Interim Analysis of Impact of Adding Low Dose Pulmonary Radiotherapy to Moderate COVID-19 Pneumonia Patients: IMpaCt-RT Study.

Background: Treatment for coronavirus disease 2019 (COVID-19) pneumonia remains largely supportive till date and multiple clinical trials took place within the short span of time to evaluate the role of investigational therapies. The anti-inflammatory effect of low dose whole lung radiation in treating pneumonia has been documented earlier. This clinical trial analyzed the effect of low dose radiation therapy (LDRT) in a moderately affected COVID-19 pneumonia patient cohort and has evaluated its effect in stopping the conversion of moderate disease into severe disease. Methods: Patients with moderate COVID-19 pneumonia as characterized by the Ministry of Health and Family Welfare (MOHFW), Government of India, were randomized (1:1) to low dose whole lung radiation versus no radiation. All treatment of patients was concurrently being given as per institutional protocol. Patients were followed up with clinical and laboratory parameters monitored on Days 1, 3, 7, and 14. Computed tomography scan (CT scan) of thorax was performed on Days 1 and 7. Patients were evaluated for conversion of moderate into severe disease as per National Early Warning Score-2 (NEWS-2 score) as the primary end point. The secondary endpoints included changes in ratio between peripheral capillary oxygen saturation and fraction of inspired oxygen (SpO2/FiO2), biochemical markers, 25-point CT severity score, and radiation induced acute pulmonary toxicities. Findings: At the interim analysis, there were seven patients in the radiation arm and six in the control. A whole lung LDRT improved the outcome of SpO2/FiO2 at Day 3; however it did not convert into a statistically significant improvement for the NEWS-2 score. The serum levels of LDH, CRP, Ferritin and D-dimer were significantly reduced on 14 days in the LDRT arm in comparison to the baseline value but were not significant between the two groups. Interpretation: LDRT seems to have the potential to prevent moderate COVID-19 pneumonia from a deteriorating to severe category. However, further randomized clinical trial with an adequate number of such patients is warranted to establish the definitive role of LDRT in the management of COVID-19 pneumonia. Funding: An intramural research project bearing code: I-27/621, was sanctioned from the All India Institute of Medical Sciences, Patna, India. Clinical Trial Registration: Clinical Trials Registry-India (CTRI/2021/06/033912, 25th May 2021) ctri.nic.in/Clinicaltrials/login.php.

A rare case report of tracheobronchial aspergillosis with endobronchial aspergilloma in a patient clinically recovered from COVID-19.

The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has led to an increased incidence of fungal infections. However, pulmonary infections are rare. COVID-associated pulmonary aspergillosis has been reported; however, there is no prior report of tracheobronchial aspergillosis with endobronchial aspergilloma as per the authors' literature search. We report such a case of a 65-year-old male with radiology and biopsy-proven endobronchial aspergilloma upon a background of tracheobronchial and pulmonary aspergillosis after having recovered clinically from severe COVID-19 disease.

Interim Analysis of Impact of Adding Low Dose Pulmonary Radiotherapy to Moderate COVID-19 Pneumonia Patients: IMpaCt-RT Study

Background Treatment for coronavirus disease 2019 (COVID-19) pneumonia remains largely supportive till date and multiple clinical trials took place within the short span of time to evaluate the role of investigational therapies. The anti-inflammatory effect of low dose whole lung radiation in treating pneumonia has been documented earlier. This clinical trial analyzed the effect of low dose radiation therapy (LDRT) in a moderately affected COVID-19 pneumonia patient cohort and has evaluated its effect in stopping the conversion of moderate disease into severe disease. Methods Patients with moderate COVID-19 pneumonia as characterized by the Ministry of Health and Family Welfare (MOHFW), Government of India, were randomized (1:1) to low dose whole lung radiation versus no radiation. All treatment of patients was concurrently being given as per institutional protocol. Patients were followed up with clinical and laboratory parameters monitored on Days 1, 3, 7, and 14. Computed tomography scan (CT scan) of thorax was performed on Days 1 and 7. Patients were evaluated for conversion of moderate into severe disease as per National Early Warning Score-2 (NEWS-2 score) as the primary end point. The secondary endpoints included changes in ratio between peripheral capillary oxygen saturation and fraction of inspired oxygen (SpO2/FiO2), biochemical markers, 25-point CT severity score, and radiation induced acute pulmonary toxicities. Findings At the interim analysis, there were seven patients in the radiation arm and six in the control. A whole lung LDRT improved the outcome of SpO2/FiO2 at Day 3;however it did not convert into a statistically significant improvement for the NEWS-2 score. The serum levels of LDH, CRP, Ferritin and D-dimer were significantly reduced on 14 days in the LDRT arm in comparison to the baseline value but were not significant between the two groups. Interpretation LDRT seems to have the potential to prevent moderate COVID-19 pneumonia from a deteriorating to severe category. However, further randomized clinical trial with an adequate number of such patients is warranted to establish the definitive role of LDRT in the management of COVID-19 pneumonia. Funding An intramural research project bearing code: I-27/621, was sanctioned from the All India Institute of Medical Sciences, Patna, India. Clinical Trial Registration Clinical Trials Registry-India (CTRI/2021/06/033912, 25th May 2021) ctri.nic.in/Clinicaltrials/login.php

Radiological Lung Sequelae of Severe COVID-19: A Retrospective Observational Study From a Dedicated COVID Centre of Eastern India.

BACKGROUND: The pulmonary sequelae of severe COVID-19 infection are yet to be fully defined. The authors undertook this study to find out the proportion of severe COVID-19 patients having fibrosis-like lung sequelae during a medium-term follow-up period. MATERIALS AND METHODS: This was a retrospective observational study from a dedicated COVID centre of Eastern India. Severe COVID-19 patients who had undergone chest computerized tomography (CT) during the acute phase of illness and at least one follow-up CT with a gap of minimum two months between the two scans were included in the study. RESULT: A total of 39 patients who had recovered from severe COVID-19 pneumonia and presented to the pulmonary medicine OPD in the months of July and August 2021 were included. Patients with pre-existing lung disease (n-4), mild to moderate (n-11), and due to unavailability of CT scan (n-2) were excluded. A total of 22 patients (thirteen males, nine females) were thus included for analysis. Follow-up scans were performed with a mean of 2.5 months after the onset of the disease. Out of 22 patients, only one patient's follow-up scan was normal. Predominant fibrotic-like features were present in six (27.2%) patients, though some evidence of fibrosis-like changes were seen in 20 out of 22 (90.9%) patients. The remaining 15 (68.2%) patients with abnormal scans had predominant non-fibrotic changes like ground-glass opacities (GGOs), consolidation, cavity, or nodule. The most common presenting symptoms at the follow-up examination were dyspnoea (81.8%), cough (54.1%) followed by fatigue in 40.9% of patients. CONCLUSION: This study concluded that most of the severe COVID-19 patients have some residual radiological findings during medium-term follow-up. Fibrotic-like lesions are present in almost all patients but most of them get resolved with time. True fibrotic features like honeycombing are rarely seen as residual lung sequelae.

Endovascular thrombectomy for critical lower limb ischaemia in a patient with COVID-19.

Hypercoagulable and proinflammatory states induced by the novel coronavirus (SARS-CoV-2) lead to thrombotic and embolic events. In this case report, the authors describe how they successfully managed acute critical limb ischaemia in a patient of COVID-19 illness with severe pulmonary disease and high thrombus burden in the infrapopliteal arteries.

Post-COVID-19 pulmonary fibrosis: A case series and review of literature.

The most common lung problem faced by a post-COVID patient is lung fibrosis. Clinical recovery is generally complete in mild-to-moderately severe COVID-19 cases but a small proportion of patients with severe disease may go on to develop lung fibrosis. Patient groups at the highest risk to develop lung fibrosis are the elderly, especially those requiring ICU stay and mechanical ventilation. No definitive therapy for managing this pulmonary fibrosis exists as of date, even though various options are being explored. This case series highlights three cases of post-COVID lung fibrosis and reviews the existing literature.

Acute Necrotizing Encephalitis as a Probable Association of COVID-19.

BACKGROUND: Meanwhile, over 50 lakh people have now been affected by coronavirus disease-2019 (COVID-19) across the globe. There are various reports on neurological manifestations of COVID-19, which have attracted broad attention. Acute necrotizing encephalopathy (ANE) is a rare complication of influenza and other viral infections and has been related to intracranial cytokine storm, which results in breach in blood-brain barrier leading to encephalitis like presentation. We report an unusual case of acute necrotizing encephalitis as a solitary presentation of COVID-19. CASE DESCRIPTION: We report a case of 35-year-old man from Bihar, presented to our emergency department in unconscious state, with high-grade fever and vomiting since last 5 days. Previous magnetic resonance imaging (MRI) brain showed a left parasellar-middle cranial fossa mass looks most likely like an invasive meningioma. Urgent noncontrast computed tomography scan (NCCT) brain showed that mass as well as hypodensities in both thalami and left caudate nucleus. As per our institutional protocol, clinical management of raised intracranial pressure was initiated. As there is no current evidence from any randomized control trails (RCTs) to recommend any specific treatment for suspected or confirmed patients with COVID-19 with acute necrotizing encephalitis. CONCLUSION: Our case highlights the importance of identifying encephalitis as a presenting sign of COVID-19 based on NCCT findings with normal cerebrospinal fluid (CSF) and normal chest X-ray (CXR) findings. HOW TO CITE THIS ARTICLE: Kumar N, Kumar S, Kumar A, Pati BK, Kumar A, Singh C, et al. Acute Necrotizing Encephalitis as a Probable Association of COVID-19. Indian J Crit Care Med 2020;24(10):991-994.