Fungal pneumonia in COVID-19 patients: Risk factors and early prediction

Objective To determine the risk factors for developing secondary fungal pneumonia in moderate to severe coronavirus disease 2019 (COVID-19) cases. Using predictors of fungal infection helps to guide the diagnosis and treatment in these cases and save their lives. Patients and methods A total of 257 patients with moderate to severe COVID-19 pneumonia were examined in this retrospective study at Al Qassimi Hospital of EHS. An assessment of clinical, laboratory, and radiologic findings was performed upon admission. The data were collected and analyzed. Results Overall, 32% of critically ill COVID cases had fungal infection;47% of them were candida, whereas aspergillosis and yeast were positive in 26.5% each. At the time of hospitalization, computed tomography chest findings had a strong correlation with fungal culture results in COVID-19 cases. Fungal infection in COVID-19 cases correlated strongly with metabolic acidosis, high erythrocyte sedimentation rate, high blood sugar, need for mechanical ventilation at admission, vasopressor use, renal replacement, long duration of steroid treatment, long stay in ICU, and long duration on mechanical ventilation. The longer the duration of PCR positivity, the higher the incidence of positive sputum fungal culture result. Conclusion COVID-19-infected patients with other risk factors for fungal infections should always be considered to have fungal infections if pathogenic organisms are isolated from respiratory secretions or other microbiological or immunological markers appear positive. Computed tomography chest finding in COVID-19 cases is an important predictor for fungal infection.Copyright © 2023 The Egyptian Journal of Chest Diseases and Tuberculosis.

POST-COVID-19 CHANGES MASKED A MALIGNANCY: INVASIVE MUCINOUS ADENOCARCINOMA

SESSION TITLE: Challenges in Lung Tumors SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Patients can have a variety of post Coronovirus induced disease (COVID) associated interstitial lung diseases (ILD) ranging from cystic lung disease to fibrinous organizing pneumonia. However, very little is known about malignancies that have been overshadowed by post COVID associated pulmonary changes. We present one such case of insidious invasive mucinous adenocarcinoma of the lung that was masked by post COVID related changes. CASE PRESENTATION: A 70 year old female with COPD, systolic heart failure and significant tobacco use disorder presented with progressively worsening hypoxemic respiratory failure. She has had 4 hospitalizations in past year all for acute on chronic hypoxemic respiratory failure following COVID. She has been on Supplemental Oxygen 3L/min since her infection with SARS-COV2. Patient was found to have worsening bibasilar ground glass opacities (GGO) on CT of chest over the past 1 year since having COVID. She was treated with several rounds of steroids without any relief. Patient had a PET scan that showed a very avid left upper lobe consolidation. Given these worsening abnormalities and symptoms, she underwent bronchoscopy with transbronchial biopsy guided by the positive PET scan and fluoroscopy. However, during bronchoscopy she had copious secretions which were therapeutically cleared helping relieve some of patient's hypoxemia. All her cultures and Fungitell assay on bronchoalveolar lavage were negative. However, post biopsy pathology came back positive for Invasive Mucinous Adenocarcinoma. Patient was treated with chemo and radiation therapy with good response against her malignancy and significant relief in her hypoxemia. DISCUSSION: COVID associated pneumonia is well known to cause chronic hypoxemic respiratory failure. Post COVID related pulmonary changes range from organizing pneumonia to fungal pneumonia. However, patients should start to recover with time as inflammatory changes resolve on CT scan with adequate steroids or anti-fungals. If patients continue to deteriorate then a prompt work-up that rules out other infections and even malignancies is warranted as seen in our patient. This case brings forth an important consideration for aggressively pursuing an adequate work-up in the face of worsening GGO on the CT and patient's continual deterioration due to her hypoxemic respiratory failure. Our patient was able to be adequately diagnosed with malignancy and was then started on chemotherapy that allowed for adequate control of her hypoxemic respiratory failure and helped improve her quality of life. CONCLUSIONS: Post COVID related pulmonary changes can be from a variety of ILD and infections. However, clinician should be vigilant in considering malignancy as a possible etiology of post COVID related changes and initiate an adequate work-up to help evaluate for cancer that can be masked amongst post COVID related ILD. Reference #1: Beck KS, Sung YE, Lee KY, Han DH. Invasive mucinous adenocarcinoma of the lung: Serial CT findings, clinical features, and treatment and survival outcomes. Thorac Cancer. 2020 Dec;11(12):3463-3472. doi: 10.1111/1759-7714.13674. Epub 2020 Oct 5. Reference #2: Matsui T, Sakakura N, Koyama S, Nakanishi K, Sasaki E, Kato S, Hosoda W, Murakami Y, Kuroda H, Yatabe Y. Comparison of Surgical Outcomes Between Invasive Mucinous and Non-Mucinous Lung Adenocarcinoma. Ann Thorac Surg. 2020 Nov 24:S0003-4975(20)32001-4. doi: 10.1016/j.athoracsur.2020.09.042. Epub ahead of print. Reference #3: Lee MA, Kang J, Lee HY, Kim W, Shon I, Hwang NY, Kim HK, Choi YS, Kim J, Zo JI, Shim YM. Spread through air spaces (STAS) in invasive mucinous adenocarcinoma of the lung: Incidence, prognostic impact, and prediction based on clinicoradiologic factors. Thorac Cancer. 2020 Nov;11(11):3145-3154. doi: 10.1111/1759-7714.13632. Epub 2020 Sep 25. DISCLOSURES: No relevant relationships by Danya Ahmed No relevant relationships by David Chambers No rele ant relationships by Jalal Damani No relevant relationships by Deon Ford No relevant relationships by Rachaita Lakra

Covid-19 Associated Fungal Pneumonia: A Case Series

Fungal pneumonias are difficult to diagnose and are likely underestimated. Aspergillus and Candida infections in COVID-19 patients will require early detection by a comprehensive diagnostic intervention {histopathology, direct microscopic examination, culture, (1,3)-β D-glucan, galactomannan, and PCR-based assays} to ensure effective treatments. Particularly in the setting of COVID-19, where the clinical picture, and radiological findings of fungal pneumonia resemble those of severe COVID-19;blood tests lack sensitivity and, most importantly, sampling of the primary site of infection is rarely performed, due to the risk of COVID-19 transmission through bronchoscopy with bronchoalveolar lavage. We performed Fiber-optic bronchoscopy and collected samples in all 5 cases of this series, and confirmed the diagnosis of CAPA which made it possible to start treatment timely.

Pulmonary mucormycosis causing pulmonary artery pseudoaneurysm - A rare entity

Background: A pseudoaneurysm is an abnormal dilatation or outpouching of the artery which is lined only by the tunica adventitia. Pulmonary artery Pseudoaneurysm is very uncommon and associated with high mortality. Usually congenital but the acquired causes include trauma and infrequently infections mainly bacterial and fungal. Pulmonary mucormycosis is a rare opportunistic fungal infection seen in immunocompromised patients with diabetes, chronic renal failure, malignancies and is one of the most uncommon causes of pseudoaneurysm. Less than 30 cases have been reported worldwide for mucormycosis causing pulmonary artery pseudoaneurysm. Case 1: A 52 year old female who was COVID 19 positive 2 months back, admitted in RICU with recurrent hemoptysis and breathlessness. She is known Diabetic and Hypertensive. As her hemoptysis was persisting she underwent bronchoscopy and a soft mass was noticed in the right lower lobe bronchus which bleeds on touch. Bronchoalveolar lavage sent for microbiology confirmed Mucormycosis. CTPA done post bronchoscopy revealed pseudoaneurysm involving right descending pulmonary artery. Injection Amphotericin B started and surgical resection of right lower lobe done. Case 2: A 65 year old male, diabetic presented with cough and hemoptysis for 20 days with fever. CT thorax was suggestive of necrotising pneumonia in left lower lobe. As his hemoptysis was persisting Bronchoalveolar lavage was taken and the bronchoscopy showed a small swelling in the left lowerlobe bronchus. CECT Thorax was later done which confirmed descending pulmonary artery pseudoaneurysm. Treatment was same as for case 1. Discussion: Fungal pneumonia is a rare acquired cause of pulmonary artery pseudoaneurysm. The pseudoaneurysms are thin walled and easily ruptures producing massive hemoptysis. Infection accounts for 33% of the causes for pseudoaneurysms. Infective causes include pyogenic bacteria like S. pyogenes, S. aureus, Klebsiella and fungus like Mucor, and Aspergillus. Infection leads to chronic inflammation of vessel and leads to weakening of vessel wall which causes the internal layers to rupture. Mucor has the potential to cause direct invasion of the vessel wall leading to pseudoaneurysm. Conclusion: Pulmonary Artery Pseudoaneurysm and Pulmonary mucormycosis are individually uncommon clinical entities, but Pulmonary Artery Pseudoaneurysm due to underlying mucormycosis is a rare condition with a limited description in the literature. A high index of suspicion for both the clinician and radiologist is required and should be suspected in patients with underlying immunosuppression who develop hemoptysis. Pulmonary Artery Pseudoaneurysm can be successfully treated with embolization, but if mucormycosis is confirmed surgical resection is the only option.

A rare case of pulmonary mucormycosis in a diabetic patients

Introduction: Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the mucorales order of the class of zygomycetes. It has emerged as one of the most common invasive mycosis in patient with hematological and allogeneic stem cell transplantation. It also remains threat in diabetic and also recently in post covid patients. Case Report: A 62 year old male farmer patient came with complaints of cough with expectoration, fever, moderate hemoptysis and headache. Patient is having uncontrolled diabetes mellitus. All routine blood investigations and coagulation profile was normal. CECT Thorax suggestive of ring like opacities with areas of ground glass opacities surrounded by ring of consolidation suggestive of fungal pneumonia. Simultaneously patient is having severe throbbing headache. So MRI brain with orbit and paranasal sinus done, which suggestive of ethamoidal sinusitis ,osteomyelitis of clivus. Hence IV antifungal amphotericin b started as immediate measure in a view of disseminated fungal infection with strict glycemic control. Sputum smear, microscopy, bacterial culture, gene xpert are negative. Lung biopsy done which suggestive of branching ribbon like hyphae. Hence patient posted for right upper lobectomy. Patient discharged on Tab. Posaconazole. Patient came follow up after 3 months , symptomatically improved and radiological resolution of lesions of chest xray. Conclusion: Mucormycosis is a life threatening infection, and usually the diagnosis late because of nonspecific clinical ,radiological features and need biopsy for confirmation of the organism. The cornerstone for the management and increase the survival rate remain on rapid diagnosis ,treatment of the underlying predisposing condition and urgent surgical debridement.

Clinical Performance of The call Score for the Prediction of Admission to ICU and Death in Hospitalized Patients with Covid-19 Pneumonia in a Reference Hospital in Peru

Objective: Determine the CALL SCORE's diagnostic accuracy for the prediction of ICU admission and death in patients hospitalized for COVID-19 pneumonia in a reference hospital in Peru. Methods: We performed an analytical cross-sectional observational study. We included patients with COVID-19 pneumonia treated at the "Dos de Mayo" National Hospital. Patients over 18 years old with a diagnosis confirmed by rapid or molecular testing were included. Those with an incomplete, illegible, or missing medical history and/or bacterial or fungal pneumonia were excluded. Data were extracted from medical records. The primary outcomes were mortality and admission to the ICU. The Call Score was calculated for each patient (4 to 13 points) and classified into three risk groups. Summary measures were presented for qualitative and quantitative variables. The area under the model curve and the operational characteristics (sensitivity, specificity) were calculated for the best cut-off point. Results: The Call Score reported an area under the curve of 0.59 (IC95%: 0.3 to 0.07), p = 0.43 for predicting death. However, for a cut-off point of 5.5, a sensitivity of 87% and a specificity of 65% were obtained. The area under the curve for ICU admission was 0.67 (95%CI: 0.3 to 0.07), p = 0.43;the 5.5 cut-off point showed a sensitivity of 82% and a specificity of 51%. Conclusions: The Call Score shows a low performance for predicting mortality and admission to the ICU in Peruvian patients.

COVID-19 and the biliary tree: Atypicall manifestations of disease during the pandemic

Case report-IntroductionCOVID-19, the infectious disease caused by the novel coronavirus SARS-CoV-2, and first described in Wuhan, China in December 2019, has affected more than 19 million patients worldwide and resulted in more than 700,000 deaths at the time of writing1. Patients with rheumatic diseases and those receiving immunosuppressive treatment are felt to be at greater risk of complications from this illness, though registry and trial data should help refine our understanding of these risks. We hereby describe a case of COVID-19 complicating an unusual rheumatic illness, resulting in severe multi-system disease and premature death.Case report-Case descriptionA 69 year-old male presented to rheumatology and haematology with symmetrical polyarthritis, thrombocytopenia (18 x 109/L), eosinophilia (25.4 x 109/L), raised C-reactive protein (CRP, 43 mg/L), positive rheumatoid factor (>200), antinuclear antibody (ANA) and anti-Ro. Bone marrow biopsy did not demonstrate evidence of haematological malignancy.Seropositive rheumatoid arthritis and connective tissue disease overlap were diagnosed, and treatment with Prednisolone 60mg daily was initiated. Despite rituximab and intravenous immunoglobulins, thrombocytopenia deteriorated on reducing corticosteroids, however the addition of mycophenolate mofetil (MMF) allowed gradual prednisolone tapering to 3mg daily. Hydroxychloroquine was briefly added but discontinued due to headaches. MMF was discontinued after he developed fungal pneumonia followed by jaundice. Liver biopsy was consistent with drug-induced cholestasis, attributed to co-amoxiclav, and his liver function tests (LFTs) improved on ursodeoxycholic acid. Following a further deterioration in thrombocytopenia, hyperferritinaemia and new onset erythema nodosum, he had a repeat bone marrow examination. This demonstrated large areas of fibrosis and granulomatous inflammation with a dense, pleomorphic T-cell infiltrate, but no haemophagocytosis. Haematologists felt this was reactive and prednisolone dose was increased to 10mg daily.Six months later he developed cholangitis. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a tight 4cm stricture of the distal common bile duct (CBD) within the head of pancreas, which was diffusely swollen without any clear focal mass. Serum amylase was mildly elevated (316 units/L). Concurrent CT thorax, abdomen and pelvis demonstrated bilateral ground-glass changes within the lungs, and a SARS-CoV-2 nasopharyngeal PCR test was positive, though he had no respiratory symptoms or oxygen requirement at that stage.Sadly, four days after the CT scan and before a planned endoscopic retrograde cholangiopancreatography (ERCP) could be performed, he became markedly hypoxic with plain chest X-ray features suggestive of COVID-19 pneumonia. Despite medical management, including doubling of his prednisolone dose, he rapidly deteriorated and died.Case report-DiscussionThis case highlights an unusual presentation of COVID-19 in a patient with a complex background of inflammatory arthritis with immune-mediated thrombocytopenia. At the time of his final illness, these conditions were managed with steroid monotherapy. Based on the COVID-19 risk matrix recommended by the British Society for Rheumatology, he was not identified as a patient requiring shielding.Cholangitis was the major problem precipitating his final admission to hospital, and at the time of admission he had no respiratory symptoms. One week prior to this admission, his father-in-law had died of COVID-19 pneumonia, though they had not been in recent direct contact. Interstitial lung changes were incidentally noted on a CT performed to identify the cause of cholangitis, which prompted the nasopharyngeal PCR that detected SARS-CoV-2. This occurred prior to widespread routine testing of hospital inpatients for SARS-CoV-2 by PCR. Unfortunately he then rapidly developed COVID-19 pneumonia and died before the underlying cause of cholangitis could be definitively identified, though an MRCP demonstrated an obstructed CBD within a diffusely swollen pancreas, where a differential diagnosis of pancreatic malignancy or autoimmune pancreatitis was suggested by the reporting radiologist.There are emerging case reports of COVID-19 resulting in significant pancreatic injuryand a further recent laboratory analysis has suggested that ACE2 receptors, which are utilised by SARS-CoV-2 to gain entry to host cells, are highly expressed on cholangiocytes at a comparable level to type II alveolar cells. Whilst the ultimate cause of cholangitis will remain unknown in this patient, this case highlights the potential for atypical presentations and extra-pulmonary manifestations of COVID-19.Case report-Key learning points COVID-19 is a multi-system illness which can cause significant extra-pulmonary as well as pulmonary pathology, with emerging reports that the biliary tract and pancreas are frequently affected.Evidence to inform accurate prediction of which patients with rheumatic diseases are at highest risk of acquiring severe COVID-19 disease remains insufficient, with current shielding guidelines based on expert consensus.This case highlights the importance of widespread testing for COVID-19 in hospital patients, as not all patients carrying the SARS-CoV-2 virus will demonstrate classical respiratory features of the disease at the point of admission.