Thelung ultrasound in children with SARS-COV 2 infection: a national multicenter prospective study (preprint)

Covid-19 causedhospitalizations, severe disease and deaths in any age, including in the youngest children. The aim of this multicenter national study is to characterize the clinical and the prognostic role of lung ultrasound (LUS) in children with Covid-19. We enrolled children between 1 month and 18 years of age diagnosed with SARS-CoV2 infection and whounderwenta lung ultrasound within 6 hours from firstmedical evaluation. A total of 213 children were enrolled, 51.6%were male, median age was2 years and 5 months (IQR 4mm- 11 yearsand4 months).One hundred and fortyeight (69.4%) children were admitted in hospital, 9 (6.1%) in pediatric intensive care unit.We found an inverse correlation between the LUS score and the oxygen saturationatthe clinical evaluation (r = − 0.16; p = 0.019). Moreover, LUS scores were significantly higher in patients requiring oxygen supplementation (8 (IQR 3–19) vs 2 (IQR 0–4); p = 0.001). Among LUS pathological findings, irregular pleural line, sub-pleural consolidations and pleural effusions were significantly more frequentin patients whoneeded oxygen supplementation (p = 0.007; p = 0.006 andp = 0.001, respectively). Conclusion: This multicentric study confirmed that LUS is able to detect Covid-19 low respiratory tract involvement, which is characterized by pleural line irregularities, vertical artifacts and subpleural consolidations. Notably, children with higher LUS score have an higher risk of hospitalization or need for oxygen supplementation, supporting LUS as a valid and safe point-of-care first level tool for the clinical evaluation of children with Covid-19.

COVID-related Constrictive Pericarditis Requiring Pericardiectomy: A Case Report (preprint)

Background The COVID-19 pandemic was primarily considered a respiratory malady in the early phases of the outbreak. However, as more patients suffer from this illness, a myriad of symptoms emerge in organ systems separate from the lungs. Among those patients with cardiac involvement, myocarditis, pericarditis, myocardial infarction, and arrhythmia were among the most common manifestations. Pericarditis with pericardial effusion requiring medical or interventional treatments has been previously reported in the acute setting. Notably, chronic pericarditis with pericardial thickening resulting in constriction requiring sternotomy and pericardiectomy has not been published to date.Case Presentation A patient with COVID-19-associated constrictive pericarditis three years after viral infection requiring pericardiectomy was reported. The COVID-19 infection originally manifested as anosmia and ageusia. Subsequently, the patient developed dyspnea, fatigue, right-sided chest pressure, bilateral leg edema, and abdominal fullness. Following recurrent right pleural effusions and a negative autoimmune work-up, the patient was referred for cardiothoracic surgery for pericardiectomy when radiographic imaging and hemodynamic assessment were consistent with constrictive pericarditis. Upon median sternotomy, the patient’s pericardium was measured to be 8 mm thick. Descriptions of the clinical, diagnostic, and therapeutic features are provided. Within the first week after the operation, the patient’s dyspnea resolved; one month later, leg edema and abdominal bloating were relieved.Conclusions Although an association between COVID-19 and cardiac complications has been established, this case adds another element of virus severity and chronic manifestations. The need for sternotomy and pericardiectomy to treat COVID-19-related constrictive pericarditis is believed to be the first reported diagnosis.

Fungal pleural infection due to Microascus gracilis with pulmonary aspergillosis after COVID-19 pneumonia (preprint)

Background: Scopulariopsis/Microascus is a rare but devastating pathogen due to its intrinsic resistance to nearly all available antifungal agents. Microascus gracilis, an ascomycetous mould in the order Microascales, family Microascaceae, has recently emerged as a significant invasive pathogen causing opportunistic infections. Objectives and Methods: We present a case of pleural infection caused by M. gracilis with pulmonary aspergillosis in an immunocompromised man after COVID-19 pneumonia. To further understand the characteristics of the pathogen isolated from the patient, we identified the strain through mycological characteristics, matrix-assisted laser desorption/ionization (MALDI) time-of-flight (TOF) mass spectrometry (MALDI-TOF MS) and internal transcribed spacer (ITS)-based sequencing, and performed in vitro drug susceptibility testing against common antifungal agents. Moreover, we assessed lymphocyte subsets and programmed cell death protein 1 (PD-1) expression in peripheral blood and pleural effusion to monitor the efficacy of therapy with thymosin-α-1 and intravenous immunoglobulin. Results: Filamentous fungi isolated from pleural fluid were identified as M. gracilis based on classical morphology, mass spectrometry and molecular biology methods. The susceptibility results in vitro revealed that multiple antifungal agents were inactive against the strain. Adjuvant immunomodulatory treatment successfully increased the levels of CD3+ T and CD4+ T cells while decreasing the levels of CD3+PD-1+ and CD4+PD-1+ T cells in both peripheral blood and pleural effusion. Conclusions: The immunocompromised host with opportunistic M. gracilis infection, rapid and accurate recognition through direct microscopic testing with calcofluor white and MOLDI-TOF MS, is the key to achieving a definite diagnosis, and a combination of antifungal therapy with immunomodulatory therapy is vital for improving survival.

Severe pneumonia with co-infection of H5N1 and SARS-CoV-2: a case report (preprint)

Background H5N1 influenza is a cause of severe pneumonia. Co-infection with influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may lead to poor prognosis in the epidemic of COVID-19. However, few studies have reported regarding patients co-infected with avian influenza and SARS-CoV-2. Case presentation A 52-year-old woman presented with fever for eight days and worsening shortness of breath and decreased blood pressure. Computed tomography (CT) revealed air bronchogram, lung consolidation and bilateral pleural effusion. Furthermore, polymerase chain reaction (PCR) of the bronchoalveolar lavage fluid (BALF) showed positivity for H5N1 and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Conclusion H5N1 influenza is a cause of severe pneumonia. The clinical presentation of the patient had a predomination of H5N1 influenza rather than COVID-19. A viral PCR analysis is necessary to demonstrate the pathogen of severe pneumonia. The patient exhibited an excellent prognosis upon the appropriate use of antiviral medicine.

COVID-19 Coinfection with Malaria and Its Presentation with Bilateral Pleural Effusion: A Case Report and Literature Review (preprint)

Background There could be misdiagnosis of COVID 19 for malaria and vice versa because of their similar presentation, particularly when clinician relies mainly on symptoms. Coinfection with COVID-19 and malaria is associated with increased all-cause in-hospital mortality compared to isolated infection with SARS-CoV-2. Presentation with pleural effusion adds another challenge in the diagnosis of COVID-19.Case summary: This is a 57-year-old woman who presented with symptoms of acute febrile illness associated with shortness of breath and cough. Physical examination was remarkable for fever, hypotension, tachycardia, tachypnea, desaturation, decreased air entry and dullness over bilateral lower 1/3rd of the chest. Upon investigations, she was found to have ring-form trophozoites of plasmodium falciparum and bilateral ground glass opacities, bilateral consolidations and bilateral pleural effusions. She was managed with supportive treatments, antimalarial agents and antibiotics. COVID-19 was diagnosed late due to the initial high diagnostic inertia.Conclusion Clinicians should be aware of the possibility of COVID-19 in any patient who presents with acute febrile illness or respiratory complaints like shortness of breath and cough. In patients with symptoms such as fever, fatigue, and headache, both malaria and COVID-19 tests should always be performed. Though pleural effusion is rarely reported in COVID-19 patients, viral etiologies like COVID-19 should be considered if alternative diagnoses are lacking.

Worm globalization.

We report the first case of eosinophilic pleural effusion due to Anisakis spp. infection in a 39-years-old European subject hospitalized for worsening dyspnoea and abdominal and thoracic pain. Lung CT scan showed bilateral pleural effusion; thoracentesis revealed significant eosinophilia (45%), with normal eosinophils in the blood. Microbiological tests on pleural effusion were negative for bacteria, SARS-CoV-2, tuberculosis, fungi and parasites. The patient used to eat raw fish; Western blot was positive for Anisakis spp. in blood and pleural effusion. In the era of globalization, unusual parasitic infections should be considered also in nonendemic countries, especially in patients with unexplained eosinophilia.

[Analysis of chest imaging features of novel coronavirus pneumonia, bacterial pneumonia and viral pneumonia].

OBJECTIVE: To investigate and summarize the chest CT imaging features of patients with novel coronavirus pneumonia (COVID-19), bacterial pneumonia and other viral pneumonia. METHODS: Chest CT data of 102 patients with pulmonary infection due to different etiologies were retrospectively analyzed, including 36 patients with COVID-19 admitted to Hainan Provincial People's Hospital and the Second Affiliated Hospital of Hainan Medical University from December 2019 to March 2020, 16 patients with other viral pneumonia admitted to Hainan Provincial People's Hospital from January 2018 to February 2020, and 50 patients with bacterial pneumonia admitted to Haikou Affiliated Hospital of Central South University Xiangya School of Medicine from April 2018 to May 2020. Two senior radiologists and two senior intensive care physicians were participated to evaluated the extent of lesions involvement and imaging features of the first chest CT after the onset of the disease. RESULTS: Bilateral pulmonary lesions were more common in patients with COVID-19 and other viral pneumonia, and the incidence was significantly higher than that of bacterial pneumonia (91.6%, 75.0% vs. 26.0%, P < 0.05). Compared with other viral pneumonia and COVID-19, bacterial pneumonia was mainly characterized by single-lung and multi-lobed lesion (62.0% vs. 18.8%, 5.6%, P < 0.05), accompanied by pleural effusion and lymph node enlargement. The proportion of ground-glass opacity in the lung tissues of patients with COVID-19 was 97.2%, that of patients with other viral pneumonia was 56.2%, and that of patients with bacterial pneumonia was only 2.0% (P < 0.05). The incidence rate of lung tissue consolidation (25.0%, 12.5%), air bronchial sign (13.9%, 6.2%) and pleural effusion (16.7%, 37.5%) in patients with COVID-19 and other viral pneumonia were significantly lower than those in patients with bacterial pneumonia (62.0%, 32.0%, 60.0%, all P < 0.05), paving stone sign (22.2%, 37.5%), fine mesh sign (38.9%, 31.2%), halo sign (11.1%, 25.0%), ground-glass opacity with interlobular septal thickening (30.6%, 37.5%), bilateral patchy pattern/rope shadow (80.6%, 50.0%) etc. were significantly higher than those of bacterial pneumonia (2.0%, 4.0%, 2.0%, 0%, 22.0%, all P < 0.05). The incidence of local patchy shadow in patients with COVID-19 was only 8.3%, significantly lower than that in patients with other viral pneumonia and bacterial pneumonia (8.3% vs. 68.8%, 50.0%, P < 0.05). There was no significant difference in the incidence of peripheral vascular shadow thickening in patients with COVID-19, other viral pneumonia and bacterial pneumonia (27.8%, 12.5%, 30.0%, P > 0.05). CONCLUSIONS: The probability of ground-glass opacity, paving stone and grid shadow in chest CT of patients with COVID-19 was significantly higher than those of bacterial pneumonia, and it was more common in the lower lungs and lateral dorsal segment. In other patients with viral pneumonia, ground-glass opacity was distributed in both upper and lower lungs. Bacterial pneumonia is usually characterized by single lung consolidation, distributed in lobules or large lobes and accompanied by pleural effusion.

A Case of Pneumothorax Ex Vacuo Associated with COVID-19.

Pneumothorax is a known complication of coronavirus disease 2019 (COVID-19). The concept of pneumothorax ex vacuo has also been proposed to describe pneumothorax that occurs after malignant pleural effusion drainage. Herein, we present the case of a 67-year-old woman who had abdominal distension for 2 months. A detailed examination led to the suspicion of an ovarian tumor and revealed an accumulation of pleural effusion and ascitic fluid. Thoracentesis was performed, raising the suspicion of metastasis of high-grade serous carcinoma arising from the ovary. An ovarian biopsy was scheduled to select subsequent pharmacotherapy, and a drain was inserted preoperatively into the left thoracic cavity. Thereafter, a polymerase chain reaction analysis revealed that the patient was positive for COVID-19. Thus, the surgery was postponed. After the thoracic cavity drain was removed, pneumothorax occurred, and mediastinal and subcutaneous emphysema was observed. Thoracic cavity drains were then placed again. The patient's condition was conservatively relieved without surgery. This patient may have developed pneumothorax ex vacuo during the course of a COVID-19 infection. Since chronic inflammation in the thoracic cavity is involved in the onset of pneumothorax ex vacuo, careful consideration is required for the thoracic cavity drainage of malignant pleural effusion and other fluid retention.

Pulmonary Paragonimiasis: A Case Series.

Paragonimiasis contributes to significant foodborne zoonosis worldwide. The major mode of transmission in humans is by consumption of uncooked or undercooked crabs and crayfish harbouring Paragonimus metacercariae. It begins with symptoms like fever and lower respiratory involvement from a few months to a year, mimicking those of tuberculosis and leading to diagnostic delay. Here, we report two cases of paragonimiasis during a period of nine months. Both cases presented with symptoms of productive cough with rusty sputum, chest pain, along with eosinophilia, and pleural effusion and had a history of consumption of smoked crab from the local river. The diagnosis was established by microscopic demonstration of Paragonimus ova in the sputum. They were treated with praziquantel and recovered. Indeed, it is challenging to diagnose paragonimiasis due to the lack of its specific symptoms but should be considered in the differential diagnosis of eosinophilia and pleural effusion in such lung diseases. Keywords: case reports; eosinophilia; paragonimiasis; pleural effusion.

Malignus pleuralis effusiókkal küzdo betegek ellátása egy regionális onkológiai központban a COVID-19-pandémia idoszakában.

INTRODUCTION: Malignant pleural effusion is a complication of tumors heralding poor outcome. It may be life-threatening, so advanced cases should be treated as an oncological emergency. OBJECTIVE: We aimed to provide complex care to patients with malignant pleural effusion during the COVID-19 pandemic at the University of Pécs Medical School, in the Department of Oncotherapy. During the pandemic, we introduced the thoracocentesis as a routine method in our department without previous experiences. METHOD: Results of diagnosing and treating pleural effusion of patients between March 18th of 2020 and May 31st of 2021 were summarized. RESULTS: We have analyzed data of 45 patients, two-thirds (66.7%) of them were women, the median age was 67 years. 57.8% of patients received systemic anticancer therapy during the study. The total number of thoracocentesis was over 120, one-third of the patients required more than five interventions. Only three iatrogenic pneumothorax cases were detected, no other serious complications were experienced. The procedures - that were aimed to mitigate symptoms in most cases (80%) - were considered successful. However, 48.9% of the patients were no longer alive at the end of the study period indicating very poor prognosis of pleural carcinosis. DISCUSSION AND CONCLUSION: Clinical care of oncological patients was continuous during the pandemic; patients treated as part of emergency care were often seen in advanced disease state. Treatment of malignant pleural effusion requires oncological foresight as well as implementing an invasive approach. Our study has shown that discussion of the topic is relevant, may reveal difficulties and need for improvement. Our results are consistent with literature data, we have experienced less complications than reported in the literature. Orv Hetil. 2022; 163(26): 1015-1022.

Chest radiograph findings in children with COVID-19-A retrospective analysis from a tertiary care paediatric hospital in South India.

OBJECTIVE: The primary aim of this study is to document the chest X-ray findings in children with COVID-19 pneumonia. The secondary aim is to correlate chest X-ray findings to patient outcome. METHODS: We performed a retrospective analysis of children (0-18 years) with SARS-CoV-2 admitted to our hospital from June 2020 to December 2021. The chest radiographs were assessed for: peribronchial cuffing, ground-glass opacities (GGOs), consolidation, pulmonary nodules and pleural effusion. The severity of the pulmonary findings was graded using a modification of the Brixia score. RESULTS: There were a total of 90 patients with SARS-CoV-2 infection; the mean age was 5.8 years (age range 7 days to 17 years). Abnormalities were seen on the CXR in 74 (82%) of the 90 patients. Bilateral peribronchial cuffing was seen in 68% (61/90), consolidation in 11% (10/90), bilateral central GGOs in 2% (2/90) and unilateral pleural effusion in 1% (1/90). Overall the average CXR score in our cohort of patients was 6. The average CXR score in patients with oxygen requirement was 10. The duration of hospital stay was significantly longer in those patients with CXR score >9. CONCLUSION: The CXR score has the potential to serve as tool to identify children at high risk and may aid planning of clinical management in such patients.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) created a global pandemic in early March 2020. There are very few studies describing the lung changes in affected children. We performed a retrospective study in children, aged between 0 days and 18 years, who tested positive for this virus. This study was conducted in a paediatric tertiary care hospital in South India. Chest X-ray (CXR) was done in children with moderate and severe SARS-CoV-2 infection; these X-rays were reviewed and scoring was done to assess the degree of abnormality. It was seen that the duration of hospital stay was longer in children with a high CXR score. Amongst the children with score >9, 60% needed oxygen support during their treatment. Thus, CXR score can play a role in the prediction of disease outcome in SARS-CoV-2 infection.

Coexistence of COVID-19, Pseudomonas, and thoracic actinomycosis in a cystic bronchiectasis case.

Actinomycosis often leads to cervicofacial infections, but thoracic involvement may also occur. However, the development of empyema is rare. While being followed up with the diagnosis of asthma and bronchiectasis, our case was hospitalized for infected bronchiectasis. As empyema developed in the follow-up, the pleural effusion was drained by tube thoracostomy. Actinomycosis was diagnosed through pleural effusion cytology. Growth of Pseudomonas aeruginosa was observed in sputum culture, and SARS-CoV2 RT-PCR was also positive in nasopharyngeal sampling. Polymicrobial agents can often be detected in actinomycosis. Actinomycosis cases have also been reported in the post-COVID period. Our case is presented since it would be the first in the literature regarding the coexistence of COVID-19, Pseudomonas, and thoracic Actinomycosis (empyema).

Predictive Value of Pulmonary Involvement Score and Clinical Parameters for Severe COVID-19: A Nomogram-Based Approach in Emergency Department (preprint)

Background This study aims to evaluate the prognostic value of a pulmonary involvement (PI) score in COVID-19 patients, both independently and in combination with clinical and laboratory parameters, following the adjustment of the dynamic zeroing policy in China.Methods A total of 288 confirmed COVID-19 pneumonia patients (mild/moderate group, 155; severe group, 133) from the Emergence Department, Beijing Chaoyang Hospital, were enrolled in this study and allocated to the training and validation cohort. The PI score of the initial chest CT was evaluated using a semi-quantitative scoring system, and clinical and laboratory parameters were collected. Radiomics and combination predictive models were developed using the least absolute shrinkage and selection operator (LASSO) logistic regression algorithm and multivariate logistic regression. The models' performance for predicting severe COVID-19 was assessed by receiver operating characteristics curve (ROC) analysis and calibration curve.Results Compared with the mild/moderate patients, the severe patients had higher levels of C-reactive protein (CRP), D-dimer, procalcitonin (PCT), and brain natriuretic peptide (BNP), but lower blood oxygen saturation and vaccination rate (P < 0.05). The severe group had a higher incidence of consolidation, multi-lobe involvement, interlobular septal thickening, air bronchogram sign, and pleural effusion compared to the mild/moderate group (P < 0.05). Moreover, the PI total score of severe patients was 16.4 ± 3.8, significantly higher than 8.5 ± 3.8 of milder patients (P < 0.001). The developed predictive nomogram, which includes four clinical characteristics and one CT feature, exhibited good performance in predicting severe COVID-19 with an area under the ROC (AUC) of 0.98 (95% CI, 0.97-1.00) in the training dataset, and 0.97 (95% CI, 0.94-1.00) in the validation dataset.Conclusions The combination predictive model, including CT score, clinical factors, and laboratory data, shows favorable predictive efficacy for severe COVID-19, which could potentially aid clinicians in triaging emergency patients.

Role of chest CT scan in patients with preexisting cancer and COVID-19 pneumonia.

BACKGROUND: Detection of COVID-19 in cancer patients is challenging due to probable preexisting pulmonary infiltration caused by many infectious and non-infectious etiologies. We evaluated chest CT scan findings of COVID-19 pneumonia in cancer patients and explored its prognostic role in mortality. METHODS: We studied 266 COVID-19 patients with a history of cancer diagnosis between 2020 and 2022. Chest CT images were reported based on Radiological Society of North America (RSNA) structural report and the CT score and pattern of involvement were noted. We used multivariate logistic regression models to determine the association between CT scan findings and mortality of the cancer COVID-19 patients. RESULTS: The mean age was 56.48 (± 18.59), and 53% were men. Gastrointestinal (29.3%), hematologic (26.3%), and breast (10.5%) cancers were the most frequent types of cancer. The prevalence of atypical or indeterminate findings in the chest CT was 42.8%. Most radiologic findings were consolidation mixed with ground-glass opacity (44.4%), pleural effusion (33.5%), and pure ground-glass opacity (19.5%). The risk of death was higher among those who had typical chest CT for COVID-19 (OR 3.47; 95% CI 1.14-8.98) and those who had a severity of score higher than 18 (OR 1.89; 95% CI 1.07-3.34). Also, presence of consolidation (P value 0.040), pleural effusion (P value 0.000), centrilobular nodules (P value 0.013), and architectural distortion (P value 0.005) were associated with a poorer prognosis. CONCLUSION: Less than half of COVID-19 patients with a history of cancer had typical imaging features of COVID-19. Radiologists should be aware of atypical, rare, or subtle chest CT findings in patients with pre-existing cancer.

Development and validation of COVID-19 Radiological Risk Score (COVID-RRS): a multivariable radiological score to estimate the in-hospital mortality risk in COVID-19 patients.

OBJECTIVE: To develop and validate in-hospital mortality risk score comprising radiological aberrances in chest computed tomography (CT) performed on admission. PATIENTS AND METHODS: Single-center, longitudinal cohort study in adult patients admitted with Coronavirus Disease 2019 (COVID-19) to our ward. Patients were followed-up during hospitalization until discharge or death. Eligibility criteria for the study comprised positive real-time reverse transcription-polymerase chain reaction test (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and ground-glass opacities in chest CT. In-hospital death was the outcome of interest. Radiological, laboratory, and clinical data were analyzed. Radiological determinants of mortality were used as variables in multivariate logistic regression analysis, and results were used to build a radiological risk score. RESULTS: 371 patients were enrolled in development and validation cohorts (181 and 190 respectively), with a total of 47 non-survivors. Univariate analysis data determined 12 predictive factors (nine risk and three protective). In multivariate analysis, we developed COVID-RRS (COVID-19 Radiological Risk Score) - a radiological score predicting in-hospital COVID-19 mortality risk comprising estimated lung involvement percentage, pleural effusion, and domination of consolidation-type changes in chest CT. Our score was superior in the prediction of COVID-19 mortality to the percentage of lung involvement alone, Chest Computed Tomography Severity Score (CTSS), and Total Severity Score (TSS) in both groups with AUC of 0.910 and 0.902, respectively (p <0.001). CONCLUSIONS: Additional imaging features independently contribute to COVID-19 mortality risk. Our model comprising lung involvement estimation, pleural effusion, and domination of consolidations performed significantly better than scores based on the extent of the changes alone. COVID-RRS is a simple, reliable, and ready-to-use tool for clinical practice.

Severity Tomographic Score as a Predictor of Mortality in Patients With Covid-19 Pneumonia From a Third-level Hospital in Peru (preprint)

Objective: Determine whether the tomographic characteristics of patients with COVID-19 pneumonia at the hospital admission and the initial tomographic severity score (TSS) as well as some laboratory tests or clinical characteristics predict mortality. Methods: Retrospective analytical study that included patients with a clinical diagnosis of SARSCoV2 virus infection, performed by reverse transcriptase polymerase chain reaction (RT-PCR), serologic reactive test (IgM/IgG) and/or thoracic computed tomography (CT). Patients were divided into two groups: recovered and deceased. Two radiologists (blind evaluators) described the tomographic findings. TSS, clinical and laboratory parameters in relation to mortality were analyzed. Mortality predictions were made by binary logistic regression. Results: Hypertension was the most frequent associated disease, the most common clinical presentation included cough, discomfort, fever, and dyspnea. The ground glass opacity pattern was the most frequent, followed by consolidation and distortion of the architecture; however, they were not associated with higher mortality. The pattern of pleural effusion and bronchial dilation showed a significant difference from mortality (p <0.05). The binary logistic regression model showed that a moderate and high TSS (≥ 8), as well as a higher degree of lymphopenia, history of asthma and age were associated with an increased risk of death (p< 0.05). Conclusions: TSS is useful in the initial and comprehensive diagnostic evaluation of COVID-19 pneumonia, in conjunction with markers such as lymphopenia that can predict a poor short-term outcome. A high TSS score is a predictor of mortality.

Capillary Leak Syndrome after SARS-CoV-2 Infection and COVID-19 Vaccines: A Comparative Review (preprint)

Systemic capillary leak syndrome (SCLS) is an uncommon, potentially life-threatening disorder defined as recurrent attacks of pseudo-shock. This syndrome occurs due to the disruption of endothelial cells, which leads to increased vascular permeability, causing intravascular fluid to leak into the extravascular space and albumin to be retained in the interstitial space. SCLS can lead to hypovolemia, peripheral hypoperfusion, and acute renal insufficiency. The syndrome is presented with fever, generalized edema, pleural effusions, dyspnea, hypovolemia, hemoconcentration, prerenal azotemia, shock, and syncope. After ruling out other causes of hypovolemic shock, the diagnosis of SCLS can be considered on the presence of the classical triad of hypotension, hemoconcentration, and hypoalbuminemia. Eliminating the precipitating factors is the cornerstone of SCLS management. It is advisable to be very cautious and weigh the risks and benefits of vaccination of people with a history of this condition. This review will discuss and compare different aspects of SLCS after SARS-CoV-2 infection and COVID-19 vaccination.

Surgical Management of Pneumothorax and Pleural Space Disease.

Pleural space diseases constitute a wide range of benign and malignant conditions, including pneumothorax, pleural effusion and empyema, chylothorax, pleural-based tumors, and mesothelioma. The focus of this article is the surgical management of the 2 most common pleural disorders seen in modern thoracic surgery practice: spontaneous pneumothorax and empyema.

Primary Cardiac Angiosarcoma With Pulmonary Metastasis in a Young Female: A Case Report and Review of Literature (preprint)

Background: Sarcomas are the most prevalent type of malignant primary cardiac tumor. Clinical presentation differs according to the size and location of the tumor and involvement  of other structures. Case presentation: In this article, we present a 38 years old lady as a case of primary cardiac angiosarcoma with a huge challenge in diagnosis and management of the disease. On the 4th of June 2020, she emergently presented to the hospital with the chief complaint of cough and tachypnea, diarrhea, and malaise, and a history of blunt chest trauma three weeks ago. Based on the presentation and transthoracic echocardiography which was compatible with cardiac tamponade, emergent pericardiocentesis was performed. The first imaging showed bilateral pleural effusion, pericardial effusion, and no significant parenchymal lung involvement, which was not compatible with rheumatologic diseases or COVID-19. Based on cardiac CT angiography and evidence of dye entrance to the peri-right atrial area, right atrial free wall rupture was suspected as the cause of the massive pericardial effusion. Following multidisciplinary consensus, she underwent cardiac surgery; in addition to the 3*3 cm right atrium free wall rupture repair, concomitant sampling from the lung nodules, lymph nodes, pericardium, and also the surrounding tissue of the right atrium ruptured defect was performed. Based on immunohistochemistry, the diagnosis was compatible with cardiac angiosarcoma with metastasis to the lung. Due to the advanced stage of the tumor, oncologists advised against chemotherapy or radiotherapy and she went through palliative care. Finally, after a 53-day ICU stay and due to right-sided heart failure, the patient unfortunately died. Conclusion: COVID-19 pandemic has brought diagnostic challenges regarding differentiating SARS-CoV-2 infection from other diagnostic entities. On the other hand, due to the rarity and fatality of primary cardiac angiosarcomas, early diagnosis and possible management seem crucial for prolonged survival. Involving cardiac angiosarcoma in the initial differential diagnosis could warrant timely diagnosis and assessment of various therapies for cure or palliative care.