Validity of diagnoses of respiratory diseases recorded in a Japanese administrative database.

BACKGROUND: Validating the information recorded in administrative databases is essential. However, no study has comprehensively validated the accuracy of Japanese Diagnosis Procedure Combination (DPC) data on various respiratory diseases. Therefore, this study aimed to evaluate the validity of diagnoses of respiratory diseases in the DPC database. METHODS: We conducted chart reviews of 400 patients hospitalized in the departments of respiratory medicine in two acute-care hospitals in Tokyo, between April 1, 2019 and March 31, 2021, and used them as reference standards. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DPC data on 25 respiratory diseases were determined. RESULTS: Sensitivity ranged from 22.2% (aspiration pneumonia) to 100% (chronic eosinophilic pneumonia and malignant pleural mesothelioma) and was <50% for eight diseases, while specificity was >90% for all diseases. PPV ranged from 40.0% (aspiration pneumonia) to 100% (coronavirus disease 2019, bronchiectasis, chronic eosinophilic pneumonia, pulmonary hypertension, squamous cell carcinoma, small cell carcinoma, lung cancer of other histological types, and malignant pleural mesothelioma) and was >80% for 16 diseases. Except for chronic obstructive pulmonary disease (82.9%) and interstitial pneumonia (other than idiopathic pulmonary fibrosis) (85.4%), NPV was >90% for all diseases. These validity indices were similar in both hospitals. CONCLUSIONS: The validity of diagnoses of respiratory diseases in the DPC database was high in general, thereby providing an important basis for future studies.

Relationship between Anti-SARS-CoV-2 S Abs and IFN-λ3 Levels in the Administration of Oxygen following COVID-19 Vaccination.

Although the effectiveness of vaccination at preventing hospitalization and severe coronavirus disease (COVID-19) has been reported in numerous studies, the detailed mechanism of innate immunity occurring in host cells by breakthrough infection is unclear. One hundred forty-six patients were included in this study. To determine the effects of vaccination and past infection on innate immunity following SARS-CoV-2 infection, we analyzed the relationship between anti-SARS-CoV-2 S Abs and biomarkers associated with the deterioration of COVID-19 (IFN-λ3, C-reactive protein, lactate dehydrogenase, ferritin, procalcitonin, and D-dimer). Anti-S Abs were classified into two groups according to titer: high titer (≥250 U/ml) and low titer (<250 U/ml). A negative correlation was observed between anti-SARS-CoV-2 S Abs and IFN-λ3 levels (r = -0.437, p < 0.001). A low titer of anti-SARS-CoV-2 S Abs showed a significant association with oxygen demand in patients, excluding aspiration pneumonia. Finally, in a multivariate analysis, a low titer of anti-SARS-CoV-2 S Abs was an independent risk factor for oxygen demand, even after adjusting for age, sex, body mass index, aspiration pneumonia, and IFN-λ3 levels. In summary, measuring anti-SARS-CoV-2 S Abs and IFN-λ3 may have clinical significance for patients with COVID-19. To predict the oxygen demand of patients with COVID-19 after hospitalization, it is important to evaluate the computed tomography findings to determine whether the pneumonia is the result of COVID-19 or aspiration pneumonia.

Death of a child following a superstitious ritual of exorcism.

INTRODUCTION: Diseases, especially those related to the psyche produced by demons, are an accepted belief in many communities. This paper elaborates on the death of a child, a victim of an exorcism ritual, and calls for adequate awareness and preventive measures. CASE REPORT: The deceased, a 9-year-old child, was taken by her mother to an exorcist to 'expel a demon from her body. The exorcist caned the child for two days while giving 'water' to drink. On the second day, the child lost consciousness and was pronounced dead on admission. On direct questioning, it was revealed that the child had been made to consume some medicinal syrups forcefully by the mother and the exorcist. The autopsy revealed multiple abrasions, tram-line contusions and burns on the body. There was mottling and consolidation in the lungs. Blood-stained secretions were found in the trachea, bronchi, and stomach. Musculoskeletal dissection revealed subcutaneous haemorrhages and muscular contusions over the buttocks and limbs. Histology revealed evidence of well-established aspiration pneumonia. There was no other significant pathology, especially no evidence of acute kidney injury due to rhabdomyolysis. Toxicological analysis was negative for common poisons, therapeutic drugs, and heavy metals. The cause of death was concluded as aspiration pneumonia in a child subjected to physical violence. CONCLUSION: With the forceful feeding of the syrup, the child can have aspiration, resulting in aspiration pneumonia. At the same time, it appears that even after the child became symptomatic, she had not been brought for medical treatment but had continued with the same exorcistic therapy. While the caregivers become responsible for the child's death, the lessons to be learnt are enormous. Thus, banning such practices against children is a need of the hour.

Electric Cell-Substrate Impedance Sensing (ECIS) as a Platform for Evaluating Barrier-Function Susceptibility and Damage from Pulmonary Atelectrauma.

Biophysical insults that either reduce barrier function (COVID-19, smoke inhalation, aspiration, and inflammation) or increase mechanical stress (surfactant dysfunction) make the lung more susceptible to atelectrauma. We investigate the susceptibility and time-dependent disruption of barrier function associated with pulmonary atelectrauma of epithelial cells that occurs in acute respiratory distress syndrome (ARDS) and ventilator-induced lung injury (VILI). This in vitro study was performed using Electric Cell-substrate Impedance Sensing (ECIS) as a noninvasive evaluating technique for repetitive stress stimulus/response on monolayers of the human lung epithelial cell line NCI-H441. Atelectrauma was mimicked through recruitment/derecruitment (RD) of a semi-infinite air bubble to the fluid-occluded micro-channel. We show that a confluent monolayer with a high level of barrier function is nearly impervious to atelectrauma for hundreds of RD events. Nevertheless, barrier function is eventually diminished, and after a critical number of RD insults, the monolayer disintegrates exponentially. Confluent layers with lower initial barrier function are less resilient. These results indicate that the first line of defense from atelectrauma resides with intercellular binding. After disruption, the epithelial layer community protection is diminished and atelectrauma ensues. ECIS may provide a platform for identifying damaging stimuli, ventilation scenarios, or pharmaceuticals that can reduce susceptibility or enhance barrier-function recovery.

Case Report: Next-Generation Sequencing in Diagnosis of Atypical Aspiration Pneumonia.

Since the pandemic of Corona Virus Disease 2019 (COVID-19), especially in the centers most affected, the symptoms such as fever, cough, myalgia or fatigue, and radioactive signs typically related to COVID-19 like ground-glass opacity (GGO) often distract the attention of physicians from other diseases. Aspiration pneumonia and COVID-19 share similarities in some aspects. There may be risk of misdiagnosis in the case of considering radiological patterns of pneumonia. Early diagnosis and treatment often greatly improve prognosis. We herein reported a case of 40-year-old patient who underwent chest CT scan with the discovery of ground-glass opacity, intralobular reticular opacity and interlobular septal thickening, consolidation, and air bronchogram sign, which were mainly located in the middle and upper lobes of the right lung. It was considered to be infection related pneumonia based on the negative reverse transcription-PCR (RT-PCR) result of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The next-generation sequencing (NGS) of bronchoalveolar lavage fluid (BALF) was performed and detected nucleic acid sequences of Klebsiella sp. Consequently, the patient accepted sensitive intravenous antibiotics therapy for 13 days and had a remarkable clinical and radiological improvement. His case was followed up through imaging procedures. Because of possible radiologic and clinical similarities between aspiration and COVID-19 pneumonia, COVID-19 can be of some value in proposing a differential diagnosis of aspiration pneumonia. Clinicians could suggest a correct diagnosis by careful examination of the CT images together with attention to the clinical history and judicious utilization of NGS, especially.

Sarcopenic dysphagia following COVID-19 infection: A new danger.

Oropharyngeal dysphagia is one of the complications of endotracheal intubation. As expected, cases of dysphagia following coronavirus disease 2019 (COVID-19) reported to date have all been intubated. We here report a case of sarcopenic dysphagia following severe COVID-19 pneumonia in a nonintubated older adult. The patient was an 85-year-old male who was readmitted to the hospital with dysphagia and subsequent aspiration pneumonia in the first week after his discharge from the COVID-19 unit. On physical examination, the patient was sarcopenic and malnourished. Flexible endoscopic evaluation of swallowing (FEES) revealed aspiration into the airway. Enteral feeding was initiated and the infusion rate gradually increased to achieve the desired protein-energy targets. Control FEES 2 months after discharge showed recovery of swallowing function, with no apparent penetration or aspiration. Clinicians caring for patients with COVID-19 should be aware that dysphagia, which is associated with increased mortality in older adults, may occur even in the absence of intubation. We recommend that the evaluation of dysphagia be part of the clinical assessment in older COVID-19 patients with malnutrition or sarcopenia.

Aspiration Pneumonia After External Dacryocystorhinostomy Under Local Anesthesia Without Sedation: A Case Report.

Amid the global coronavirus disease 2019 (COVID-19) outbreak, an 89-year-old male with chronic kidney disease presented with acute dacryocystitis and a persistent dry cough. After a course of antibiotics, external dacryocystorhinostomy was performed under local anesthesia without sedation. During planned hemodialysis in the early hours after the procedure, the patient developed nausea and hematemesis followed by severe dyspnea and hypoxemia. The patient was diagnosed with aspiration pneumonia, a previously unreported complication in lacrimal surgery.

COVID-19 with early neurological and cardiac thromboembolic phenomena--timeline of incidence and clinical features (preprint)

BackgroundAt our tertiary care public hospital, we saw COVID-19 presenting with thromboembolic phenomena, indicating a possible early thrombo-inflammatory pathology. ObjectivesWe documented patients with cardiac and neurological thromboembolic phenomena as a primary presentation of COVID-19, and compared a subset of COVID associated strokes against COVID-19 patients without thrombotic manifestations. MethodsWe included all COVID-Stroke and COVID-ACS (COVID-19, with ischemic arterial stroke/Acute Coronary Syndrome presenting prior to/simultaneous with/within 72 hours of systemic/respiratory COVID manifestations) admitted from April to November 2020. In the nested case control analysis, we used unpaired T-test and chi-square test to study differences between COVID-Strokes (case group) and non-thrombotic COVID controls. Results and ConclusionsWe noted 68 strokes and 122 ACS associated with COVID-19. ACS peaked in May-June, while stroke admissions peaked later in September-October, possibly because severe strokes may have expired at home during the lockdown. In the case-control analysis, cases (n=43; 12F:31M; mean age 51.5 years) had significantly higher D-Dimer values than controls (n=50; 9F:41M; mean age 51.6 years). Mortality was significantly higher in cases (51.2% vs. 26.0%; p = 0.018). We noted 7.5 times higher mortality in cases versus controls even among patients needing minimal oxygen support. Imaging in 37 patients showed both anterior and posterior circulation territories affected in seven, with almost half of Carotid territory strokes being large hemispherical strokes. Additionally, CT/MRI angiography in 28 strokes showed large vessel occlusions in 19 patients. Death in cases thus probably occurred before progression to intense respiratory support, due to severe central nervous system insult. Binary logistic regression analysis showed respiratory support intensity to be the sole independent predictor of mortality among cases. Respiratory distress could have been due to COVID-19 lung infection or aspiration pneumonia resulting from obtunded sensorium. In controls, mortality was predicted by increasing age, female sex, and respiratory support intensity.

Delay of COVID-19 diagnosis due to aspiration pneumonia.

COVID-19 was first confirmed in December 2019 in Wuhan, China and is now spreading worldwide. Diagnosis of COVID-19 is sometimes difficult due to the absence of symptoms and its tendency to be masked by other diseases. In this paper, we report a COVID-19 case in which diagnosis was delayed due to aspiration pneumonia. A 64-year-old man visited our department for evaluation of swallowing function. However, during the examination, the patient aspirated testing food and subsequently developed a fever. Based on his medical history and computed tomography (CT) images, he was diagnosed with aspiration pneumonia and admitted to the hospital to begin treatment. However, after admission, his respiratory condition deteriorated, and the result of a COVID-19 polymerase chain reaction (PCR) test was positive. Previous reports have shown that CT images in cases of COVID-19 pneumonia were normal in the early phase, and abnormalities usually appeared approximately 6-11 days after onset. Common findings of COVID-19 are consolidation, ground-glass opacities, and a distribution of lesions predominantly in the bilateral inferior lung field periphery. It is difficult to differentiate COVID-19 pneumonia from other types of pneumonia; it should therefore be listed as a differential diagnosis during the current pandemic.

The Spectrum of Histopathologic Findings in Lungs of Patients With Fatal Coronavirus Disease 2019 (COVID-19) Infection.

CONTEXT.­: Respiratory failure appears to be the ultimate mechanism of death in most patients with severe coronavirus disease 2019 (COVID-19) infection. Studies of postmortem COVID-19 lungs largely report diffuse alveolar damage and capillary fibrin thrombi, but we have also observed other patterns. OBJECTIVE.­: To report demographic and radiographic features along with macroscopic, microscopic, and microbiologic postmortem lung findings in patients with COVID-19 infections. DESIGN.­: Patients with confirmed COVID-19 infection and postmortem examination (March 2020-May 2020) were included. Clinical findings were abstracted from medical records. Lungs were microscopically reviewed independently by 4 thoracic pathologists. Imaging studies were reviewed by a thoracic radiologist. RESULTS.­: Eight patients (7 men, 87.5%; median age, 79 years; range, 69-96 years) died within a median of 17 days (range, 6-100 days) from onset of symptoms. The median lung weight was 1220 g (range, 960-1760 g); consolidations were found in 5 patients (62.5%) and gross thromboemboli were noted in 1 patient (12.5%). Histologically, all patients had acute bronchopneumonia; 6 patients (75%) also had diffuse alveolar damage. Two patients (25%) had aspiration pneumonia in addition. Thromboemboli, usually scattered and rare, were identified in 5 patients (62.5%) in small vessels and in 2 of these patients also in pulmonary arteries. Four patients (50%) had perivascular chronic inflammation. Postmortem bacterial lung cultures were positive in 4 patients (50%). Imaging studies (available in 4 patients) were typical (n = 2, 50%), indeterminate (n = 1, 25%), or negative (n = 1, 25%) for COVID-19 infection. CONCLUSIONS.­: Our study shows that patients infected with COVID-19 not only have diffuse alveolar damage but also commonly have acute bronchopneumonia and aspiration pneumonia. These findings are important for management of these patients.

COVID-19 and aspiration pneumonia: similar pulmonary findings with different diagnoses. A pitfall in [18F]FDG PET/CT. (preprint)

Since December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a worldwide pandemic. Especially in the centers most affected by the pandemic, symptoms (such as fever, cough, myalgia, or fatigue) and/or radiological signs (such as ground-glass opacity) typically related to COVID-19 often diverted clinicians’ attention from other diseases. Despite the urgency to recognize and cure SARS-CoV-2 infection, a plethora of differential diagnoses must be considered, and other diseases must be equally and promptly treated, as described in this case report.

Posterior circulation stroke presenting as a new continuous cough: not always COVID-19.

A 19-year-old man was admitted with a 2-week history of continuous cough along with a day history of acute onset unsteadiness and hiccups. Given the current pandemic, he was initially suspected to have COVID-19, however he tested negative on two occasions. Subsequent brain magnetic resonance imaging (MRI)confirmed a small left acute and subacute lateral medullary infarction with chest X-ray suggesting aspiration pneumonia with right lower lobe collapse. This is a distinctive case of posterior circulation stroke presenting with a new continuous cough in this era of COVID-19 pandemic. We anticipate based on MRI findings that his persistent cough was likely due to silent aspiration from dysphagia because of the subacute medullary infarction. It is therefore imperative that healthcare workers evaluate people who present with new continuous cough thoroughly to exclude any other sinister pathology. We should also be familiar with the possible presentations of posterior circulation stroke in this pandemic era.

Early onset SARS-CoV-2 pneumonia in a preterm neonate – Probably acquired through vertical transmission (preprint)

With the increasing number of published case reports and studies, probability of newborns acquiring COVID-19 infection through vertical transmission is on rise. Although the modes of transmission for neonatal COVID-19 infection are becoming clearer, the clinical spectrum in the form of radiology and laboratory parameters have still not been studied well. We report a case of a preterm neonate, whose mother had tested positive for COVID-19 infection before delivery. The neonate was asphyxiated and had meconium aspiration syndrome. RT-PCR of her endotracheal secretions for COVID-19 tested positive within 24 hours of life and at 72 hours. The laboratory investigations were suggestive of cytokine storm syndrome (CSS) and the CT scan chest supported the diagnosis of COVID-19 pneumonia. This is probably the youngest neonate with COVID-19 infection showing CSS.  

A 95-year-old patient with unexpected coronavirus disease 2019 masked by aspiration pneumonia: a case report.

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 infection has become a pandemic disease (coronavirus disease 2019). The infection has moved from China to the rest of the world and Italy represents one of the most affected countries. Older adults are more susceptible to develop complications with the consequent highest mortality rates. CASE PRESENTATION: We report a case of a 95-year-old Caucasian woman affected by pneumonia, initially defined as common aspiration pneumonia in a bedridden patient with vascular dementia, which later turned out to be coronavirus disease 2019 pneumonia during the initial spread of severe acute respiratory syndrome coronavirus-2 in our district. Some features of a computed tomography scan of her chest and her clinical history with known dysphagia had led at first to a different diagnosis with a consequent exposure of health professionals to infectious risk in two distinct hospitals. In this case report, we describe the clinical/imaging features of coronavirus disease 2019 pneumonia and the diagnostic process that led to a correct diagnosis in a nonagenarian with multiple comorbidities. CONCLUSIONS: This case report highlights both the possible pitfalls in diagnosing coronavirus disease 2019 pneumonia in very old patients with comorbidities and the greater than expected spread of the infection, even in individuals with reduced interpersonal contacts and no defined epidemiological link.

Case Report of 78 –year-old man with meningitis, Pulmonary Thromboembolism & SARS-Coronavirus-2 infection (preprint)

The novel corona virus infection involve both Central & Peripheral Nervous System . Some of the presentations include: acute cerebrovascular disease, impaired consciousness, transverse myelitis, encephalopathy, encephalitis and epilepsy. Our patient was 78 year –old man with dementia and diabetic nephropathy which was admitted two times for possibly COVID19 infection. At the first hospitalization, the patient is treated with hydroxychloroquine and kaletra based on clinical symptoms and initial laboratory findings due to suspicion of COVID19 . After the negative RT-PCR test of nasopharyngeal sample for covid19 and evidence of aspiration pneumonia in CT scan, the patient was discharged with oral antibiotics. Five weeks later, he was rehospitalized with loss of consciousness, fever and hypoxemia in physical exam he had neck stiffness in all directions, So the CNS infection was suspected, the CSF sample was in favor of aseptic meningitis and second RT-PCR test of nasopharyngeal sample for COVID19 was positive but Brain MRI just showed small vessel disease without evidence of encephalitis. In the second hospitalization, he had acute renal failure, which was treated with supportive care, and also suffered from pulmonary embolism with cavitary lesions in his lungs. Meningitis with pulmonary embolism and acute renal failure have not yet reported. Our patient is the first one, so we decided to share it. This case showed different presentation of COVID19 without typical lung involvement. So we must pay attention to any sign & symptoms in a patient suspected of having a COVID19 .