula) of the upper lobe were established. The procedure was converted to conventional operation with atypical resection of the upper lobe of the lung with removing the necrotic cavitary lesion. Histological examination of the resected lung specimen showed bland cavitary pulmonary infarct. Conclusion(s): This case presents one rare pathological condition in post COVID-19 period - blunt pulmonary cavitary infarct complicated with spontaneous pneumothorax.

A clinical case of SARS-CoV-2 infection complicated by acute respiratory distress syndrome, pulmonary edema, and heart failure in the presence of chronic venous congestion in a patient with chronic rheumatic heart disease

The article presents a clinical case of SARS-CoV-2 infection complicated by acute respiratory distress syndrome, pulmonary edema, and heart failure in the presence of chronic venous congestion in a patient with chronic rheumatic heart disease. A female patient R., 65 years old, was hospitalized at the Republican Cardiological Dispensary with a diagnosis of novel coronavirus infection COVID-19 (severe course);the virus was identified. Competing diagnosis: (1) acute viral myocarditis;(2) chronic rheumatic heart disease with combined mitral-aortic disease. Complications of the underlying disease included viral interstitial pneumonia (75%) and pulmonary edema. The patient was admitted at day 8 from the onset of the disease with complaints of increase in body temperature up to 38.5 °C, chest pain, and shortness of breath. She was treated in the outpatient setting without visible improvement. The patient had a history of chronic rheumatic heart disease. Due to persistent fever, patient received computed tomography showing interstitial pneumonia of viral etiology. The diagnosis of COVID-19 was based on a typical clinical presentation and a positive PCR test in nasopharyngeal swabs. Nonspecific changes were observed in the electrocardiogram. Treatment was initiated without positive dynamics, and a fatal outcome occurred. According to the autopsy data, the organs showed signs of chronic venous congestion (brown induration of the lungs, nutmeg fibrosis, cyanotic induration of the spleen and kidneys). The infiltrates consisting of lymphocytes and eosinophils were detected in the myocardium. Also, edema of the intercellular space, plethora of microvasculature vessels, and dystrophic changes in cardiomyocytes were detected. The presence of Aschoff-Talalaev granulomas with fibrinoid necrosis and avulsion of the chorda of the mitral valve leaflet was observed. Morphologically, there were signs of pulmonary infarction with a polysegmental character. Thus, in the presented case, the scientific novelty was the extremely rare development of mitral valve chord avulsion in aortic-mitral disease after infection with SARS-CoV-2, which was the cause of acute heart failure. It is likely that the process was aggravated by concomitant diffuse interstitial serous myocarditis and fibrinoid necrosis in granulomas. © 2022 by the Author(s).

Imaging of Septic Pulmonary Embolism in Right-Side Infective Endocarditis

Early and correct diagnosis of infective endocarditis (IE) of the right heart does not lose its importance due to the persistence of the problem of intravenous drug use and an increase in the number of surgical interventions on the heart. Septic pulmonary embolism (SPE) is a typical sign of right-side IE, and, with a number of nonspecific respiratory symptoms in patients with fever, its detection by radiology allows to start a diagnostic search for IE and locate the primary embolic source in the right parts of the heart. The review examines the current state of the problem of right-side IE, morphology and clinical evidence, main CT signs and differential diagnostics of SPE, including the context of the COVID-19 pandemic. © 2022 Sklifosovsky Research Institute for Emergency Medicine. All rights reserved.

Pathological Changes in the Lungs of Patients with a Lethal COVID-19 Clinical Course.

The novel coronavirus SARS-CoV-2 was identified in 2019 and quickly became the cause of the fifth worst pandemic in human history. Our goal for this research paper was to examine the morphology of the lungs in 88 patients that died from COVID-19 in Latvia, thus increasing the data available about the histological characteristics of SARS-CoV-2-induced disease. Lung tissue samples from 88 autopsies were visualized in hematoxylin-eosin and assessed by light microscopy. The male-to-female ratio was 56:32, and the mean age was 62 years ± 15.5 years (22-94 years). Clinically important laboratory data were assessed, including leucocyte count, CRP (C-reactive protein) and D-dimer levels. Signs of diffuse alveolar damage were found in 83/88 (94.3%; 95% CI 87.0-97.9) of patients, 38/88 (43.2%; 95% CI 33.3-53.6) in the exudative phase, and 45/88 (51.1%; 95% CI 40.8-61.3) in the proliferative phase. Vascular damage was identified in 70/88 (79.5%; 95% CI 69.9-86.7) of patients, and 83/88 (94.3%; 95% CI 87.0-97.9) had signs of thrombosis. A sparse inflammatory infiltrate of lymphocytes and macrophages was a common finding aside from cases with an identified coinfection. Eighty patients had significant co-morbidities, including coronary heart disease (49), primary arterial hypertension (41), and diabetes mellitus (34). Since our group's demographic profile and spectrum of co-morbidities were analogous to other reports, the histological findings of marked diffuse alveolar damage, widespread vascular lesions, and active thrombosis can be considered representative of severe COVID-19.

PFIZER COVID-19 VACCINE CAUSES SHORTNESS OF BREATH IN A 24-YEAR-OLD PATIENT: A CASE REPORT

SESSION TITLE: Variety in Risk Factors and Treatment of VTE SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: The year of 2020 will be a year never forgotten when the COVID-19 pandemic began. The healthcare system is going into a crisis facing a disease that is unknown and overwhelming. Companies were frantic to find a solution to help prevent so many unnecessary deaths. Pfizer mRNA COVID-19 vaccine was granted emergency use by the FDA after proving efficacy in early trials. Many side effects were unknown and discovered as time went on. Unprovoked isolated pulmonary embolisms are rare. CASE PRESENTATION: A 24 year old male with no significant past medical history presented to the emergency department due to shortness of breath, hemoptysis and chest pain. He denied any family history or personal history of clotting disorders. He received the mRNA COVID-19 Pfizer vaccine 5 days prior to symptom onset. He describes it as constant sharp pain with varying intensity that he rates a 6/10 and can reach a 10/10 pain exacerbated with lying flat and deep breathing. He also states he has been coughing up a teaspoon amount of blood with this chest pain. Physical examination revealed reduced breath sounds in the left lower lobe. Patient was hemodynamically stable. Labs were stable and hemoglobin was stable throughout the hospital course. Fibrinogen was elevated and hypercoagulable work-up was negative. CTA of chest was performed and revealed left-sided pulmonary emboli involving the left lower lobe with pulmonary infarction. Therefore, he was managed by Eliquis. DISCUSSION: Pfizer released a safety and efficacy report of the BNT162b2 mRNA Covid-19 Vaccine. Many of the common side effects reported were pain at the injection site, fatigue, headache, and fever [1]. Adverse events that were reported were shoulder injury, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia [1]. Isolated PE in a young healthy patient was never reported as an adverse event from the Pfizer safety and efficacy report. Severe acute respiratory syndrome-coronavirus-2 has been proven to increase the risk of venous thromboembolism because it is a prothrombotic virus [2]. Vaccination reports of pulmonary embolism are increasing, however, isolated PE without a DVT is still very underreported and rare. The literature states that a lot of patients that are having PE after mRNA vaccine also have associated thrombocytopenia, however, this is not what this patient demonstrates [3]. A total of 43, 548 participants were observed for the safety and efficacy report of the Pfizer COVID-19 report and not a single patient demonstrated an isolated pulmonary embolism event [1]. CONCLUSIONS: This case is a demonstration of a rare occurrence of isolated PE with no evidence of DVT in such close proximity to receiving the mRNA COVID-19 Pfizer vaccination.There are few reports of pulmonary embolism in healthy patients with no history of clotting disorders and further data are needed to support this association. Reference #1: Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577 Reference #2: Hesam-Shariati S, Fatehi P, Abouzaripour M, Fathi F, Hesam-Shariati N, Hesam Shariati MB. Increased pulmonary embolism in patients with COVID-19: a case series and literature review. Trop Dis Travel Med Vaccines. 2021;7(1):16. Published 2021 Jun 12. doi:10.1186/s40794-021-00145-3 Reference #3: Muster V, Gary T, Raggam RB, Wölfler A, Brodmann M. Pulmonary embolism and thrombocytopenia following ChAdOx1 vaccination. Lancet. 2021;397(10287):1842. doi:10.1016/S0140-6736(21)00871-0 DISCLOSURES: No relevant relationships by Muhammad Azaz Cheema No relevant relationships by Morcos Fahmy No relevant relationships by Christina Gearges No relevant relationships by Asma Iftikhar

Fatal MIS-C in a child with palliated single-ventricle physiology

INTRODUCTION: We report a case of MIS-C, confirmed on autopsy, in a toddler with hypoplastic left heart syndrome (HLHS). DESCRIPTION: The patient was a 15 month-old male with HLHS (aortic and mitral atresia) with a superior cavopulmonary anastomosis, and complete heart block with a pacemaker, admitted for respiratory distress. He had known exposure to multiple COVID+ family members, a positive SARS-COV-2 RT-PCR, fevers, elevated inflammatory markers, skin and mucosal changes, and multi-system organ dysfunction, evolving into severe, irreversible multiple organ failure. He met laboratory and clinical criteria for MIS-C. He was treated with high-dose Methylprednisolone, IVIG, Anakinra, and convalescent plasma, but continued to clinically deteriorate. Upon death, the family elected for autopsy. Significant autopsy findings included: acute ischemia of the papillary muscles;peripheral lung infarcts and hemophagocytosis in the bone marrow. The hemophagocytosis in the bone marrow has been noted on several of the small number of autopsies performed on children with fatal MIS-C. DISCUSSION: The patient met WHO and CDC criteria for MIS-C during his hospital stay. Both criteria require fever, elevated inflammatory markers without alternative cause, evidence of prior COVID-19 infection/exposure, and multi-organ involvement. While the pathophysiology of MIS-C remains unknown, the syndrome clinically and immunologically overlaps with other hyperferritinemic syndromes, such as hemophagocytic lymphohistiocytosis and macrophage activating syndrome, where immune-mediated multi-organ injury results from a dysregulated innate immune response-related cytokine storm. The finding of marrow hemophagocytosis on this patient's autopsy adds to the small body of literature on autopsies of children with fatal MIS-C, which also note hemophagocytosis in the marrow and/or spleen. The immune profile and pathology of patients with MIS-C suggests that Macrophages have a significant role in MIS-C. This case thus adds additional credence to this important role of Macrophages, which in turn can further direct studies into its management, to prevent similar deaths.

Unusual presentation of COVID-19 in a child complicated by massive acute pulmonary embolism and lung infarction.

The Novel Coronavirus 2019 (SARSCoV- 2), which was first reported on in Wuhan, China, in late December 2019, causes a respiratory illness called COVID- 19 Disease. COVID-19 is most likely causing a hypercoagulable state, however the prevalence of acute venothromboembolism is still unknown. Limited data suggest pulmonary microvascular thrombosis may play a role in progressive respiratory failure. Here, we report a case of a child with an unusual presentation of COVID-19 presented initially by dry cough without fever and complicated by massive acute pulmonary embolism and lung infarction and treated successfully by hydroxychloroquine and azithromycin, in addition to anticoagulant therapy.