Acute Fibrinous Organizing Pneumonia in a COVID-19 Patient: A Case Report

Background: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has varied clinical and radiographic manifestations. Severe initial viral infection, cytokine release, opportunistic infection and post-viral inflammation may all contribute to progressive symptoms and severe lung injury. Acute fibrinous and organizing pneumonitis (AFOP), a rare pattern of acute lung injury characterized by intra-alveolar fibrin ball, has so far been reported associated with infections, connective tissue diseases, drugs and toxins, hematologic malignancy, altered immune status and inhalation injury. Case Report: The authors report a case of 26-year-old man with severe COVID-19 pneumonia that clinical and radiographic imaging worsened after episode of cytokine storm. The diagnosis of AFOP was confirmed by transbronchial biopsy, and the patient was successfully treated with high-dose corticosteroids. Conclusion(s): AFOP can be found in severe COVID-19 patients especially when clinical deterioration occurs later in disease course. Clinical suspicion is needed for prompt diagnosis and treatment. High-dose corticosteroid is an effective medication.Copyright © 2023 JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND.

COVID-19 Pneumonia with Migratory Pattern in Agammaglobulinemic Patients: A Report of Two Cases and Review of Literature.

X-linked agammaglobulinemia (XLA) is a primary immunodeficiency characterized by marked reduction in serum immunoglobulins and early-onset infections. Coronavirus Disease-2019 (COVID-19) pneumonia in immunocompromised patients presents clinical and radiological peculiarities which have not yet been completely understood. Very few cases of agammaglobulinemic patients with COVID-19 have been reported since the beginning of the pandemic in February 2020. We report two cases of migrant COVID-19 pneumonia in XLA patients.

Pneumocystis jirovecii and methicillin-resistant Staphylococcus aureus superinfection, a challenge in a post-COVID-19 scenario

We present a case of an 87-year-old nonsmoker female who recovered after infection by SARS-CoV-2 and was readmitted two weeks later due to respiratory sepsis. Radiological imaging showed a significant radiological worsening with extensive areas of bronchopneumonia and ground-glass opacities suggestive of organizing pneumonia. Empirical treatment with meropenem 1g/8h was started;however, clinical worsening persisted with tachypnea and desaturation requiring heated high-flow nasal cannula oxygen therapy, with poor response. Methicillin-resistant Staphylococcus aureus was isolated both in nasal screening swab and sputum, and RNA polymerase chain reaction in induced sputum was positive for P. jirovecii. Serum (1-3)-beta-D-glucan was normal, and blood cultures were sterile. Antibiotic therapy was adjusted with intravenous linezolid 600mg/12h and trimethoprim-sulfamethoxazole 320/1600mg/6h, plus methylprednisolone 40mg/day. Unfortunately, the patient had no response to optimized treatment and finally died. Clinicians should be aware of opportunistic and resistant microorganisms superinfections in relation to SARS-CoV-2 infection, even more, when corticosteroids are widely used.

Erythema Multiforme: A Presentation of COVID-19 Pneumonia.

Since its emergence in December 2019, coronavirus disease 2019 (COVID-19) has been detrimental worldwide. Although COVID-19 infection is primarily known for its respiratory manifestations, extrapulmonary features are increasingly being reported. Among these, cutaneous manifestations are apparent but have a high likelihood of not being attributed to COVID-19. We present the case of a 63-year-old female unvaccinated against COVID-19. She presented with fever, cough, shortness of breath, and rash. The symptoms were present for four days and appeared after contact with a confirmed symptomatic COVID-19-positive family member. The rash started first on the chest and then spread to the face and whole body including the palms and soles. It was erythematous and maculopapular and is associated with ulceration and swelling of the lips. In places, it was confluent and had a target-like appearance. On admission, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) was negative. As she was septic with initial suspicion of tick-borne infections, she was started on doxycycline. Given her symptoms on presentation, the suspicion of COVID-19 was very high, and the SARS-CoV-2 nasal swab PCR was repeated, which was negative yet again. With the index of suspicion being very high, her presentation was speculated to be atypical, especially in the setting of a target-like rash involving the palms and soles. The antibody was checked. IgG antibodies for SARS-CoV-2 were positive. All other antibodies for mycoplasma, Lyme disease, Ehrlichia, and Rocky Mountain spotted fever (RMSF) were negative. Parvovirus DNA and chikungunya IgG, antinuclear antibody (ANA), and antineutrophil cytoplasmic antibody (ANCA) screens were negative. IgG for mycoplasma, dengue, and herpes simplex virus 1 (HSV1) were positive. During all this time, the patient did not show clinical improvement in spite of being on antibiotics. In fact, her oxygen saturation dropped, and she required oxygen through the nasal cannula. A lung tissue biopsy taken on bronchoscopy showed chronic inflammation and organizing pneumonia. To note, mycoplasma DNA PCR and HSV culture from bronchoalveolar lavage (BAL) were negative. The patient was started on intravenous steroids. A confirmatory skin biopsy was done, and it showed perivascular, interstitial, and spongiotic dermatitis related to a viral infection. While on steroids, the patient improved dramatically. Her skin rash also improved, and she was discharged. On outpatient follow-up, she was doing exceptionally well with ambulatory oxygen saturation of 100%. This patient who was COVID-19 PCR-negative twice could have been easily deemed as not having COVID-19. However, the fact that she was unvaccinated, had positive sick contact with imaging concern for COVID-19 pneumonia, and COVID-19 antibody being positive and no other test being positive clearly attributes her manifestations to the virus. The presence of a rash could easily be misleading. Awareness of the fact that a rash like erythema multiforme (EM) could be a sign of underlying COVID-19 is extremely prudent and is an addition to the ever-expanding knowledge of this virus.

An unexpected diagnosis: Good's syndrome

Case report Introduction: Good's syndrome (GS) represents an acquired adult-onset immunodeficiency associated with thymoma. GS affects patients over 40 yrs in form of recurrent infections especially with encapsulated bacteria, opportunistic viral and fungal invasions as a result of combined T/B cell deficiency. The imbalanced immunity may also provoke autoimmune phenomena and tumorigenesis. Case report: We present a 40-year- old male with a newly onset of dull thoracic pain and with no history of previous diseases. Chest CT revealed an anterior mediastinal mass in 2021, without lympadenopathy. A CT-guided core biopsy was suggestive for malignant thymoma, so the patient underwent total thymectomy. Histology indicated a thymoma of the AB type (WHO), and stage I. (Masaoka-Koga);(pT1a pNo). After surgery he was readmitted due to recurrent febrile respiratory tract infections, caused by Gram (-) bacteria or fungi;combination therapy of antibiotics and antifungal drugs was used. With suspicion of GS we determined immunoglobulin levels and the distribution of peripheral lymphocyte subsets. Hypogammaglobulinemia (IgG/A/M), and by flow cytometry markedly reduced peripheral B cells, and an inverse ratio of CD4+/CD8+ T cells were detected, confirming the diagnosis. Blast transformation assay indicated decreased T cell proliferation. Thus, following thymectomy, the patient exhibited severe T/B cell alterations with subsequent recurrent infections. Detailed autoantibody and complement analyses indicated no autoimmune laboratory abnormalities so far. There are still no effective protocols for GS therapy, except of antibiotic prophylaxis, preventive vaccination, and regular immunoglobulin replacement, so IVIG was introduced. As part of the follow-up repeated CT indicated no thymoma recurrence or metastasis. In December 2021 the vaccination refusing patient survived a severe bilateral organizing pneumonia secondary to SARS-CoV2. Conclusion(s): Incidence of the thymic epithelial tumor, thymoma is 0.15-0.33 cases/100.000/year. Depending on histology it could be linked to various immunological abnormalities. Appr. 0.2%-6% of thymomas corresponds to GS. GS, with a still elusive pathogenesis is considered as an uncommon combined immunodeficiency of adults with a variable phenotype and certain similarities to CVID. The prevalence is estimated appr. as 1/500.000. Combination of the high infection susceptibility and concomitant autoimmune diseases could make the diagnosis a challenging task.

Rituximab in the Treatment of Idiopathic Inflammatory Myopathies with Interstitial Lung Disease, Long-Term Follow-Up

Background. Interstitial lung disease (ILD) is the common internal organ manifestation of idiopathic inflammatory myopathies (IIM) that can severely affect the course and prognosis of the disease. Rituximab (RTX) has been used to treat IIM, including variants with ILD. Objectives. To describe the course of disease in IIM patients with ILD, treated with RTX in long-term follow-up. Methods. Our prospective study included 35 pts with IIM fulfilling Bohan and Peter criteria and having ILD. The mean age was 51.8+/-11.9 years, female-26 pts (74%);24 (68.5%) with antisynthetase syndrome, 5 (14.3%) dermatomyositis (DM), 5 (14.3%) with a-Pm/Scl overlap myositis and 1 (2,9%) with a-SRP necrotizing myopathy were included. 25 (71,4% ) patients had nonspecific interstitial pneumonia, 9 (25,7%) organizing pneumonia (OP) and 1 (2,9%) OP, transformed to diffuse alveolar damage. All pts had the standard examination including manual muscle testing (MMT), creatinkinase (CK) anti-Jo-1 antibodies (anti-Jo-1) assay;forced vital capacity (FVC) and carbon monoxide diffusion capacity (DLCO) evaluation as well as high-resolution computed tomography (HRCT) scanning of the chest were performed at baseline, and 36 and more months. The median disease duration was 3.2 [0.16-18] years, 21 (60%) of pts were positive for a-Jo-1 antibody. All pts received prednisolone at a mean dose of 24.3+/-13 mg/day, immunosupressants at inclusion received 25 (71%) pts: cyclophosphamide 18 , mycophenolate mofetil 6 and comdination 1;Rituximab (RTX) was administered in case of severe course of disease and intolerance or inadequate response to GC and other immunosuppressive drugs. Results. The mean follow-up period after the first infusion of RTX was 47.2+/-11.9 months. Pts received 1-11 courses of RTX . The cumulative mean dose of RTX was 4.6 +/-2.5g. MMT 8 increased from 135.8+/-13.5 to 148.75+/-3.5 (p=0.000001). CK level decreased DELTACK - 762 u/l(median 340;25th% 9;75th% 821). anti-Jo-1 decreased from 173.4+/-37 to 96.5+/-79 u/ml (p=0.00002), FVC increased from 82+/-22.6 to 96,9+/-22% (p=0.00011). DLCO increased from 51.4+/-15.2 to 60+/-77.8% (p=0.0001). The mean prednisone dose was reduced from 24.3+/-13 to 5.7+/-2.4 mg/day. 3 pts died: ILD progression was the cause of death in 1 case, 1 bacterial pneumonia and COVID19 pneumonia. Conclusions. The results of this study confirm the positive effect of RTX in IIM patients with ILD (increase of muscle strength and improve lung function, decrease in anti-Jo-1 levels) and also its good steroid-sparing effect. RTX could be considered as an effective drug for the complex therapy of IIM patients with ILD when standard therapy is ineffective or impossible.

Organizing Pneumonia and Ulcerative Colitis: A Relationship To Remember.

Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterised by relapsing and remitting mucosal inflammation of the colon. Despite primarily affecting the gastrointestinal tract, UC has various extraintestinal manifestations that often affect other organs and systems. Although pulmonary involvement is uncommon, organising pneumonia (OP), which affects the lung parenchyma, is one of the potential extraintestinal manifestations of UC. We report a case of OP in a 35-year-old male with a longstanding history of UC, well-medicated with sulfasalazine (SSZ). He presented to the emergency department (ED) with complaints of fatigue, coughing, myalgia, thoracalgia and dyspnoea. A chest X-ray showed parenchymal infiltrates and computed tomography revealed bilateral consolidation. Under a preliminary diagnosis of atypical pneumonia, he was treated with an empirical broad-spectrum antimicrobial agent, which did not lead to any clinical, laboratory or imaging improvement. Furthermore, the diagnostic work-up excluded any malignancy or infectious cause. A probable diagnostic hypothesis was OP as an extraintestinal manifestation of UC or as an adverse effect of SSZ therapy. Hence, SSZ was discontinued, and he was successfully treated with corticosteroids, exhibiting significant improvements and recovering completely during the follow-up period. Despite lung involvement in UC being rare, we present this case to emphasise the importance of a thorough differential diagnosis when treating acute respiratory illness in patients with UC, including extraintestinal manifestations of UC, especially OP, even during a period of remission. We also emphasise the importance of early initiation of corticosteroid therapy to prevent major complications and promote recovery.

Pleuropulmonary Manifestations of Vacuoles, E1 Enzyme, X-Linked, Autoinflammatory, Somatic Syndrome.

BACKGROUND: The vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a newly identified autoinflammatory disorder related to somatic UBA1 mutations. Up to 72% of patients may show lung involvement. RESEARCH QUESTION: What are the pleuropulmonary manifestations in VEXAS syndrome? STUDY DESIGN AND METHODS: One hundred fourteen patients were included in the French cohort of VEXAS syndrome between November 2020 and May 2021. Each patient included in the study who had an available chest CT scan was discussed in an adjudication multidisciplinary team and classified as showing potentially pleuropulmonary-specific involvement of VEXAS syndrome or others. RESULTS: Fifty-one patients had a CT scan available for review and 45 patients (39%) showed pleuropulmonary abnormalities on chest CT scan that were considered related to VEXAS syndrome after adjudication. Most patients were men (95%) with a median age 67.0 years at the onset of symptoms. Among these 45 patients, 44% reported dyspnea and 40% reported cough. All 45 patients showed lung opacities on chest CT scan (including ground-glass opacities [87%], consolidations [49%], reticulation [38%], and septal lines [51%]) and 53% of patients showed pleural effusion. Most patients showed improvement with prednisone, but usually required > 20 mg/d. The main clinical and biological features as well the median survival did not differ between the 45 patients with pleuropulmonary involvement and the rest of the cohort, suggesting that the prevalence of pleuropulmonary involvement might have been underdiagnosed in the rest of the cohort. INTERPRETATION: Pulmonary manifestations are frequent in VEXAS syndrome, but rarely are at the forefront. The initial outcome is favorable with prednisone and does not seem to lead to pulmonary fibrosis.

CXR severity as a predictor for post-COVID-19 related ILD

COVID-19 is caused by SARS COV-2, which first emerged in China and spread widely worldwide. Chest X-ray(CXR) is the first-line tool for COVID-19, and it allows initial assessment and follow-up, giving a great insight into the disease course. A high-resolution computed tomography (HRCT) has become essential for the diagnosis of postCOVID related interstitial lung disease (ILD). Our aim was to determine the COVID-19 disease severity using the CXR scoring system and then evaluate whether the severity of admission CXR could predict the presence of post-COVID related ILD. Data were analysed retrospectively for all adult patients presenting to our hospital between August 2020 and December 2021. 44 patients were found with post-COVID related ILD on HRCT which was performed as a result of persistent abnormalities on 6-12 week follow up CXR. We used severity scoring systems which were classified as mild, moderate, and severe depending on the number of lung segments involved. Severity scoring was performed by an experienced radiologist. Each CXR classification was then compared to HRCT findings. A total of 44 patients with COVID-19, 31 men and 13 women were included. The mean age was 67.7 (range 45-93). The following disease patterns were reported on HRCT: ground-glass opacities, traction bronchiectasis, reticulation, fibrosis, consolidation, organizing pneumonia, and honeycombing. When HRCTs were correlated, 18 admission CXRs were classified as mild, 23 as moderate and 3 as severe. This suggests that the severity of admission CXR does not predict the subsequent emergence of post-covid related ILD. We would recommend looking at other possible predictors such as the need for ventilatory support, comorbidities, and intensive care admissions.

Organizing pneumonia due to COVID-19: the experience of one year in an intensive care unit

Introduction: Organizing pneumonia due to COVID-19 (OP) has been described more frequently. The burden and most adequate therapeutical strategy are yet to be determined. Objetive: descriptive analysis of patients diagnosed with OP in an intensive care unit (ICU). Method(s): We reviewed all admissions in a polyvalent ICU in 2021 and selected those with the diagnosis of OP (established after review of thoracic computed-tomography images by a thoracic radiologist). Statistical analysis was performed with IBM SPSS Statistics 25. Discussion/results: There were 117 admissions because of acute respiratory failure due to COVID-19 (male=77.8%). OP diagnosis was made in 39 patients (pts). Mean age at diagnosis was 49.6 years old. Obesity was present in 46.2% and high blood pressure in 30.8%. The mean length of stay in the ICU was of 31.9 days however it was 11,4 days in pts without OP. Mortality rate was 25.6%. OP diagnosis was made about 22.7 days after COVID-19 diagnosis. Extracorporeal-membrane-oxygenation was needed in 27 pts (6 pts died) with runs ranging from 2 to 87 days. Only 6 pts did not receive initial dexamethasone for unknown reasons. Pts with hemodynamic compromise and severe ARF would receive 1g of methylprednisolone followed by 1 mg/kg/day. It was given to 27 pts and only 2 of these died (p<0.05);8 of those who started methylprednisolone with no pulse (n=12) died. Six months after, 3 pts still needed supplementary oxygen. Every patient described subjective idea of irretrievable quality-of-life. Conclusion(s): Pulse of methylprenisolone seems to reduce mortality in severe OP. When OP is present length of stay increases significantly which inevitably has more impact in quality of life.

Prosthetic valve thrombosis: literature review and two case reports

Prosthetic heart valve thrombosis is one of the most dangerous prosthetic valve complications. Proper monitoring and management of these patients help to prevent this complication. Fluoroscopy is advantageous in cases of thrombosis to assess the function of the prosthetic valve by measuring opening and closing angles. We describe two cases of aortic mechanical valve thrombosis with different mechanisms of thrombus formation. The first case was a 48-year-old woman admitted to the hospital because of shortness of breath during minimal exertion and significantly reduced exercise tolerance. Due to rheumatic heart disease the patient underwent aortic and mitral mechanical prosthesis and has been using warfarin in therapeutic norms. During echocardioscopy aortic prosthesis obstruction and severe tricuspid valve regurgitation were observed. The patient was scheduled for aortic root and TV prosthesis surgery. The second patient also had aortic mechanical valve due to severe aortic stenosis caused by rheumatism and presented with organizing pneumonia and progressing respiratory failure as complications of the COVID-19 infection and was admitted with dyspnea, cough, and weakness. Aortic prosthetic valve thrombosis was diagnosed despite optimal treatment and therapeutic INR.Copyright © 2023, CKS.

No benefit of a prolonged course of corticosteroids in patients with COVID-19 secondary organizing pneumonia

Introduction: Secondary organizing pneumonia (OP) has been reported in the clinical course of SARS-CoV2 pneumonia. Based on data from cryptogenic OP, it might be treated with corticosteroids (CS) but there is no recommendation regarding the best steroid regimen and whether extending the duration of steroids could provide a benefit for patients with secondary OP after COVID-19. Aims and objectives: Our main objective was to evaluate the impact of a prolonged CS therapy in patients with COVID-19 secondary OP. Method(s): Between March 2020 and March 2021, we included patients hospitalized for COVID-19 pneumonia and for whom OP was described on CT scan. We collected data regarding steroid regimens and clinical, functional and radiological outcomes after 4 months of follow-up. Result(s): Among the 129 included patients, 26.4% received no CS (during to the beginning of the first COVID-19 wave), 38.0% had CS <=10 days and 35.7% had >10 days. The median follow-up time was 129.5 [101.2-151] days. The duration of CS was not different in patients hospitalized in intensive care units compared to those treated in conventional units (22.2 versus 22.8 days;p=0.94). At the time of follow-up, patients who received >10 days of CS had no improvement on dyspnea (p=0.33) and no significant change on pulmonary fibrosis features (p=0.09) but had a significantly more impaired diffusing capacity of lung for carbon monoxide (mean value 61.8%, p <0.005). Conclusion(s): Based on this retrospective analysis of a real-world cohort, the use of a prolonged corticosteroid regimen >10 days does not appear to provide any benefit on clinical, functional and radiological outcomes in patients with COVID-19 secondary OP.

Histopathologic changes in lung tissue after Covid-19 pneumonia

Current knowledge of histopathological changes in Covid-19 pneumonia is mainly based on autopsy findings. There are few data on dynamics of lung lesions in vivo after acute phase of disease. The aim of this study was to determine histopathologic changes during the long/post-Covid stage in patients who had suffered from moderate to severe Covid-19 pneumonia. Bronchoscopy with transbronchial lung biopsy was performed in patients with HRCT lesions involving >40% of lung parenchyma, at least 4 weeks after discharge. Additional criteria were restrictive pattern in lung function tests and signed informed consent. Histopathologic analyses were performed using H&E, MSB, MOVAT, TTF1, CD34 and CD68 staining. Research was approved by the Hospital Ethical Committee. Among 26 patients that met inclusion criteria, adequate biopsy samples were obtained from 24. The mean time from the onset of disease to biopsy was 13 weeks. We found 4 histopathologic patterns: diffuse alveolar damage-DAD with vascular abnormalities, nonspecific interstitial inflammation, organizing pneumonia and interstitial fibrosis in 11, 9, 2 and 2 patients, respectively. Vascular abnormalities included capillary thrombi, dilated venules and dissection of small pulmonary arteries. Given the duration of disease, DAD and vascular abnormalities were detected up to the 12 week from the onset of symptoms. All patients biopsied after 12th weeks had some degree of tissue inflammation without vascular changes. Our findings show rather slow recovery of lung tissue after Covid-19 pneumonia. Long lasting DAD with vascular abnormalities may explain prolonged dyspnea and exercise intolerance and should be taken into consideration when planning further rehabilitation.

Post COVID Lung function after mild to moderate disease: Good prognosis, but high prevalence of hyperventilation (HV)

Background: There is evidence of persistent symptoms after COVID-19 disease in more than 50 %. of patients (pts.). We hereby report our experience with lung function tests in Post-COVID pts. in an outpatient clinic. Method(s): Since spring 2020, we offered ambulatory control of lung function and imaging after COVID-19 disease. Lung function tests (LFT) including blood gas analysis were performed. Result(s): 66 consecutive pts. (39M, 27F, age 50+/-15.1 Y, BMI 29+/-6 kg/m2) without pulmonary pre-existing condition presented with persistent symptoms 168+/-122 days after COVID. 41 pts. were treated ambulatory and 25 pts. were hospitalized (none with prolonged ventilation). LFT's were normal (TLC 99+/-18 %, VC 91+/-20 %, FEV1/VC 80+/-10 %, pO2 86+/-10 mmHg, pCO2 37+/-4 mmHg), except in 6 pts., where LFT was slightly impaired: 2 showed moderate obstruction and 4 a restrictive pattern. Interestingly 22 pts. (34.9%) presented with a low pCO2, indicating different degrees of HV, inclining in F (M 7/39 vs. F 15/27, p=0.004). Also, 12 pts. with known pulmonary precondition diagnoses (6 sarcoidosis, 2 chronic hypersensitivity pneumonitis (HP), 1 non-specific interstitial pneumonia, 1 CTD-ILD, 1 asthma, 1 organizing pneumonia (OP) by primary biliary cirrhosis) presented after COVID-19 disease. In 8 of these pts. the LFT was comparable as before COVID-19 disease. One patient with HP showed prolonged recovery, one asthmatic needed intensified treatment, and one presented with a new episode of OP. Discussion(s): Our pts., who recovered from mild to moderate COVID-19 disease, presented with good prognosis with regard to LFT. HV could be one pathophysiologic mechanism for Post-COVID symptoms, particularly in F.

Persistent respiratory failure in severe COVID-19 patients - A tertiary centre experience in Kuala Lumpur, Malaysia

Background: The evidence for management of severe COVID-19 with persistent respiratory failure (PRF) after acute treatment is scarce, despite some authors reported a good response to corticosteroid in histological proven secondary organising pneumonia (OP). Objective(s): This study aimed to study the disease course of COVID-19 patients with persistent respiratory failure, and its radiological pattern. Method(s): A single centre retrospective cohort study on severe COVID-19 patients was conducted from January 2021 to June 2021. All radiological imaging and data were retrieved from electronic database. Result(s): Severe COVID-19 pneumonia had a 78% (584/750) survival in our cohort. Among the survival, 48% (279/584) had PRF beyond 14 days of illness and 10% of them required oxygen therapy upon discharge. Eighty-six percent (240/279) of patients with PRF had a HRCT performed. Eighty percent (187/240) of them attended clinic follow up with 81% had a radiological pattern consistent with OP. The mean severity CT score was 10 (SD+/-3). [Jin C et al. Front Public Heal.2020;8] Seventy-eight percent of patients were perceived with WHO functional class of 1-2. Sixty-eight percent of patients (128/187) were given short course of prednisolone during admission with tapering doses. The mean prednisolone dose was 0.69mg/kg/day with a mean duration of 47 days (SD+/-18). Seventy-eight percent (146/187) had a follow up chest x-ray (CXR) at 12+/-8 weeks. Only 6.4% (12/187) of them had abnormal CXR findings whereby two patients were later confirmed to have pulmonary tuberculosis. Conclusion(s): Radiological pattern of OP is common in COVID-19 with PRF. HRCT is a non-invasive tool to assess this entity.

Glucocorticoid Therapy in COVID-19-Induced Organizing Pneumonia: A Rare Occurrence.

Background Although the incidence of post-COVID-19 organizing pneumonia (OP) is low, the mortality and morbidity in select patients appear to be high. Anticipating specific populations who may be at higher risk and initiating treatment earlier could reduce mortality. Research question Does treatment with high dose, standard dose, or no glucocorticoids for COVID-19 infection impact the incidence and clinical outcome in COVID-19-induced OP? Study design and methods This was a single-center, retrospective, observational cohort study conducted from 03/01/2020 to 06/30/2021 in hospitalized patients over the age of 18 with confirmed COVID-19 infection and computed tomography (CT) scan evidence of OP. Institutional review board (IRB) approval was obtained from the institution (STUDY00002241). Patients' demographics and oxygen requirements at the time of diagnosis, at the time of discharge, and at one, three, six, 10, and 12 months post-discharge were obtained. The dose, duration, and choice of glucocorticoid therapy were recorded for each subject, as well as oxygen requirements during hospitalization. Despite radiological evidence of OP, patients on minimal supplemental oxygen requirements did not receive high-dose or long-duration glucocorticoid therapy. Results A total of 881 patients were admitted with COVID-19, of which 42 met the study criteria. Three patients underwent a lung biopsy to confirm the diagnosis of organizing pneumonia. All other patients were diagnosed based on CT imaging and clinical presentation. Of the patients, 17% did not receive any steroid treatment, while 36% received dexamethasone and 43% received prednisone. The most common oxygen requirement at the time of discharge for steroid-treated patients was nasal cannula (55%) and room air (29%). The incidence of OP in this patient population was 0.05 with a mortality rate of 14%. Interpretation and relevance The incidence of post-COVID-19 OP appears to be lower than anticipated. Steroids for patients on lower supplemental oxygen requirements were discontinued although they had radiological evidence of OP. Patients who were on higher supplemental oxygen requirements at 10 days were continued on steroids regardless of imaging. The decision to continue steroids should be based on individual patient characteristics such as oxygen requirements. In the future, larger multicenter cohort studies would help understand further treatment of post-COVID-19-associated OP. Anticipating specific populations who may be at higher risk and starting treatment earlier could help reduce mortality.

Persistent Pneumonic Consolidations due to Secondary Organizing Pneumonia in a Patient Recovering from COVID-19 Pneumonia: A Case Report and Literature Review.

In patients recovering from coronavirus disease 2019 (COVID-19) pneumonia, respiratory symptoms and radiographic pneumonic infiltrate occasionally persist for many weeks even after viral clearance; thereby, making it difficult to decide on an appropriate treatment. Here, we describe a 46-year-old woman with COVID-19 pneumonia who had persistent radiographic pneumonic infiltration and respiratory symptoms for almost 4 weeks after illness onset, despite viral clearance, and was subsequently diagnosed with secondary organizing pneumonia (SOP) using video-assisted thoracoscopic (VATS) wedge lung biopsy. Intravenous methylprednisolone was administered at an initial dose of 50 mg/day (1 mg/kg) for 7 days and was tapered to a dose of prednisolone 30 mg/day following improvement in the patient's respiratory symptoms and chest radiographic findings. The patient was discharged from the hospital 14 days after the initiation of corticosteroid treatment. The dose of prednisolone was tapered monthly to 20, 15, 10, and 5 mg/day, respectively, at the outpatient clinic for a total duration of 6 months; nearly resolved pneumonic infiltrations were observed in a follow-up computed tomography scan approximately 2 months after she was admitted. To the best of our knowledge, this is the first case report of a COVID-19 associated SOP that was pathologically confirmed through VATS wedge lung biopsy in Korea. SOP should be considered in the differential diagnosis of patients with COVID-19 pneumonia with persistent respiratory symptoms and radiographic pneumonic infiltrations during the recovery phase to avoid the redundant use of antimicrobial or antiviral agents. Furthermore, histological confirmation is essential for the definitive diagnosis of SOP to avoid unnecessarily prolonged corticosteroid treatment.

Severe COVID-19 pneumonia leads to post-COVID-19 lung abnormalities on follow-up CT scans.

Purpose: To investigate the association of the maximal severity of pneumonia on CT scans obtained within 6-week of diagnosis with the subsequent development of post-COVID-19 lung abnormalities (Co-LA). Methods: COVID-19 patients diagnosed at our hospital between March 2020 and September 2021 were studied retrospectively. The patients were included if they had (1) at least one chest CT scan available within 6-week of diagnosis; and (2) at least one follow-up chest CT scan available ≥ 6 months after diagnosis, which were evaluated by two independent radiologists. Pneumonia Severity Categories were assigned on CT at diagnosis according to the CT patterns of pneumonia and extent as: 1) no pneumonia (Estimated Extent, 0%); 2) non-extensive pneumonia (GGO and OP, <40%); and 3) extensive pneumonia (extensive OP and DAD, >40%). Co-LA on follow-up CT scans, categorized using a 3-point Co-LA Score (0, No Co-LA; 1, Indeterminate Co-LA; and 2, Co-LA). Results: Out of 132 patients, 42 patients (32%) developed Co-LA on their follow-up CT scans 6-24 months post diagnosis. The severity of COVID-19 pneumonia was associated with Co-LA: In 47 patients with extensive pneumonia, 33 patients (70%) developed Co-LA, of whom 18 (55%) developed fibrotic Co-LA. In 52 with non-extensive pneumonia, 9 (17%) developed Co-LA: In 33 with no pneumonia, none (0%) developed Co-LA. Conclusions: Higher severity of pneumonia at diagnosis was associated with the increased risk of development of Co-LA after 6-24 months of SARS-CoV-2 infection.

ORGANIZING PNEUMONIA: AN UNUSUAL SEQUELA OF COVID-19 INFECTION.

Organizing pneumonia (OP) is a form of interstitial lung disease that develops in response to acute lung injury. SARS-CoV-2 causes a wide range of lung and extrapulmonary disease, but there are few data suggesting an association between COVID-19 and OP. We describe a patient with COVID-19 pneumonia who developed severe progressive OP with significant morbidity. LEARNING POINTS: COVID-19 pneumonia is one of the secondary causes of organizing pneumonia (OP).Early initiation of steroids in OP is associated with improvement in symptoms and prognosis.A prolonged course of steroids may be needed in COVID-induced OP.