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1.
Diagnostics (Basel) ; 12(5)2022 May 21.
Article in English | MEDLINE | ID: covidwho-1953134

ABSTRACT

BACKGROUND: COVID-19 is a disease with multiple variants, and is quickly spreading throughout the world. It is crucial to identify patients who are suspected of having COVID-19 early, because the vaccine is not readily available in certain parts of the world. METHODOLOGY: Lung computed tomography (CT) imaging can be used to diagnose COVID-19 as an alternative to the RT-PCR test in some cases. The occurrence of ground-glass opacities in the lung region is a characteristic of COVID-19 in chest CT scans, and these are daunting to locate and segment manually. The proposed study consists of a combination of solo deep learning (DL) and hybrid DL (HDL) models to tackle the lesion location and segmentation more quickly. One DL and four HDL models-namely, PSPNet, VGG-SegNet, ResNet-SegNet, VGG-UNet, and ResNet-UNet-were trained by an expert radiologist. The training scheme adopted a fivefold cross-validation strategy on a cohort of 3000 images selected from a set of 40 COVID-19-positive individuals. RESULTS: The proposed variability study uses tracings from two trained radiologists as part of the validation. Five artificial intelligence (AI) models were benchmarked against MedSeg. The best AI model, ResNet-UNet, was superior to MedSeg by 9% and 15% for Dice and Jaccard, respectively, when compared against MD 1, and by 4% and 8%, respectively, when compared against MD 2. Statistical tests-namely, the Mann-Whitney test, paired t-test, and Wilcoxon test-demonstrated its stability and reliability, with p < 0.0001. The online system for each slice was <1 s. CONCLUSIONS: The AI models reliably located and segmented COVID-19 lesions in CT scans. The COVLIAS 1.0Lesion lesion locator passed the intervariability test.

2.
Mol Biomed ; 3(1): 15, 2022 May 20.
Article in English | MEDLINE | ID: covidwho-1951435

ABSTRACT

COVID-19 caused by SARS-CoV-2 has created formidable damage to public health and market economy. Currently, SARS-CoV-2 variants has exacerbated the transmission from person-to-person. Even after a great deal of investigation on COVID-19, SARS-CoV-2 is still rampaging globally, emphasizing the urgent need to reformulate effective prevention and treatment strategies. Here, we review the latest research progress of COVID-19 and provide distinct perspectives on the mechanism and management of COVID-19. Specially, we highlight the significance of Human Identical Sequences (HIS), hyaluronan, and hymecromone ("Three-H") for the understanding and intervention of COVID-19. Firstly, HIS activate inflammation-related genes to influence COVID-19 progress through NamiRNA-Enhancer network. Accumulation of hyaluronan induced by HIS-mediated HAS2 upregulation is a substantial basis for clinical manifestations of COVID-19, especially in lymphocytopenia and pulmonary ground-glass opacity. Secondly, detection of plasma hyaluronan can be effective for evaluating the progression and severity of COVID-19. Thirdly, spike glycoprotein of SARS-CoV-2 may bind to hyaluronan and further serve as an allergen to stimulate allergic reaction, causing sudden adverse effects after vaccination or the aggravation of COVID-19. Finally, antisense oligonucleotides of HIS or inhibitors of hyaluronan synthesis (hymecromone) or antiallergic agents could be promising therapeutic agents for COVID-19. Collectively, Three-H could hold the key to understand the pathogenic mechanism and create effective therapeutic strategies for COVID-19.

3.
SAGE Open Med Case Rep ; 10: 2050313X221091391, 2022.
Article in English | MEDLINE | ID: covidwho-1950591

ABSTRACT

Pneumocystis jiroveci pneumonia is a common pathology in HIV-infected but also in uninfected immunocompromised individuals. The pandemic coronavirus disease 2019 (COVID-2019) is a new type of coronavirus disease caused by SARS-COV-2, and the chest imaging is often used as complementary tool in patients' evaluation. The imaging finding is similar with many pulmonary pathologies. Chest computed tomography scan is gold standard imaging and shows a central and diffuse distribution, ground- glass pattern with septal thickening with "crazy paving pattern." We reported a case of 57-year-old man patient, followed in oncology for laryngeal cancer who presented of Pneumocystis jiroveci pneumonia during his follow-up. The diagnosis is confirmed by polymerase chain reaction with bronchoalveolar lavage fluid. Other immunochemical tests can be performed but are less specific. Both curative and preventive treatment in subjects at risk remains trimethoprim-sulfamethoxazole. Corticosteroid therapy may be associated depending on the case.

4.
Pakistan Journal of Medical and Health Sciences ; 16(6):355-356, 2022.
Article in English | EMBASE | ID: covidwho-1939796

ABSTRACT

Objective: To analyze multisystem imaging techniques for diagnosis of Covid-19 viral pathogenesis and pulmonary complications. Study Design: Retrospective study. Place and Duration of Study: Department of Pulmonology, Ghulam Muhammad Mahar Medical College, Sukkur from 1st June 2021 to 31st December 2021. Methodology: Two hundred patients admitted due to Covid-19 positive results were enrolled. Pulmonary consolidations and pneumonia related alterations were observed due to these images. Changes which were related with acute respiratory distress syndrome in complicate Covid-19 cases were also observed. Patients with serious illness were further underwent chest computer topographic imaging scan. Pulmonary-US scan was also performed on the bedside of severe ill Covid-19 patients. In patients with acute respiratory decline and acute dyspnea were also further diagnosed through computed tomography angiography. Results: The mean age of the patients was 41.2±6.5 years. Chest radiograph presented bilateral pneumonia opacities. In a typical progressive pneumonia could be seen through non-contrast enhanced computed tomography imaging in covid-19 patients with glass opacities and bilateral ground glass opacities. In many cases multifocal, patchy as well as distribution findings which were confluent and organizing as pneumonia were also observed. Pulmonary embolism was also identified through computed tomography imaging in Covid-19 patients. Conclusion: Multisystem imaging techniques are significantly important and efficient in diagnosis of various manifestations of Covid-19.

5.
Journal of the Nepal Medical Association ; 60(251):608-611, 2022.
Article in English | EMBASE | ID: covidwho-1939706

ABSTRACT

Introduction: COVID-19 has emerged as a pandemic and has varied clinical presentation. Computed Tomography scans of the chest play an important role in evaluating the lung parenchymal changes and aids in better planning the management of COVID-19 patients. The purpose of this study was to find the prevalence of abnormal chest computed tomography findings among admitted symptomatic COVID-19 patients in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted from 25 October 2020 to January 2021 in a tertiary care hospital. Ethical approval was taken from the Institutional Review Committee (Registration number: 348). Convenience sampling method was used. Chest computed tomography findings of the admitted symptomatic COVID-19 patients were evaluated for abnormal findings. Point estimate and 95% Confidence Interval were calculated. Results: Among 153 patients, abnormal chest computed tomography findings were seen in 147 (96.07%) (92.99-99.15, 95% Confidence Interval). The findings of ground-glass opacities with consolidations were seen in 78 (53.06%) patients. Conclusions: The prevalence of abnormal chest findings among symptomatic COVID-19 patients in our study was similar to the studies done in other countries in similar settings. Majority of the symptomatic COVID-19 patients showed abnormal chest computed tomography scan findings in the form of ground glass opacities and consolidations.

6.
Caspian Journal of Internal Medicine ; 13:221-227, 2022.
Article in English | EMBASE | ID: covidwho-1939558

ABSTRACT

Background: Frequent waves of corona virus disease (COVID-19) and lack of specific drugs against that, warrant studies to reduce the morbidity and mortality of this pandemic disease. In this study, we investigated the association between influenza vaccination and the severity and outcome of COVID-19 disease in Iranian patients living in the North. Methods: This retrospective case-control study was performed on186 patients with COVID-19 infection between March and April, 2020. Patients with positive PCR were divided into two groups of case and control;Patients with moderate to severe and normal to mild lung involvement, respectively. The lung opacities in all of the 5 lobes were evaluated on chest CT images using a CT severity scoring system. The history of influenza vaccination during the fall of 2019-2020 was determined by a phone call. Statistical analysis was done using the chi-square test, student’s t-test, and logistic regression. The significance level was p<0.05. Results: The mean age of patients was 54.67±15.05years. Most patients had pulmonary manifestations including ground-glass opacity (57%), consolidation (80%) and pleural effusion (3.2%). Adjusting for age, gender, and history of underlying disease, vaccination is an effective factor in the severity of pulmonary involvement (AOR=0.39;95%CI: (0.21, 0.73);P=0.003). Furthermore, the chance of ICU admission decreased via influenza vaccination (OR=0.21, P=0.001). Conclusion: The results showed that the severity of COVID-19 pulmonary involvement and outcome as ICU admission, and severe symptoms in patients with history of influenza vaccination were significantly lower than those without history of vaccination. This strategy can be used to prevent and reduce the complications of COVID-19.

7.
Journal of Hypertension ; 40:e170-e171, 2022.
Article in English | EMBASE | ID: covidwho-1937713

ABSTRACT

Objective: The patient was a 61-year-old woman who typically underwent mitral valve replacement and tricuspid valve repair in 2011. During these years, she underwent an annual checkup and experienced no particular problems. The potential patient contracted Covid 19 a month ago and underwent conservative treatment. The patient displayed no specific symptoms, no fever, and her Covid 19 disease was mild. In the accompanying echocardiography, we notice a lump on the atrial surface of the Tricuspid valve that we instantly suspect of local vegetation or heart mass. As a result, we admitted the patient to resume the examination. Design and method: Multi-slice (16) spiral thoracic CT scan: Sternotomy and MVR are seen. Cardiomegaly is evident. Patchy peripheral ground-glass opacities are seen bilaterally, suggesting covid-19 pneumonia;correlation with clinical and paraclinical data is recommended. Degenerative changes are perceived in the thoracic spine. There is no pleural effusion. Blood cultures and urinary trachea were requested to diagnose endocarditis, and she was also asked to have an esophageal echocardiogram. The antibiotic Meropenem 500 was started three times a day with vancomycin 1 gram twice a day for prophylaxis. After these examinations, the mass diagnosis was rejected as the image of vegetation on echocardiography did not found echogenicity similar to cardiac tissue and was denser. Consequently, we diagnosed vegetation. According to the negative culture results, and the patient had no symptoms (chills, heart pain), this patient's diagnosis of an immunological reaction caused by Covid disease was made. Libman -sacks endocarditis is a type of sterile nonbacterial thrombotic endocarditis (NBTE) secondary to inflammation. Results: In this rare case, the vital point is that immunological reaction after covid can give rise to vegetation on the heart artificial valve and can be typically established with endocarditis. Covid can cause libman sac endocarditis, then we consider patients with heart disease maybe get limban sac or other forms of immunological reaction after covid virus. Conclusions: Concerning the explicit rejection of all the causes, the patient was diagnosed correctly with limb sac endocarditis. She underwent anticoagulant therapy and corticosteroid therapy accordingly and was recovered fully.

8.
Pakistan Journal of Medical Sciences ; 38(6):1649-1655, 2022.
Article in English | EMBASE | ID: covidwho-1928887

ABSTRACT

Objectives: To investigate the correlations of initial lab and imaging findings in COVID-19 patients of different clinical types. Methods: We retrospective analyzed patients confirmed with COVID-19 in the Fifth Medical Center of the People’s Liberation Army (PLA) General Hospital between February to April 2020, selected a total of 58 (N) patients with lab and imaging examinations that met the study criteria, using Artificial intelligence (AI) software to calculate the percentage of COVID-19 lesions in the volume of the whole lung, then the correlations of general information, initial chest CT examination after admission and laboratory examinations were analyzed. Results: The 58 (N) COVID-19 patients were divided into mild group [41(n) cases] and severe group [17(n) cases] according to patient’s condition. CT findings of the severe group and mild group mainly included single or multiple ground glass opacity (GGO), with lesions mainly distributed in the periphery of lungs or GGO mixed with consolidation, with lesions involved in peripheral and central areas of both lungs, accompanied other signs. A significant difference in CRP, IL-6, D-D, GGT was observed between the two groups (p < 0.05). The ratios regarding lymphocyte abnormality and neutrophil abnormality in the severe group were higher than those in the mild group (p < 0.05). Conclusion: The CT features at initial diagnosis of COVID-19 were mainly characterized by multiple GGO with or without partial consolidation in both lungs, with the lesions mainly distributed at the subpleural regions. Some lab test indexes were correlated with the clinical types of COVID-19.

9.
Revista Latinoamericana de Hipertension ; 17(1):8-12, 2022.
Article in English | EMBASE | ID: covidwho-1928805

ABSTRACT

This study analyzed the chest CT of COVID-19 patients with clinical and laboratory features. A retrospective study of chest CT, laboratory analysis, and clinical features of patients with COVID-19 was conducted from March to September 2020. Sixty-nine symptomatic patients agreed to join the study. The scoring for chest CT was based on the proportion of lobar involvement with visual assessment. Chest CT scores were paired with clinical and laboratory findings. The relation of all these findings with the patients’ outcomes was statistically assessed with univariate and multivariate analyses. Ground glass opacity was the most common finding in the early course of the disease (≤ 7 days), while crazy-paving, consolidation, and fibrosis were dominantly observed in the late phase (>7 days). The CT score was significantly higher in severe patients (p < 0.0001) and late-phase than that in early-phase patients (p < 0.0001). CT score was significantly correlated with CRP (p<0.001), ALC (p=0.002) and NLR (p<0.001). Chest CT score correlates significantly with laboratory findings and disease severity in COVID-19 patients. Therefore, chest CT score has a potential role in estimating the outcomes of these patients. In addition, a Faster diagnostic workup in symptomatic cases would be beneficial to the patients.

10.
Egyptian Journal of Radiology and Nuclear Medicine ; 53(1), 2022.
Article in English | EMBASE | ID: covidwho-1928214

ABSTRACT

Background: Coronavirus disease (COVID-19) is a new infection with three pandemic waves up till now. CT plays an important role in diagnosis with multiple reporting systems that can be used during CT analysis. We aimed to compare reporting using the recommendations of the radiological society of North America (RSNA) versus the coronavirus disease reporting and data system (CO-RADS) and to assess the performance of CT if used in asymptomatic patients as a screening. Two hundred and fifty-one patients who underwent chest CT scanning either due to clinical suspicion or as screening before hospital admission were included in this retrospective observational cross-sectional study. This was followed by RT-PCR for confirmation. Three radiologists with different years of experience interpreted the CT findings using the RSNA recommendations and the CO-RADS reporting. The data were collected and compared. Results: There was no statistically significant difference noted in the diagnostic accuracy obtained while using the RSNA recommendations and the CO-RADS reporting system. Also, a good inter-rater agreement was noticed while using the two reporting systems. The CT showed a highly significant value while used in the assessment of symptomatic patients in controversy to the screening of asymptomatic patients. Conclusion: Both reporting systems show similar diagnostic accuracy with a good almost similar inter-rater agreement. Both can be used while interpreting the CT images of cases with suspected COVID-19 infection. CT can be used effectively in the detection of COVID-19 infection between symptomatic patients while it is of a lower value in the screening of asymptomatic patients.

11.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927915

ABSTRACT

Introduction: In our study, we are reporting pulmonary function testing (PFT) changes post recovery from SARS-CoV-2 infection in the pediatric and adolescents. This is a unique paper which may shed light on a matter of utter importance that has been poorly reported in the literature. Studies reviewing SARS-CoV-2 infection PFT, mostly from adult, had shown obstructive and restrictive impairment, small airway dysfunction, and decreased diffusion capacity for carbon monoxide (DLCO), which gives an overall assessment of the lung's ability of gas exchange likely due to SARS-CoV-2 triggered pulmonary vasculopathy. Restrictive pattern and decreased DLCO were the most frequently impaired PFT parameter. Method: This is a single-site retrospective charts review of children and adolescents, ages 6 to 22 years old, who presented to pediatric pulmonology outpatient after having a SARS-CoV-2 infection. They were either managed in the hospital and had at least one pulmonary symptom or they were managed as outpatient. Results: In our case series of 33 patients, mean age was 16.8 years, the majority were seen as an outpatient (78.7%, 26/33). PFT results were interpreted using ATS standard, 4 PFT were suboptimal, mean time from SARSCoV- 2 infection and PFT was 4.3 months. Among patients with optimal PFT, 72.4% (21/29) had abnormal PFT (table 1). Subjects with PFT changes, 9 previously healthy subjects had PFT changes post- SARS-CoV-2, compared to 12 patients who had history of asthma. All hospitalized patients had measured DLCO except one whom DLCO wasn't measured. Among all hospitalized patients, whose pulmonary imaging exhibited ground glass opacities, 2 patients had normal DLCO (42.8%, 2/6). The rate of low DLCO was higher inpatient than outpatient cases (42.9% vs. 4.5%, p<0.0369) with mean DLCO 71.2% predicted. All hospitalized patients with decreased DLCO had elevated lactate dehydrogenase (LDH) and D-dimer.The most common co-morbid conditions noted to have were asthma (55%, 16/29) and obesity/overweight (51.7%, 15/29). Subjects who were hospitalized, 71% (5/7) required supplemental oxygen;most common chest imaging findings were bilateral ground-glass opacity, or patchy infiltrates. LDH was elevated in 71% (5/7) whereas D-dimer was elevated in 85.7% (6/7). All received steroids, and 85.7% (6/7) received remdesivir. Conclusion: SARS-CoV-2 related pulmonary complications remains a topic of research and is poorly studied in pediatric population. Impaired DLCO could correlate imaging findings However;we didn't find that association in our report, which is limited by low sample size. PFT may be useful as an objective measure for post-COVID infection follow up. (Figure Presented).

12.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927864

ABSTRACT

Introduction / Case Presentation:46yo female with a history of CKD, atrial flutter, bioprosthetic valve with mitral ring, and recent COVID-19 pneumonia who presented to the emergency department (ED) with shortness of breath, fevers, and fatigue. Three months prior, she had been diagnosed with severe COVID-19 pneumonia, for which she received dexamethasone, remdesivir, tocilizumab, anakinra, and IVIG. She was discharged to a nursing facility with a prolonged steroid taper, ending 1 month prior to admission.In the ED, the patient had a chest x-ray that demonstrated bibasilar atelectasis and opacification, and a CT chest revealed right lower lobe consolidation and surrounding ground glass opacities. A respiratory pathogen PCR swab was negative. Sputum culture was negative for bacterial and fungal growth. Blood cultures did not grow any organisms. Given recent immunosuppression and imaging findings, a serum Cryptococcal antigen was drawn, which was positive with a titer of 1:128. A transthoracic needle biopsy of the patient's right lower lung was then performed. The specimen did not grow any bacteria or fungi and AFB stain on the tissue was negative. Pathology demonstrated a collection of histiocytes, neutrophils, and necrotic debris. PAS, GMS, and mucicarmine stains were positive for fungal organisms consistent with Cryptococcus species. Discussion: Cryptococcosis is a fungal infection due predominately to one of two encapsulated yeasts, Cryptococcus neoformans or Cryptococcus gattii. C. neoformans is found in soil worldwide, and infection typically begins with spore inhalation. Clinically significant disease is seen mostly in immunocompromised patients.Corticosteroids and interleukin inhibitors, such as anakinra (IL-1) and tocilizumab (IL-6), are used in the treatment of COVID-19. These medications have been associated with increased risk for opportunistic infections, including invasive fungal infections. The diagnosis of pulmonary cryptococcosis may be challenging, as symptoms are often nonspecific and may radiographically resemble bacterial pneumonia, malignancy, or other infections. Serum cryptococcal antigen detection tests may be helpful in establishing the diagnosis, as well as histopathology showing narrow-based budding yeast. Conclusion: Patients with prior COVID-19 infection commonly return to healthcare settings with sequelae of their previous coronavirus infection. In our case, it was the prior treatment of COVID-19, which included immunomodulating therapy, that lead to a secondary pulmonary cryptococcal infection. When evaluating pulmonary processes that evolve after an acute infection with COVID-19, it is important to keep a broad differential, including uncommon and/or opportunistic infectious etiologies, particularly when a patient has received prolonged courses of steroids and tocilizumab.

13.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927853

ABSTRACT

Introduction:Immunocompromised individuals, such as those with HIV and low CD4 counts, are at increased risk for opportunistic infections. Although uncommon, these patients can be infected with multiple organisms, making diagnosis and management challenging for clinicians. Mortality remains high, as the data on initiating and adjusting antimicrobials when there is concern for co-infection is lacking. We present a case of Pneumocystis jiroveci (PCP) and cytomegalovirus (CMV) coinfection resulting in severe hypoxic respiratory failure and death. Case Report:A 38-year-old male with no past medical history presented with fever, dyspnea, and nonproductive cough. Vital signs were notable for a fever of 102.3°F, respiratory rate of 24, and oxygen saturation of 77% on room air. Physical examination revealed an ill-appearing male with bilateral rhonchi who became dyspneic with minimal conversation. Laboratory studies were significant for an elevated c-reactive protein, erythrocyte sedimentation rate, ferritin and lactate dehydrogenase. CT chest demonstrated bilateral ground glass opacities with multifocal consolidations. The patient was admitted for hypoxic respiratory failure secondary to suspected COVID pneumonia, despite negative testing. By hospital day 4, the patient had shown little improvement. Further work-up revealed that he was HIV positive with a CD4 count of 5, so he was empirically started on oral trimethoprim-sulfamethoxazole (TMPSMX) for presumed PCP pneumonia. On hospital day 9, the patient underwent endotracheal intubation for worsening hypoxia and subsequent bronchoscopy for further evaluation. PCP PCR confirmed the diagnosis, and the patient was transitioned to intravenous TMP-SMX. Still with minimal improvement, micafungin was added as potential salvage therapy. After 12 days of TMPSMX, treatment was changed to clindamycin/primaquine. CMV PCR from the bronchoalveolar lavage fluid came back positive at this time, so ganciclovir was added to the regimen. Despite multiple antimicrobials, the patient continued to decline. He was deemed not to be a candidate for ECMO given his profoundly immunocompromised status and ultimately died. Discussion:This case highlights the difficulties clinicians have in managing severely immunocompromised patients who worsen despite appropriate care. Little data exists providing guidelines on when to change to second and/or third-line agents in treating PCP pneumonia. Additionally, further studies need to be completed to delineate in whom empiric antimicrobials should be initiated early when co-infection is a possibility. ECMO may serve a purpose in this patient population given that lung rest is necessary to allow healing, but only a few cases of its use exist at this time.

14.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927837

ABSTRACT

Introduction: The Fungitell assay is an in vitro diagnostic test for the qualitative detection of (1-3)-beta-D-Glucan (BDG) in serum. It can be particularly useful in early diagnosis of fungal infections that would otherwise take weeks to finalize in culture.Description:This is a case of a 73 year old Filipino female with a history of diffuse large B-cell lymphoma status post RCHOP therapy, currently maintained on Ritixumab, and rheumatoid arthritis treated with Methotrexate who was admitted to the hospital with increasing shortness of breath for several weeks. In the Emergency Department she was hypoxic and required 2 liters of oxygen via nasal cannula and with 92% oxygen saturation. Her vital signs were otherwise normal. She was afebrile and WBC was 9.4. She had a negative respiratory viral PCR which included COVID-19. Infectious work up including sputum culture and urine antigens were also sent. A CT chest was performed and showed bilateral ground glass opacities suspicious for atypical pneumonia.There was concern for drug toxicity from Methotrexate which was subsequently suspended. A bronchoscopy and bronchoalveolar lavage (BAL) was performed to rule out infection prior to starting steroids for suspected pneumonitis. Cell count from the BAL revealed low neutrophils. There was negative growth over the next 48 hours. Steroids were initiated at 1 mg/kg daily and patient was discharged home with close outpatient follow up scheduled. A fungitell (serum beta D glucan) that was collected from the BAL had resulted after the patient was discharged home. The level returned very elevated (>500). The patient was contacted and she reported that her symptoms did not improve with the steroids. She was still requiring up to four liters of oxygen at home. She was asked to return to the hospital to work up an undiagnosed fungal or PJP pneumonia. A repeat bronchoscopy was performed and a PJP PCR was tested on the BAL. This returned positive. She was started on Bactrim for 14 days to treat PJP pneumonia. She was weaned down to 2 liters of oxygen and was doing well from a pulmonary standpoint at her outpatient follow up visit 2 weeks later. Discussion: The Fungitell assay test in this case was crucial to help guide us to the correct diagnosis. In patients who are immunocompromised, physicians should utilize specialty testing such as Fungitell when it is available. Compared to microbial fungal culture, Fungitell results faster, has a higher sensitivity and a higher negative predictive value. (Figure Presented).

15.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927832

ABSTRACT

Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem disorder characterized by asthma, prominent peripheral blood eosinophilia, and small-vessel vasculitis. We report a case of EGPA in an adolescent with uncontrolled asthma who was receiving montelukast. Case: A 12-year-old boy who is known to have asthma and allergic rhinitis which were previously controlled on ICS, intranasal steroids, and prolonged use of montelukast for 4 years. He presented with cough and nasal blockage for 2 months. He also reported an increase in the frequency of asthma attacks and received multiple courses of systemic steroids. Subsequently, his asthma controller medications were upgraded to ICS/LABA few weeks prior to admission. His symptoms were also associated with weight loss, diarrhoea and haematochezia. He was vitally stable and maintained oxygen saturation on room air. Physical examination revealed nasal polyps, purple skin flat lesions on palms and feet (Figure1), and bilateral crackles on chest auscultation. His blood investigations were significant for leukocytosis with marked eosinophilia (11x103/uL, (51%)), high inflammatory markers and total-IgE (1975 kU/L). Initial chest XR showed bilateral interstitial thickening and small pleural effusions (Figure2). Chest CT showed centrilobular nodules and peripheral ground-glass opacities, tree-in-bud appearance with no peripheral sparing in addition to moderate pericardial effusion and bilateral mild pleural effusion (Figure3). Sinus CT showed extensive sino-nasal polyposis with pansinusitis (Figure4). Initial echocardiography showed moderate pericardial effusion with normal biventricular function. Patient was started on IV furosemide. During his hospitalization, patient developed chest pain. His serial troponin was rising and LV contractility was depressed. ECG showed ST-segment depression. Therefore, EGPA with cardiac involvement was suspected. Cardiac MR showed features of a peri-myocarditis. IVIG was commenced for suspicion of coronary artery involvement, which was later disputed by cardiac cath. He was also started on IV pulse steroids at a dose of 30 mg/kg for 3 days which resulted in dramatic decrease in troponin level, eosinophil count and CRP. Skin biopsy, which was later performed after administration of steroids, showed perivascular non-necrotizing granulomas. His ANA, ANCA and COVID-19 PCR came negative. Serum chemistries and urine microscopy were unremarkable. Patient was later started on Rituximab with significant clinical, serological and radiological (Figure5,6) improvement after 10-months of follow-up. Discussion: EGPA is rare but should be considered in children with uncontrolled asthma, eosinophilia and rhino-sinusitis. This case shows the importance of being aware that montelukast could cause EGPA, in spite of the uncertainty about its mechanism. (Figure Presented).

16.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927823

ABSTRACT

Rhinoviridae are the most common cause of upper respiratory tract infections, especially in children, and often referred to as “the common cold”. Symptoms are usually mild, nasopharyngeal in nature;they have, however, been implicated in cases of infantile viral pericarditis. Its role in the presentation of adult viral pericarditis remains unclear. We present the case of a 45-year-old male with a past medical history of pre-diabetes, hyperlipidemia and hypertension with complaints of severe left-sided chest pain that worsened with movement and coughing but improved when lying supine. Two weeks prior to presentation, he had developed an intermittent cough, treated with antibiotics and steroids. On presentation to the ED, the patient was afebrile but hypotensive to 80/52 mmHg, tachycardic to 116 BPM, hypoxic to 88% on room air, improving to 91% with 3L nasal cannula. Physical examination was notable for wheezing and egophony. Laboratory findings were concerning for WBC 19.97x10-3/uL, Hgb 13.4 g/dL, CRP 176 mg/L, Ferritin 772 ug/L, D-dimer 3.70 ug/mL FEU;procalcitonin 0.2 ng/mL and troponin <0.015 ng/mL. Respiratory viral panel revealed negative COVID-19 test but positive for rhinovirus/enterovirus. Electrocardiogram showed sinus tachycardia. Chest computed tomography demonstrated moderate pericardial effusion, ground glass attenuation of the lungs bilaterally with moderate left pleural effusion and reflux of contrast into the hepatic veins, suggestive of right heart failure. Echocardiogram demonstrated small to moderate pericardial effusion. The patient was admitted with the diagnosis of acute rhino/enteroviral-associated pleuropericarditis. Broad-spectrum antibiotics, prednisone, colchicine and indomethacin were commenced. Upon clinical stabilization of his condition, steroids were discontinued and he was discharged home with close follow-up. While rhinovirus has been associated with infantile viral pericarditis, it is implicated in pneumonia and COPD exacerbations in adults but rarely reported as a cause of adult pericarditis. A case-control study of adults diagnosed with acute idiopathic pericarditis had an independent association with an upper respiratory tract infection or gastroenteritis in the month preceding pericarditis diagnosis but did not delineate causative viruses. Therefore in cases of unknown causes of viral pericarditis, thorough history is vital. Steroids as part of the treatment algorithm for pleuropericarditis management has long been debated. Older literature has not favored the use of steroids due to high recurrence rate. However, Perrone et al refuted this point, noting that low-dose steroids with gradual tapers have equal efficacy and recurrence rates as compared with NSAIDs/colchicine. Therefore, steroids may be a reasonable option for patients with contraindications to NSAIDs/colchicine.

17.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927822

ABSTRACT

Introduction: Pulmonary alveolar proteinosis (PAP) is a rare disorder that results from impaired clearance of surfactant. The classic radiographic appearance on chest computed tomography (CT) is patchy, ground glass opacities with interlobular septal thickening frequently described as a “crazy paving” pattern. Although the diagnosis can sometimes be established by transbronchial biopsy, surgical lung biopsy is the gold standard. There are few case reports of PAP in lung transplant recipients. Case Description: We report the case of a 57 year-old man with chronic hypersensitivity pneumonitis who underwent left single lung transplantation. His post-operative course was complicated by persistent Coronavirus HKU1 infection or shedding. Approximately one year after transplant, he was diagnosed with PAP by surgical lung biopsy showing periodic acid-Schiff (PAS)-positive lipoproteinaceous material within alveoli. While whole lung lavage is the mainstay of treatment for PAP, given his severely fibrotic native lung and significant hypoxemia, he was successfully treated with bronchoscopic lobar lavage of his allograft in two sessions one week apart. Unfortunately, he was later was diagnosed with peritoneal mesothelioma. Discussion: We highlight the challenges in the diagnosis, discuss potential etiologies and describe a unique therapy of this rare disorder in lung transplant recipients. In addition to more common etiologies, such as infection, pulmonary edema, and allograft rejection, PAP should be considered in the differential diagnosis for lung transplant recipients presenting with hypoxemia and ground glass opacities in their allograft. In some cases, such as this one, PAP can be the initial manifestation prior to the diagnosis of a malignancy;however, while hematologic malignancies are commonly associated with PAP, there is only one prior reported case of a patient with long-standing PAP and later diagnosis of mesothelioma. In addition to the association between PAP and mesothelioma, this case suggests the possibility of an association between PAP and transplant immunosuppression or persistent Coronavirus infection/shedding. Therapeutic bronchoscopic lobar lung lavage can be an effective intervention in lieu of whole-lung lavage, particularly for single lung transplant recipients who would not tolerate whole-lung lavage.

18.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927786

ABSTRACT

Introduction: Pneumonic-type lung adenocarcinoma (P-ADC) exhibits a pattern of lung cancer that is radiologically like pneumonia1. It may be misdiagnosed and represents a diagnostic challenge in the setting of progressive respiratory failure. We report a case of P-ADC which presented with rarely described extensive diffuse air-space consolidation. Case Presentation: This is a 74-year-old female with a history of Crohn's disease on Mesalamine, Diabetes Mellitus, Hypertension, Hyperlipidemia and former smoker of 40 pack years admitted to the ICU for hypoxic respiratory failure requiring 100% O2 via HFNC. Twenty-two months prior to admission the patient underwent an EBUS following abnormal low dose lung cancer screening CT (Figure 1A-B). The CT demonstrated left infrahilar consolidation and multiple ground-glass nodules. The EBUS with biopsy/brushings of the mass in addition to bronchoalveolar lavage (BAL) were negative. She was lost to follow-up due to the COVID-19 pandemic. Two weeks prior to admission she was admitted for cough and dyspnea, treated for a community acquired pneumonia following CT showing excessive nodular opacities with left dense consolidations. On day of admission the patient presented from outpatient PFT with hypoxemia requiring 8LPM O2 and saturation of 90%, admitted to ICU on HFNC. Associated symptoms were recent unintentional 20 lbs weight loss and fatigue. CT imaging was remarkable for progressive, fulminant left lung consolidation and contralateral lung nodules (Figure 1C-D). The patient underwent a bedside bronchoscopy which showed normal anatomy and copious thin clear secretions. BAL samples showed malignant cells favouring nonsmall cell carcinoma. Further CT guided FNA showed the tumor cells were consistent with adenocarcinoma and positive for TTF1/Napsin A, negative for p40, and KRAS mutation detected. The patient was started on methylprednisolone, Carboplatin and Pemetrexad and discharged home on 6 LPM oxygen. The patient was shortly after re-admitted for a post obstructive pneumonia and progressive hypoxemic respiratory failure, she transitioned to hospice care and passed away during the hospitalization. Conclusion: P-ADC is uncommon and often misdiagnosed due to unusual presentation mimicking infectious and inflammatory diseases2. It is unclear whether P-ADC represents an extreme form, later stage, or entirely different entity of lung cancer and large airspace consolidations are rarely reported3. Lesions of pneumonia type that extend beyond one lobe on CT are associated with microscopy involvement of both lungs and pathologic correlation shows that CT is unable to reveal multifocality in a high percentage of cases which makes the extend of multifocal consolidations in this case rarely described4-6. (Figure Presented).

19.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927775

ABSTRACT

IntroductionCrack lung is a clinically diagnosed form of diffuse alveolar hemorrhage that occurs acutely within 48 hours of smoking crack cocaine. The diagnosis of crack lung is based on history, clinical presentation, laboratory, and radiographic findings. Unlike most other forms of alveolar hemorrhage, crack lung does not require extensive or invasive work up and is managed symptomatically. We hereby present a case of acute diffuse alveolar hemorrhage secondary to crack cocaine which was clinically diagnosed and managed symptomatically. Case reportPatient was a 46-year-old female with a past medical history of type II diabetes mellitus, chronic obstructive pulmonary disease and polysubstance abuse that was brought to the emergency room after she was found unresponsive. 4mg of Narcan was administered and she became alert. Following Narcan administration, patient remained altered and confused. At the emergency room patient endorsed shortness of breath at rest which she associated it with a prior COVID-19 pneumonia one month ago. Vital signs were significant for a Temperature:99.2 blood pressure: 130/66, heart rate: 125, respiratory rate:27, Oxygen saturation: 95% on non-rebreather at 15L/min. Laboratory investigations were significant elevated creatinine (1.38, baseline unknown);white blood cell count (30.25), arterial blood gas was reported as 7.26/45/69 on 100%. Serum troponin was elevated at 3.12. Electrocardiogram showed sinus tachycardia, chest x-ray showed diffuse bilateral patchy airspace disease, computed tomography of the chest showed bilateral diffuse lung consolidation with small ground glass opacities (figure 1). Computed tomography of the head showed no acute intracranial process and urine drug screen was positive for cocaine. Patient was started on 4 mg of Narcan, 125 mg of methylprednisolone and transferred to the medical intensive care unit (MICU). In the MICU, blood, sputum and urine culture were obtained. Pt was empirically managed on vancomycin and piperacillin-tozabactam. Because of diffuse alveolar hemorrhage was in the differential, patient was continued on 80 mg of IV methylprednisolone every 8 hours. Patient was observed in the unit for 2 days. During stay in the MICU, repeat chest x-ray showed improvement in lung opacities bilaterally. Vitals were within normal range. Patient was weaned down from non-rebreather to 2 Liters of oxygen and then transferred to the general floor. ConclusionPatients with crack lung often present with shortness of breath, fever, cough with or without hemoptysis and sometimes hypoxemia within 48 hours of insult. Early diagnosis based on history, physical examination, laboratory and radiographic findings can ensure prudent management.

20.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927774

ABSTRACT

Introduction: Electronic vaping-associated lung injury (EVALI), attributed to inhalation through E-cigarettes and other devices was first characterized in the US in July 2019. By February 2020, 2807 cases were reported. Patients often present with respiratory, gastrointestinal, and constitutional symptoms. The presence of EVALI without respiratory complaints is under-recognized, only reported three times in the literature thus far. Case: A 22-year-old female student presented with five days of fever, watery, nonmucoid, non-bloody diarrhea, nausea, 3-4 episodes of vomiting, and generalized weakness, without cough, dyspnea, chest or abdominal pain. Social history revealed vaping e-cigarettes containing nicotine and tetrahydrocannabinol for the past 3-4 years with increased use recently due to upcoming exams. She denied smoking traditional cigarettes, marijuana, or illicit drugs. A temperature of 101oF and 98% SaO2 were recorded. Physical examination was notable for bilateral diffuse crackles with a normal abdominal examination. Initial labs demonstrated a WBC of 14,600 without a shift and the remaining labs were within normal limits. Despite the absence of respiratory symptoms, her chest radiograph revealed bilateral multifocal airspace disease. Further investigation with Chest CT showed extensive multifocal bilateral infiltrates and predominantly peripheral ground-glass opacities. COVID-19 PCR was negative three times. Influenza A and B, RSV, mycoplasma, and legionella testing were negative. She was unable to provide sputum for culture. Stool cultures were negative and an abdominal and pelvic CT was normal. She denied any history of dietary intolerances, prior diarrhea, or chronic colitis. Empiric treatment for atypical community-acquired pneumonia with intravenous ceftriaxone and azithromycin was initiated, with little improvement over the subsequent 4 days. Lack of clinical effect with antibiotics prompted a suspicion for EVALI and intravenous methylprednisolone 1mg/kg every 8 hours was initiated. There was a significant improvement of her gastrointestinal and constitutional symptoms within 24 hours. After three days of IV steroids, she was discharged on an enteral taper. A repeat Chest CT scan 2 weeks later demonstrated complete resolution of the previously identified ground-glass opacities. Discussion: The use of E-cigarettes has grown by 900% between 2011 and 2019 among young adults but used by older individuals as well. This has contributed to the burgeoning EVALI epidemic. Although COVID has taken the centre stage while identifying diffuse interstitial lung abnormalities, there must be a high index of suspicion regarding the incidence of EVALI, especially in young patients, considering the varied presentations and the potential absence of respiratory symptoms.

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