Bilateral Spontaneous Pneumothorax in a Child with Multisystem Inflammatory Syndrome Associated with COVID-19

Introduction: Spontaneous pneumothorax is a rare complication of coronavirus disease 2019 (COVID-19), primarily reported in adults. Pediatric cases with bilateral pneumothorax are much less reported. Case Presentation: We presented the case of a five-year-old previously healthy boy who developed persistent fever, abdominal pain, generalized maculopapular rash, and dyspnea before admission. His chest computed tomography (CT) showed a viral involvement pattern of pneumonia suggestive of COVID-19. Subsequently, he was confirmed with multisystem inflammatory syndrome in children (MIS-C). While he responded well to the therapies, on the fifth day of admission, he developed respiratory distress again. A chest roentgenogram showed bilateral spontaneous pneumothorax. Bilateral chest tubes were inserted, and his condition improved sig-nificantly after five days of admission to the intensive care unit. Two weeks later, he was discharged in good condition. Conclusion(s): Children with MIS-C associated with COVID-19 may develop primary spontaneous pneumothorax. Owing to the clinical picture overlapping with MIS-C associated with COVID-19, the timely diagnosis of pneumothorax may be challenging in such patients.Copyright © 2022, Author(s).

Serum catestatin is correlated with clinical parameters in non-critical COVID-19 patients

Introduction: Catestatin (CST) is a peptid with imunomodulatory, antiinflammatory, and antimicrobial activities. Acute coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus can cause a systemic disease range unpredictably from mild flu-like disease to multiple organ failure. Despite many studies and scientific interest for COVID 19, there is lack of information regarding correlation between serum CST levels and clinical course od COVID 19. There are only few studies investigated CST plasma levels at COVID 19 patients, but mostly at ICU-patients, and those studies revealed that COVID 19 patients release significant amounts of CST in the plasma and CST predicts a poor COVID-19 outcome. In our work the aim was to demonstrate plasma CST levels and correlation with clinical outcome in a group of severe COVID 19 patients admitted in non-ICU department. Method(s): The subjects were patients admitted during second surge of COVID 19 in April and May 2020 in non-ICU unit for COVID 19 patients (high dependency unit) in Infectology department of University Hospital Split, Croatia. The reason of admission was pulmonary infiltrates and COVID 19 positivity confirmed with nucleic acid test. In study were included 32 subjects (25 females, 7 males) (Table 1). An enzyme-linked immunosorbent assay was used for serum CST levels assessment. Result(s): We found significant positive correlation between serum CST levels and: C-reactive protein (r = 0.423, p = 0.008), D-dimers (r = 0.395, p = 0.013), hsTNT (high sensitivity troponin T) (r = 0.603, p < 0.001), proBNP (N-terminal-pro brain natriuretic peptide) (r = 0.569, p < 0.001), and hospitalisation days (r = 0.388, p = 0.014). There was significant difference between groups of participants with SOFA < 3 (n = 18) and SOFA > 3 (n = 14) in catestatin serum levels (7.25 +/- 3.66 vs. 11.05 +/- 9.52 ng/ml;p = 0.065). Conclusion(s): This study confirmed that serum CST levels could have important role as clinical prognostic parameter among non-ICU COVID 19 patients.

Characterization of the Immune Reaction to Covid-19 Treatment with Dexamethasone: A Narrative Review

Purpose of Study: The spread of SARS-CoV-2 and the resulting Coronavirus Disease 2019 (COVID-19) continues to manifest in individuals in varying severity with limited treatment options available. Despite research efforts put forth in developing therapeutic options for treatment of COVID-19 disease, effective and well understood mechanisms remain limited. Corticosteroid treatment with dexamethasone was shown to be beneficial for those with severe illness early in the pandemic with little understanding of its beneficial mechanism. This narrative review describes the current findings regarding the mechanism of action of dexamethasone treatment in the setting of SARS-CoV-2 infection. Methods Used: A comprehensive search of Embase and PubMed was conducted in consultation with a health sciences librarian. Search terms included (1) COVID-19 (2) dexamethasone (3) animal model and (4) immune response. No limits were used on the search and other reviews were excluded. Search results were screened based on titles and s before being selected for full text review. Outcomes recorded included characterization of the microenvironment of lung tissue following SARS-CoV-2 through cytokine measurement, histopathological staining and analysis of lung tissue, and clinical outcomes such as survival time. Summary of Results: The search resulted in 100 articles. Of these, 8 articles were identified that met the inclusion criteria. Three conducted experiments with Syrian hamsters, two with mice, two with alveolar macrophages, and one study was conducted with human subjects. Dexamethasone treatment was found to diminish inflammatory cytokine levels and preserve the integrity of lung tissue in several animal models and in vitro experiments in the setting of SARS-CoV-2 infection. Dexamethasone treatment was also found to reduce inflammatory cell infiltration of lung tissue infected with SARS-CoV-2. In humans, combination therapy of low dose dexamethasone with spironolactone proved more effective at lowering inflammatory markers than high dose dexamethasone alone. Conclusion(s): Collectively, the articles included in this review support the use of dexamethasone treatment in SARS-CoV-2 infection. Protective effects exhibited with dexamethasone treatment suggest that its action may be linked to the inflammatory nature of COVID-19 disease. Macrophage regulation and diminished inflammatory cytokine levels were hypothesized as possible mechanistic features of dexamethasone action but lacked exact characterization. Further exploration of combination treatment with dexamethasone and its mechanism of action is needed to identify specific and effective therapeutic strategies in the future.

Effects of some biological factors on Coronavirus

This research was been adopted to study the relationship between Covid and some necessary biological factors in human body and how these factors affected, This studying included three stages (Sever - Moderate - Mild) it was studied 20 patient for every stage and monitor the biological factors during infection and after infection.Copyright © 2023, Codon Publications. All rights reserved.

COVID-19 and androgenic status: testosterone or dihydrotestosterone have a pivotal role?

The aim of our study is analysis of the androgenic status including testosterone (T) and dihydrotestosterone (DHT) in men hospitalized with coronavirus disease 2019 (COVID-19) and them relationship with the course of the disease. This is a monocentric prospective study performed on 125 male patients hospitalized for COVID-19. We conducted hematological examination, blood biochemical profile, hemostasis analysis and hormonal examination (T and DHT levels) lung and chest computed tomography and also assessed outcomes of hospitalization. Low DHT serum level was found only in 18 patients (14.4%). Subjects with low DHT were significantly older compare to subjects with normal DHT. At the same time in patients with normal DHT white blood cells (WBC) count, neutrophils at admission were higher than in patients with low DHT. No correlation was observed between T and DHT serum blood levels. C-reactive protein (CRP) has a weak positive correlation of DHT serum blood concentration (r = 0.22;p = 0.016). The inverse pattern was obtained for T serum blood concentration (r = -0.285;p = 0.001). After divided all males according to T concentrations we conducted next correlation analysis for DHT and CRP in two different groups: with normal T levels and with low T levels. We found that in males with normal T DHT levels are not correlated with CRP (r = 0.095;p = 0.462). However, in males with low T DHT and CRP had weak positive correlation with r = 0.317 (p = 0.012). Higher DHT concentrations are associated with higher CRP levels, however correlation is weak and in patients with normal T is absent, that may indicate anti-inflammatory effect of T and possible proinflammatory effect of DHT.Copyright © 2023 The Author(s).

Post-recovery pulmonary function test and thorax CT correlations in COVID-19 survivors

Aim: Long-COVID has been described as persistent symptoms involving multiorgan systems in COVID-19 survivors. This single-centred study investigated the correlation between pulmonary function test (PFT) and thorax computed tomography (CT) results in COVID-19 survivors after six months of follow-up period. Material(s) and Method(s): Patients recovered from COVID-19 aged between 18 and 50 years were included in this study and divided into two groups according to PFT results as patients with normal PFT results (PFT normal;n = 74) and with PFT results with restrictive pattern (PFT restrictive;n = 12). The primary aim of this study was to try to predict the prognosis of long-term chronic pulmonary system diseases using pulmonary function test, thorax CT and laboratory findings in the sixth month after recovery. Result(s): There were no significant differences between the patients in PFT normal and PFT restrictive groups in terms of symptoms and CT findings at admission. On the other hand, the rate of dyspnoea and exertional dyspnoea was significantly more pronounced in patients in PFT restrictive group, while there were no significant differences between CT findings. Both univariate and multivariate regression analyses showed that percent forced expiratory volume in one second (%FEV1) and percent forced vital capacity (%FVC) results are associated factors in discriminating normal and PFT results with restrictive pattern in COVID-19 survivors. Discussion(s): PFTs should be included in follow-up evaluations of COVID-19 patients in order to elucidate the post-COVID-19 pulmonary abnormalities.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Lung ultrasound for detection of pneumonic changes in patients with COVID-19 infection

This study aims to determine the suitability of lung ultrasound as an alternative to CT chest to aid in the initial management of these patients. The aim was to determine the value of lung ultrasound in the diagnosis of lung parenchymal affection in patients with COVID-19. Patients and Methods: A prospective including 150 patients was carried out in the Chest, Interventional Radiology and Clinical Pathology Departments in Bab-El-Sha'aria and Al-Hussin Hospitals, Al-Azhar University, during the period from May 2020 to September 2020. Lung ultrasound was performed in 150 patients with COVID-19 pneumonia diagnosed based on the integrated clinical, laboratory, and CT chest radiological data. Result(s): Among 150 patients, there were 86 males and 64 males, ranging in age from 30 to 75 years and a mean age of 55.8+/-12.1 years. Bilateral lung infiltrates in the CT scan were present in 146 patients (97.3%), CXR infiltrates were present in 63 patients (42%), sonographic evidence of pleuropulmonary involvement was present in 139 patients (92.7%), B lines and pleural line thickening were present in all patients with ultrasound findings (100%), subpleural consolidation associated with B lines was present only in 33 patients (23.7%) and pleural effusion was absent in all cases;crackles were only present in 53 (35.3%) patients. Conclusion(s): Because of its simplicity in interpretation, bedside availability, lack of risk of radiation and good sensitivity in the detection of lung parenchymal affection, the chest ultrasound is a useful tool in the management of patients with symptoms suspicious of COVID-19 infection and seems to be a suitable substitute for the CT chest in such circumstances.

Tocilizumab reduces the need for mechanical ventilation in severe Coronavirus Disease 2019 (COVID19), the Greek Experience in a pragmatic clinical setting

Introduction: Severe COVID-19 can result in rapid clinical deterioration consistent with cytokine release syndrome leading to mechanical ventilation. Aim(s): To evaluate clinical outcomes in patients with severe COVID-19 pneumonia who were treated with Tocilizumab in an attempt to hinder their downfall to mechanical ventilation. Material(s) and Method(s): We reviewed consecutive inpatients with severe pneumonia secondary to COVID-19 confirmed by nasopharyngeal polymerase chain reaction (PCR) between March 2021 and December 2021 who presented with >50% lung infiltrates on chect CT scan, WHO score 6-8, pO2/FiO2<200. Result(s): 135 patients received Tocilizumab compared to 160 controls who received standard care. Baseline demographics, comorbidities, inflammatory markers, and corticosteroid treatment were similar between the two groups. Patients who received Tocilizumab had significantly lower intubation rates (6% vs 19%, P = 0.001) than controls and lower 60day mortality (3% versus 8.9%, p=0.02). Age range was similar in the Tocilizumab and control group. Importantly, there were no secondary infections observed in the Tocilizumab group. Conclusion(s): Administration of tocilizumab in carefully selected patients with severe COVID19 pneumonia hindered their downfall to intubation, decreased 60day mortality and improved clinical outcomes.

Can SARSCov2 infection drive in an acute rejection in lung transplant recipients?

Objective: to describe the clinical presentation and outcomes of COVID-19 in lung transplant recipients (LTRs) when managed with high-dose corticosteroids along with standard therapy. Method(s): all nine (9) adult LTRs with confirmed SARS-CoV-2 infection and chest X-ray with predominant bilateral infiltrates and hypoxemia, treated with high-doses corticosteroids similar to an acute rejection treatment were included. All our treated patients presented acute respiratory failure and bilateral pulmonary infiltrates. Result(s): six (6) out of nine (9) patients (66%) treated with bolus evolved favorably. Patients without corticosteroids treatment and severe disease died. Despite lymphopenia and methylprednisolone pulse therapy there were no infectious complications. As per protocol antiviral, bacterial and fungal prophylaxis was prescribed during this period. RT- PCR took long time in becoming negative. Patients who received megadoses of corticosteroids were more likely to live than those who received low doses Conclusion(s): COVID-19 in lung transplant recipients with acute respiratory failure presents a favorable outcome when is managed with high-doses corticosteroids along with standard therapy.

The effect of lifestyle on the course of COVID-19 infection

Aim: Our study's goal was to see how pre-illness lifestyle affected the course of COVID-19 infection in patients hospitalized with COVID-19. Material(s) and Method(s): From January to May 2021, 66 patients aged 50 years and older whose PCR tests were positive for COVID-19 were studied in the pandemic service. The Pittsburgh Sleep Quality Index (PSQI), Mini Nutritional Assessment (MNA) scale, and International Short Physical Activity Questionnaire (IPAQ) were utilized to examine the impact of COVID-19 infected individuals lifestyles such as sleep, nutrition and physical activities on the illness before the infection. Result(s): According to the PSQI scale;the increases in discharged lymphocyte measurements were significant compared to the first hospitalization in the good and bad sleep group cases. A higher increase in NLR for the first hospitalization was seen in the bad sleep group compared to good sleep group. According to the MNA scale, all three groups had increased lymphocyte counts in discharge disposition in comparison to the first hospitalization. Patients at risk of malnutrition had higher increases in lymphocytes at discharge than malnourished individuals (p=0.049). Normal nutritional status had greater platelet measures than patients at risk of malnutrition (p=0.028). According to the IPAQ survey, very active cases had higher platelet measurements than minimally active cases. Discussion(s): In our study on the effect of lifestyle on the course of COVID-19 infection, patients with proper nutrition, good sleep quality, and sufficient physical activity did not require treatment in the ICU. This finding revealed the importance of adopting and maintaining a healthy lifestyle.Copyright © 2022, Derman Medical Publishing. All rights reserved.

An Important Clinical Condition in Differential Diagnosis of Coronavirus Disease 2019: Crack Lung

Crack cocaine has been associated with a variety of pulmonary manifestations. We report a 44-year-old man been diagnosed with severe acute respiratory syndrome coronavirus 2 infection, presenting shortness of breath, non-productive cough, chest pain, headache, dizzi-ness, and fever lasting for 2 days. At first, all findings of our patient called for an impression of coronavirus disease 2019. During admis-sion, he presented with acute respiratory symptoms, patchy ground-glass opacities, and laboratory abnormalities, such as elevated acute phase response and lymphopenia. After, the presence of transient lung infiltrations in the follow-up triggered the cause for a re-evaluation of the diagnosis of coronavirus disease 2019. After a detailed inquiry, it was revealed that he had had a history of intense inhaled cocaine use 2 days before hospitalization. We speculate that the crack lung should also be considered in the differential diagnosis in patients with suspected coronavirus disease 2019 pneumonia.Copyright © Author(s).

Comorbidities and Clinical Outcomes of Patients with COVID 19 in a Tertiary Care Center at Goa: A Prospective Observational Study

Background: It is believed that COVID-19, in those with comorbidities, has an increasingly rapid and severe progression, often resulting in mortality. This study explores various comorbid conditions, disease severity, and clinical outcomes in patients infected with COVID-19. Method(s): This is a prospective observational study. Clinical data of COVID-19 patients admitted at Goa Medical College between November 23, 2020, to December 23, 2020, are summarized and analyzed using Google forms, spreadsheets, and R programming language. Result(s): A total of 100 patient data was collected, including 5% mild, 61% moderate, and 34% severe cases. Fever (83%) was the most common symptom, followed by dry cough (83%), dyspnoea (79%), and fatigue (32%). The most common comorbidities identified were diabetes (66%), hypertension (57%), and cardiovascular and cerebrovascular conditions (27%). Clinical outcome in patients was pneumonia (84%), ARDS (40%), bronchiolitis (10%), and shock (3%). Conclusion(s): Our study estimated that older men with underlying hypertension, diabetes, cardiovascular, and cerebrovascular conditions are at higher risk for severe clinical form. Fever, cough, and dyspnea were the most common signs on admission. The laboratory parameters showed a significant increase in CRP, ferritin, LDH, procalcitonin, ESR, and d-dimer in the case of SARS-CoV-2 infection.Copyright © 2023, Institute of Medico-legal Publication. All rights reserved.

MALIGNANT HYPERTENSION AFTER COVD-19 VACCINE INJECTION

Case;40 y/o male. Clinical course;The patient was transferred to our university hospital because of DOE and severe headache. He had been well and had no history of hypertension or obesity. He had experienced the COVID-19 vaccine injection two week before this visit. After the injection he had been experienced high fever and general fatigue as well as 7 kg of weight loss. On examnation, it was found that he had severe hypertension (190/110 mmHg) and hypertensive optic fundi. On chest X-ray, cardiomegaly and bilateral lung infiltrations was evident and biochemical data indicated renal dysfunction (serum creatinine 2.35 mg/dl), high levels of plasma renin activity (39.1 ng/ml/hour normal;0.6-3.9) and aldosterone concentration (176 pg/ml normal;4.0-82.1), and inflammatory changes (CRP = 23 mg/dl). We also found that increased levels of LDH and decreased levels of hemoglobin which indicated hemolytic anemia and thrombotic microangiopathy. After the control of high blood pressure by intravenous administration of Calcium channel blockades, We performed renal biopsy, which had a finding of diffuse findings of onion skin lesion and global glomerular sclerosis compatible with the diagnosis of malignant hypertension. Any secondary etiologies including renal artery disease or collagen disease had not been identified. Seven days after the admission, we started hemodialysis for this patient because of the renal failure was not resolved. We also had startred ACE inhibitors. We stopped the diuretics and minimized the ultrafiltration. Twenty-five days after the admission the patients was withdrawn from dialysis with the urine volume around 2000 ml/day and the serum creatinine concentration 5.29 mg/dl. He was discharged without any aid of dialysis and with small number of anti-hypertensives. Four months after the discharge, his serum creatinine concentration was 3.36 mg/dl and his blood pressure was 139/85 mmHg with the ACE inhibitor and calcium channel blockades. Conclusions;The case suggested that the malignant hypertension might be triggered by COVID-19 vaccine injection, which is of clinical importance.

Lung Ultrasound and High-Resolution Computed Tomography in Suspected COVID-19 Patients Admitted to the Emergency Department: A Comparison

Objective: To analyze the diagnostic accuracy of lung ultrasonography (LUS) and high-resolution computed tomography (HRCT), to detect COVID-19. Materials and Methods: This study recruited all patients admitted to the emergency medicine unit, due to a suspected COVID-19 infection, during the first wave of the COVID-19 pandemic. These patients also who underwent a standardized LUS examination and a chest HRCT. The signs detected by both LUS and HRCT were reported, as well as the sensitivity, specificity, positive predictive value, and negative predictive value for LUS and HRCT. Results: This cohort included 159 patients, 101 (63%) were diagnosed with COVID-19. COVID-19 patients showed more often confluent subpleural consolidations and parenchymal consolidations in lower lung regions of LUS. They also had "ground glass” opacities and "crazy paving” on HRCT, while pleural effusion and pulmonary consolidations were more common in non-COVID-19 patients. LUS had a sensitivity of 0.97 (95% CI 0.92–0.99) and a specificity of 0.24 (95% CI 0.07–0.5) for COVID-19 lung infections. HRCT abnormalities resulted in a 0.98 sensitivity (95% CI 0.92–0.99) and 0.1 specificity (95% CI 0.04–0.23) for COVID-19 lung infections. Conclusion: In this cohort, LUS proved to be a noninvasive, diagnostic tool with high sensitivity for lung abnormalities that were likewise detected by HRCT. Furthermore, LUS, despite its lower specificity, has a high sensitivity for COVID-19, which could prove to be as effective as HRCT in excluding a COVID-19 lung infection.

The importance of LDH/Albumin, LDH/Lymphocyte, and LDH/Platelet ratios in the evaluation of COVID-19 B.1.1.7 variant

Objectives: The aim is to investigate the usefulness of lactate dehydrogenase (LDH)/Albumin, LDH/Lymphocyte and LDH/Platelet ratios on the prognosis of coronavirus disease (COVID-19) Alpha (B.1.1.7) variant pneumonia. Method(s): A total of 113 patients who were diagnosed with COVID-19 pneumonia and 60 healthy control group were included in this study. The cases were divided into 2 as classic COVID-19 group, and COVID-19 B.1.1.7 variant group. Complete blood count (CBC) and biochemical parameters of the patients were analyzed retrospectively. Patients with COVID-19 B.1.1.7 variant group were also grouped according to the length of stay in the hospital and the days of hospitalization. Result(s): LDH/Albumin, LDH/Platelet, and LDH/Lymphocyte ratios were found to be higher in COVID-19 B.1.1.7 variant group when compared to the control group (p<0.001). The ferritin, neutrophils/lymphocyte (NLR) ratio, procalcitonin (PCT) and LDH/Albumin had the highest area under the curve (AUC) values in the COVID-19 B.1.1.7 variant group (0.950, 0.802, 0.759, and 0.742, respectively). Albumin, Lymphocytes and hemoglobin values were significantly higher in the COVID-19 B.1.1.7 variant group than in the classic COVID-19 group (p<0.05). Conclusion(s): LDH/Albumin and LDH/Lymphocyte ratios may be useful for clinicians in predicting the risk of progression to pneumonia in COVID-19 B.1.1.7 variant patients. Copyright © 2022 the author(s), published by De Gruyter.

Spotting the Needle Amongst the Haystack - When Asthma Isn't Asthma

Introduction/Background: Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss Syndrome, is a rare, small to medium vessel ANCA associated vasculitis. Hallmarks of EGPA include asthma, chronic rhinosinusitis, and peripheral neuropathy. EGPA is characterized by a prodrome of asthma and allergic rhinitis, followed by peripheral blood hyper-eosinophilia and accumulation of extravascular eosinophils, and finally systemic vasculitis. Extrapulmonary involvement is common, sometimes with fatal outcomes. The onset of EPGA is typically between 25-50 years;however, EGPA also occurs during childhood and has a significant morbidity and mortality. Description/Method: Our patient presented to the emergency department with a 2-week history of lethargy, wheeze and left sided neck swelling. After testing COVID-19 positive eight months prior to this, she developed wheezy episodes and was subsequently diagnosed with asthma which was managed with bronchodilators as required. She was reviewed by an allergist who confirmed a dust mite allergy and prescribed Montelukast. She remained well during the summer months however during winter she had 3 distinctive episodes of wheeze and cough which were managed by antibiotics and prednisolone. In the emergency department, an echocardiogram was performed which showed a cardiac tamponade. She was transferred to CICU where she had a pericardial drain inserted. The fluid was abundant with inflammatory cells. Multiple investigations were performed as follows: Hb: 135g/L, wbc: 20.30 x 10 9/L, Eosinophils: 12.77 x 10 9/L, CRP: 51 mg/L, ESR: 75 mm/hr, LDH: 1188 IU/L, IgE: 8000 UI/ml, ANA, ANCA: negative. CT chest showed mediastinal lymphadenopathy and patchy bilateral infiltrate and cardiac MRI showed myopericarditis and LV fibrosis. BMA showed no malignant cells and sinusitis was confirmed by CT. On examination, she was underweight. Her nasal mucosa looked inflamed. Otherwise systemic examination was unremarkable. In the context of poor ejection fraction (20%) with LV fibrosis, urgent MDT was arranged and concluded that our working diagnosis was EGPA. The decision was made to start IV methylprednisolone 10mg/kg/day for 3 days and Ivermectin. That night our patient had a VF arrest which required a single shock conversion 4J/kg. There was 7-minute downtime. Treatment was escalated to include cyclophosphamide, rituximab and plasmapheresis. The patient made a remarkable recovery, extubated and transferred to a normal ward. Her eosinophils count and inflammatory markers improved dramatically following treatment. However, she developed severe neuropathic left leg pain and NCS confirmed peripheral neuropathy Discussion/Results: EGPA is a very rare disease and diagnosis can be challenging especially with the absence of histopathology diagnosis. Early empirical treatment especially in a very ill child in intensive care unit can save lives and divert the progress of the disease. This patient has fulfilled the American College of Rheumatology criteria to diagnose EGPA including asthma, eosinophil count > 10% of upper normal, peripheral neuropathy, pulmonary infiltrates on CT thorax and paranasal sinuses abnormalities. Cardiac biopsy of the fibrotic mass may be a useful tool for diagnosis;however, this invasive procedure may expose this patient with high risk of fatal arrhythmias. Since other causes of eosinophilia were ruled out including parasitic infections, lymphoproliferative disorders, and rare primary immunodeficiency syndromes (hyper-IgE syndrome due to STAT3 or DOCK8 deficiency and Omenn syndrome) and the patient responded well to treatment, the diagnosis of EGPA was supported. Key learning points/Conclusion: Asthma not responding to bronchodilator could be another diagnosis Eosinophilia should be interpreted with caution. Defer the need for histopathology diagnosis in critically ill children Cardiac involvement is a life-threatening marker Early diagnosis prevents life threatening complications.

Coughing up a lung? Expectoration of obstructive fibrinous tracheal pseudomembrane

Case Report: Most common causes of shortness of breath are asthma, COPD, CHF, pulmonary embolism, diffuse lung parenchymal diseases and obesity hypoventilation syndrome. Rare conditions can be bronchiectasis, constrictive pericarditis, kyphoscoliosis, tracheomalacia, cardiomyopathies and so on. We present a rare case of tracheal stenosis presenting with repeated hospital admissions followed by intubations and resolution after spontaneous expectoration. A 52-year-old female with a history of end stage renal disease on hemodialysis, resistant hypertension, and COVID pneumonia on supplemental oxygen, presented with dyspnea associated with yellowish productive sputum for one day. She was admitted one week prior due to the same complaint associated with encephalopathy due to hypercapnia, required endotracheal intubation, got extubated four days later, was provisionally diagnosed with asthma and volume overload, and discharged home. During the admission of interest, the patient's examwas normal except severe hypertension with BP of 192/101, bilateral crackles and rhonchi. Arterial blood gasses (ABGs) again showed hypercapnia. CT thorax showed evidence of left lower lobe pulmonary infiltrate and ground-glass opacities. Due to repeated admissions for hypercapnic respiratory failure, suspicion for persistent anatomic or pathologic abnormality was high. Reexamination of CT thorax suggested subglottic stenosis and she underwent fiberoptic laryngoscopy which revealed grade 3 subglottic stenosis. On day three, she became hypoxic and unresponsive, ABGs revealed PCO2 of 150, and got intubated again. Soon after intubation, the patient had spontaneous expectoration of a large piece of firm, fleshy, blood-tinged, thick, luminal tissue. On the histologic examination, the material was found to be a plug of fibrin with small to moderate numbers of inflammatory cells embedded in the matrix. Follow-up CT neck and chest revealed resolution of previously visualized tracheal stenosis. She underwent repeat direct laryngoscopy and flexible bronchoscopy which did not show any tracheal stenosis. The patient remained hemodynamically stable and was discharged home. Tracheal stenosis is challenging to diagnose. Examples of tracheal stenosis due to pseudomembrane formation are rare in medical literature, and the expectoration of fibrin material after intubation in a person with this condition is even rarer. A similar case has been described before with an identical situation of coughing up soft tissue and comparable histopathology report. Our case highlights the importance of critical analysis for broad differentials, adding up pieces of the puzzle to explain the missing link. This patient came with recurrent episodes of dyspnea that were misdiagnosed as volume overload, pneumonia, and asthma exacerbations. CT chest findings of possible subglottic stenosis were the missing link in this case which steered further work-up and led to the final diagnosis. Copyright © 2023 Southern Society for Clinical Investigation.

Alterations in the coagulation profile and mortality due to covid-19 during the first and second wave in peruvians: A retrospective cohort in a national reference center

Background: Changes in the coagulation profile have been associated with adverse clinical outcomes in patients with COVID-19. It is relevant to evaluate the changes in the coagulation profile and its impact on mortality from COVID-19 during the first and second waves in Peru. Aim(s): To evaluate the alterations and impact of the coagulation profile on mortality from COVID-19 during the first and second waves in Peruvians. Method(s): Retrospective cohort carried out at the "Dos de Mayo" National Hospital, Lima-Peru during the years 2020 and 2021. Peruvians over 18 years of age were included, excluding those with congenital hemostasis disorders, pneumonia caused by other agents and chronic users of anticoagulants. SARS-COV2 pneumonia was defined as infiltrate in lung TEM + positive RT-PCR. Alterations in coagulation parameters were determined by prolonged prothrombin time (PT>14s) and/or prolonged activated thromboplastin time (APTT>35s) and/or fibrinogen < 200 mg/dl and/or fibrinogen >400 mg/dl. dl. The sample was consecutive, reaching a sample of 300 patients from the first and 300 from the second wave. Data was collected and entered into a database and sent for analysis after quality control. Were presented summary measures for the qualitative and quantitative variables. A logistic regression equation was modeled to estimate the adjusted OR of the different coagulation parameters altered. The data were processed RStudio version 1.3.1093. Result(s): A total of 600 patients were included. Male was the most frequent sex during the two periods. Figure 1 shows the baseline characteristics. Fibrinogen < 200 mg/dl during the first wave was associated with a lower risk of death (OR: 0.07;95%-CI: 0.01, 0.90). Table 2 shows the results of the multivariate analysis. Conclusion(s): Apparently the changes in the coagulation profile caused by COVID-19 in Peruvians during the first and second waves were not associated with higher mortality. Low fibrinogen seemed to offer protection during the first wave. (Table Presented).