Chylothorax due to hepatic alveolar echinococcosis with infiltration of diaphragm and left pleura: a case report.

BACKGROUND: Alveolar echinococcosis (AE) is an endemic parasitic zoonosis in Germany. In most cases, the liver is the primary organ affected. CASE PRESENTATION: A 59-year old female patient presented with increasing exertional dyspnea and unintentional weight loss. A computed tomography (CT) scan showed a left-sided chylous pleural effusion and multiple intrahepatic masses with infiltration of the diaphragm and the pleura. The findings were initially misinterpreted as hepatocellular carcinoma (HCC) with infiltrating growth. Liver biopsy of one of the masses showed no evidence of malignancy, but an amorphous necrosis of unclear origin. HCC was further ruled out by magnetic resonance imaging (MRI). However, MRI findings were highly suspicious for hepatothoracic dissemination and complications due to AE. Typical histologic findings in a repeated and more specific examination of the liver tissue and a positive serology for echinococcosis confirmed the diagnosis of AE. As the hepatic and pulmonary manifestations were considered inoperable in a curative matter, an anti-parasitic treatment with albendazole was initiated. A video-assisted thoracoscopic surgery (VATS) with removal of the chylous effusion as well as a talc pleurodesis was performed to relieve the patient from dyspnea. Two months later, the patient was asymptomatic and a positron emission tomography (PET)-CT-scan with [18 F] fluoro-2-deoxy-d-glucose (FDG) showed a remarkable diminution of the hepatic manifestation. CONCLUSIONS: This case demonstrates a rare presentation of alveolar echinococcosis with a focus on pulmonary symptoms, emphasizing the importance of evaluation for pulmonary involvement in patients with AE and respiratory symptoms.

Pleural fluid cytology in prompt diagnosis of pleuro-pulmonary nocardiosis masquerading as COVID-19.

Introduction: There are few reports of nocardial infections among the Indian population. We report this case because of its rarity and unique presentation and to highlight the role of cytology in diagnosis. Case Details: A 74-year-old woman presented with fever and chest pain of a duration of 15 days. In view of the coronavirus disease (COVID) pandemic, she was given steroids. She developed breathlessness and was referred to a tertiary care hospital. Her pleural fluid cytology showed filamentous bacteria. A diagnosis of nocardia was confirmed by culture. Discussion: Nocardiosis refers to the localized or disseminated infection caused by filamentous aerobic bacteria of the genus Nocardia. The clinical presentation of nocardiosis is highly variable. In our case, clinical misdiagnosis as COVID-19 and steroid treatment would have caused deterioration of nocardiosis. Conclusion: All patients with pulmonary symptoms should be thoroughly evaluated before considering a diagnosis of COVID-19. Pleural fluid cytology can be of help in the diagnosis of nocardiosis.

Ultrasound findings of lung ultrasonography in COVID-19: A systematic review.

PURPOSE: To identify the defining lung ultrasound (LUS) findings of COVID-19, and establish its association to the initial severity of the disease and prognostic outcomes. METHOD: Systematic review was conducted according to the PRISMA guidelines. We queried PubMed, Embase, Web of Science, Cochrane Database and Scopus using the terms ((coronavirus) OR (covid-19) OR (sars AND cov AND 2) OR (2019-nCoV)) AND (("lung ultrasound") OR (LUS)), from 31st of December 2019 to 31st of January 2021. PCR-confirmed cases of SARS-CoV-2 infection, obtained from original studies with at least 10 participants 18 years old or older, were included. Risk of bias and applicability was evaluated with QUADAS-2. RESULTS: We found 1333 articles, from which 66 articles were included, with a pooled population of 4687 patients. The most examined findings were at least 3 B-lines, confluent B-lines, subpleural consolidation, pleural effusion and bilateral or unilateral distribution. B-lines, its confluent presentation and pleural abnormalities are the most frequent findings. LUS score was higher in intensive care unit (ICU) patients and emergency department (ED), and it was associated with a higher risk of developing unfavorable outcomes (death, ICU admission or need for mechanical ventilation). LUS findings and/or the LUS score had a good negative predictive value in the diagnosis of COVID-19 compared to RT-PCR. CONCLUSIONS: The most frequent ultrasound findings of COVID-19 are B-lines and pleural abnormalities. High LUS score is associated with developing unfavorable outcomes. The inclusion of pleural effusion in the LUS score and the standardisation of the imaging protocol in COVID-19 LUS remains to be defined.

Novel technique for parietal pleural dissection using a laparoscopic hernia balloon.

We describe a novel technique for the creation of a pleural tent and pleurectomy via the use of a laparoscopic hernia balloon. In this method a Spacemaker™ Structural Balloon Trocar (Covidien, USA) is tunnelled under the pleura at the site of thoracotomy or video assisted thoracoscopic surgery port and incrementally inflated under vision. This method is less traumatic than traditional methods, is more likely to provide an intact pleural tent, and allows the surgeon to operate in a near bloodless operative field.

The Value of Lung Ultrasound to Detect the Early Pleural and Pulmonary Pathologies in Nonhospitalized COVID-19-Suspected Cases in a Population With a Low Prevalence of COVID-19 Infection: A Prospective Study in 297 Subjects.

OBJECTIVES: This prospective study aimed to evaluate the value of B-mode lung ultrasound (LUS) for the early diagnosis of coronavirus disease 2019 (COVID-19) infection in nonhospitalized COVID-19 suspected cases in a population with a low prevalence of disease. METHODS: From April 2020 to June 2020, in an ambulatory testing center for COVID-19-suspected cases, 297 subjects were examined by LUS before a nasopharyngeal swab was taken for a reverse transcription polymerase chain reaction (RT-PCR) test. The following LUS findings were defined as pathological ultrasound findings and were analyzed: the presence of 1) pleural effusion, 2) B-lines, 3) fragmented visceral pleura, 4) consolidation, and 5) air bronchogram in the consolidation. The LUS findings were compared with the RT-PCR test results. RESULTS: The result of the RT-PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive in 11 and negative in 286 subjects, and the prevalence of COVID-19 infection in the study participants was 3.7%. On LUS, a pathological finding could be detected in 56/297 (18.9%) study participants. The LUS revealed a sensitivity of 27.3%, a specificity of 81.5%, a positive predictive value of 5.4%, a negative predictive value of 96.7%, and a diagnostic accuracy of 79.9% for the identification of COVID-19 infection. CONCLUSIONS: For the identification of COVID-19 infection, LUS is highly sensitive to the patient spectrum and to the prevalence of the disease. Due to the low diagnostic performance in nonhospitalized COVID-19 cases in low-prevalence areas, LUS cannot be considered to be an adequate method for making a diagnosis in this group.

Tension hydrothorax in a patient with SARS-CoV-2 pneumonitis and pleural Mycobacterium tuberculosis.

Unilateral pleural effusions are uncommonly reported in patients with SARS-CoV-2 pneumonitis. Herein, we report a case of a 42-year-old woman who presented to hospital with worsening dyspnoea on a background of a 2-week history of typical SARS-CoV-2 symptoms. On admission to the emergency department, the patient was severely hypoxic and hypotensive. A chest radiograph demonstrated a large left-sided pleural effusion with associated contralateral mediastinal shift (tension hydrothorax) and typical SARS-CoV-2 changes within the right lung. She was treated with thoracocentesis in which 2 L of serosanguinous, lymphocyte-rich fluid was drained from the left lung pleura. Following incubation, the pleural aspirate sample tested positive for Mycobacterium tuberculosis This case demonstrates the need to exclude non-SARS-CoV-2-related causes of pleural effusions, particularly when patients present in an atypical manner, that is, with tension hydrothorax. Given the non-specific symptomatology of SARS-CoV-2 pneumonitis, this case illustrates the importance of excluding other causes of respiratory distress.

[Ultrasound in the management of the critically ill patient with SARS-CoV-2 infection (COVID-19): narrative review]. / Ecografía en el manejo del paciente crítico con infección por SARS-CoV-2 (COVID-19): una revisión narrativa.

The clinical picture of SARS-CoV-2 infection (COVID-19) is characterized in its more severe form, by an acute respiratory failure which can worsen to pneumonia and acute respiratory distress syndrome (ARDS) and get complicated with thrombotic events and heart dysfunction. Therefore, admission to the Intensive Care Unit (ICU) is common. Ultrasound, which has become an everyday tool in the ICU, can be very useful during COVID-19 pandemic, since it provides the clinician with information which can be interpreted and integrated within a global assessment during the physical examination. A description of some of the potential applications of ultrasound is depicted in this document, in order to supply the physicians taking care of these patients with an adapted guide to the intensive care setting. Some of its applications since ICU admission include verification of the correct position of the endotracheal tube, contribution to safe cannulation of lines, and identification of complications and thrombotic events. Furthermore, pleural and lung ultrasound can be an alternative diagnostic test to assess the degree of involvement of the lung parenchyma by means of the evaluation of specific ultrasound patterns, identification of pleural effusions and barotrauma. Echocardiography provides information of heart involvement, detects cor pulmonale and shock states.

The Significance of Subpleural Sparing in CT Chest: A State-of-the-Art Review.

The subpleural sparing pattern is a common finding on computed tomography (CT) of the lungs. It comprises of pulmonary opacities sparing the lung peripheries, typically 1cm and less from the pleural surface. This finding has a variety of causes, including idiopathic, inflammatory, infectious, inhalational, cardiac, traumatic, and bleeding disorders. Specific disorders that can cause subpleural sparing patterns include nonspecific interstitial pneumonia (NSIP), organizing pneumonia (OP), pulmonary alveolar proteinosis (PAP), diffuse alveolar hemorrhage (DAH), vaping-associated lung injury (VALI), cracked lung, pulmonary edema, pneumocystis jirovecii pneumonia (PJP), pulmonary contusion, and more recently, Coronavirus disease 2019 (COVID-19) pneumonia. Knowledge of the many etiologies of this pattern can be useful in preventing diagnostic errors. In addition, although the etiology of subpleural sparing pattern is frequently indistinguishable during an initial radiologic evaluation, the differences in location of opacities in the lungs, as well as the presence of additional radiologic findings, patient history, and clinical presentation, can often be useful to suggest the appropriate diagnosis. We did a comprehensive search on Pubmed and Google Scholar database using keywords of "subpleural sparing," "peripheral sparing," "sparing of peripheries," "CT chest," "chest imaging," and "pulmonary disease." This review aims to describe the primary differential diagnosis of subpleural sparing pattern seen on chest imaging with a strong emphasis on clinical and radiographic findings. We also discuss the pathogenesis and essential clues that are crucial to narrow the differential diagnosis.

Automatic Pleural Line Extraction and COVID-19 Scoring From Lung Ultrasound Data.

Recent works highlighted the significant potential of lung ultrasound (LUS) imaging in the management of subjects affected by COVID-19. In general, the development of objective, fast, and accurate automatic methods for LUS data evaluation is still at an early stage. This is particularly true for COVID-19 diagnostic. In this article, we propose an automatic and unsupervised method for the detection and localization of the pleural line in LUS data based on the hidden Markov model and Viterbi Algorithm. The pleural line localization step is followed by a supervised classification procedure based on the support vector machine (SVM). The classifier evaluates the healthiness level of a patient and, if present, the severity of the pathology, i.e., the score value for each image of a given LUS acquisition. The experiments performed on a variety of LUS data acquired in Italian hospitals with both linear and convex probes highlight the effectiveness of the proposed method. The average overall accuracy in detecting the pleura is 84% and 94% for convex and linear probes, respectively. The accuracy of the SVM classification in correctly evaluating the severity of COVID-19 related pleural line alterations is about 88% and 94% for convex and linear probes, respectively. The results as well as the visualization of the detected pleural line and the predicted score chart, provide a significant support to medical staff for further evaluating the patient condition.

Detection of Line Artifacts in Lung Ultrasound Images of COVID-19 Patients Via Nonconvex Regularization.

In this article, we present a novel method for line artifacts quantification in lung ultrasound (LUS) images of COVID-19 patients. We formulate this as a nonconvex regularization problem involving a sparsity-enforcing, Cauchy-based penalty function, and the inverse Radon transform. We employ a simple local maxima detection technique in the Radon transform domain, associated with known clinical definitions of line artifacts. Despite being nonconvex, the proposed technique is guaranteed to convergence through our proposed Cauchy proximal splitting (CPS) method, and accurately identifies both horizontal and vertical line artifacts in LUS images. To reduce the number of false and missed detection, our method includes a two-stage validation mechanism, which is performed in both Radon and image domains. We evaluate the performance of the proposed method in comparison to the current state-of-the-art B-line identification method, and show a considerable performance gain with 87% correctly detected B-lines in LUS images of nine COVID-19 patients.

Management of Persistent Pneumothorax With Thoracoscopy and Bleb Resection in COVID-19 Patients.

Several studies have been published describing the clinical and radiographic findings of coronavirus disease 2019-related pneumonia. Therefore, there is currently a lack of pathologic data on its effects in intubated patients. Pneumothorax may occur rarely and results from a combination of fibrotic parenchyma and prolonged high-pressure ventilation. Chest drainage represents first-line treatment. However, in cases of persistent pneumothorax, thoracoscopy and bleb resection may be feasible options to reduce air leak and improve ventilation. This report describes the cases of 2 patients with coronavirus disease 2019 who were successfully treated with thoracoscopy, bleb resection, and pleurectomy for persistent pneumothorax.

Lung ultrasound predicts clinical course and outcomes in COVID-19 patients.

PURPOSE: Information regarding the use of lung ultrasound (LUS) in patients with Coronavirus disease 2019 (COVID-19) is quickly accumulating, but its use for risk stratification and outcome prediction has yet to be described. We performed the first systematic and comprehensive LUS evaluation of consecutive patients hospitalized with COVID-19 infection, in order to describe LUS findings and their association with clinical course and outcome. METHODS: Between 21/03/2020 and 04/05/2020, 120 consecutive patients admitted to the Tel Aviv Medical Center due to COVID-19, underwent complete LUS within 24 h of admission. A second exam was performed in case of clinical deterioration. LUS score of 0 (best)-36 (worst) was assigned to each patient. LUS findings were compared with clinical data. RESULTS: The median baseline total LUS score was 15, IQR [7-20]. Baseline LUS score was 0-18 in 80 (67%) patients, and 19-36 in 40 (33%) patients. The majority had patchy pleural thickening (n = 100; 83%), or patchy subpleural consolidations (n = 93; 78%) in at least one zone. The prevalence of pleural thickening, subpleural consolidations and the total LUS score were all correlated with severity of illness on admission. Clinical deterioration was associated with increased follow-up LUS scores (p = 0.0009), mostly due to loss of aeration in anterior lung segments. The optimal cutoff point for LUS score was 18 (sensitivity = 62%, specificity = 74%). Both mortality and need for invasive mechanical ventilation were increased with baseline LUS score > 18 compared to baseline LUS score 0-18. Unadjusted hazard ratio of death for LUS score was 1.08 per point [1.02-1.16], p = 0.008; Unadjusted hazard ratio of the composite endpoint (death or need for invasive mechanical ventilation) for LUS score was 1.12 per point [1.05-1.2], p = 0.0008. CONCLUSION: Hospitalized patients with COVID-19, at all clinical grades, present with pathological LUS findings. Baseline LUS score strongly correlates with the eventual need for invasive mechanical ventilation and is a strong predictor of mortality. Routine use of LUS may guide patients' management strategies, as well as resource allocation in case of surge capacity.

Comparison of Chest CT Manifestations of Coronavirus Disease 2019 (COVID-19) and Pneumonia Associated with Lymphoma.

Objective: To retrospectively compare the clinical features and chest computed tomography (CT) characteristics of coronavirus disease 2019 (COVID-19) and pneumonia in lymphoma patients. Materials and Methods: Ten lymphoma patients with pneumonia and 12 patients with COVID-19 infections were enrolled from January 15 to March 14, 2020. The clinical features were recorded. All pulmonary lesions on chest CT were assessed for location, shape, density and diffusion degree. Other typical CT features were also evaluated. Results: The most commonly observed patchy lesions were ground-glass opacities (GGOs) and mixed GGOs in both groups. Regarding the diffusion degree, 82% (92/112) of the lesions in the COVID-19 group were relatively limited, while 69% (52/75) of those in the lymphoma group were diffuse (p < 0.001). The proportions of interlobular septal thickening, vascular thickening, pleural involvement and fibrous stripes observed in the lymphoma cases were statistically compatible with those observed in the COVID-19 cases (p > 0.05). Air bronchograms were observed more frequently in COVID-19 patients (45%, 50/112) than in lymphoma patients with pneumonia (5%, 4/75) (p < 0.001). Halo sign (6%) and reversed halo sign (1%) were observed in several COVID-19 patients but not in lymphoma-associated pneumonia patients. Conclusion: Both lymphoma-associated pneumonia and COVID-19 generally manifested as patchy GGOs and mixed GGOs in more than one lobe. Compared to COVID-19, lymphoma-associated pneumonia tended to be relatively diffuse, with fewer air bronchograms, and no halo or reversed halo signs observed on chest CT.

Late histological findings in symptomatic COVID-19 patients: A case report.

RATIONALE: Although there have been several studies describing clinical and radiographic features about the novel coronavirus (COVID-19) infection, there is a lack of pathologic data conducted on biopsies or autopsies. PATIENT CONCERNS: A 56-year-old and a 70-year-old men with fever, cough, and respiratory fatigue were admitted to the intensive care unit and intubated for respiratory distress. DIAGNOSIS: The nasopharyngeal swab was positive for COVID-19 and the chest Computed Tomography (CT) scan showed the presence of peripheral and bilateral ground-glass opacities. INTERVENTIONS: Both patients developed pneumothoraces after intubation and was managed with chest tube. Due to persistent air leak, thoracoscopies with blebs resection and pleurectomies were performed on 23rd and 16th days from symptoms onset. OUTCOMES: The procedures were successful with no evidence of postoperative air-leak, with respiratory improvement. Pathological specimens were analyzed with evidence of diffuse alveolar septum disruption, interstitium thickness, and infiltration of inflammatory cells with diffuse endothelial dysfunction and hemorrhagic thrombosis. LESSONS: Despite well-known pulmonary damages induced by the COVID-19, the late-phase histological changes include diffused peripheral vessels endothelial hyperplasia, in toto muscular wall thickening, and intravascular hemorrhagic thrombosis.

CT features of coronavirus disease 2019 (COVID-19) pneumonia: experience of a single center in Southern Italy.

PURPOSE: The aim of this study was to report the radiological features of chest CT scan of patients with coronavirus disease 2019 (COVID-19) living in a town in Southern Italy where a significant outbreak of the disease occurred. METHODS: We revised the CT scan of 62 patients (34 male, 28 female, mean age 71 +/- 14 years) with clinical and laboratory signs of COVID-19, as assessed by positive SARS-CoV-2 RT-PCR testing. All patients underwent chest CT at the time of admission to the hospital. A semi-quantitative scoring system was used to evaluate the extension of the disease. RESULTS: Out of the 62 patients the main radiological findings were reticular pattern (29%), ground-glass opacities (24%), crazy paving pattern (11%) and consolidation (35%). Most of the lesions were bilateral (97%), posterior (95%) and located near pleura (50%) or lung fissures (45%), mainly involving the lower right lobe (56%) and lower left lobe (23%). Pleural thickening was observed in 72.6% of patients and pleural effusion in 18%. Median value of the score was 7.0 and was significantly higher in male than female (8.5 vs 6.0, p=0.03) and in patients with pleural thickening compared to those without this finding (8.0 vs 5.0, p=0.03).

The association of lung ultrasound images with COVID-19 infection in an emergency room cohort.

Lung ultrasound could facilitate the triage of patients with suspected COVID-19 infection admitted to the emergency room. We developed a predictive model for COVID-19 diagnosis based on lung ultrasound and clinical features. We used ultrasound to image the lung bilaterally at two anterior sites, one and two hands below each clavicle, and a posterolateral site that was the posterior transverse continuation from the lower anterior site. We studied 100 patients, 31 of whom had a COVID-19 positive reverse transcriptase polymerase chain reaction. A positive test was independently associated with: quick sequential organ failure assessment score ≥1; ≥3 B-lines at the upper site; consolidation and thickened pleura at the lower site; and thickened pleura line at the posterolateral site. The model discrimination was an area (95%CI) under the receiver operating characteristic curve of 0.82 (0.75-0.90). The characteristics (95%CI) of the model's diagnostic threshold, applied to the population from which it was derived, were: sensitivity, 97% (83-100%); specificity, 62% (50-74%); positive predictive value, 54% (41-98%); and negative predictive value, 98% (88-99%). This model may facilitate triage of patients with suspected COVID-19 infection admitted to the emergency room.

The pulmonary sequalae in discharged patients with COVID-19: a short-term observational study.

BACKGROUND: A cluster of patients with coronavirus disease 2019 (COVID-19) pneumonia were discharged from hospitals in Wuhan, China. We aimed to determine the cumulative percentage of complete radiological resolution at each time point, to explore the relevant affecting factors, and to describe the chest CT findings at different time points after hospital discharge. METHODS: Patients with COVID-19 pneumonia confirmed by RT-PCR who were discharged consecutively from the hospital between 5 February 2020 and 10 March 2020 and who underwent serial chest CT scans on schedule were enrolled. The radiological characteristics of all patients were collected and analysed. The total CT score was the sum of non-GGO involvement determined at discharge. Afterwards, all patients underwent chest CT scans during the 1st, 2nd, and 3rd weeks after discharge. Imaging features and distributions were analysed across different time points. RESULTS: A total of 149 patients who completed all CT scans were evaluated; there were 67 (45.0%) men and 82 (55.0%) women, with a median age of 43 years old (IQR 36-56). The cumulative percentage of complete radiological resolution was 8.1% (12 patients), 41.6% (62), 50.3% (75), and 53.0% (79) at discharge and during the 1st, 2nd, and 3rd weeks after discharge, respectively. Patients ≤44 years old showed a significantly higher cumulative percentage of complete radiological resolution than patients > 44 years old at the 3-week follow-up. The predominant patterns of abnormalities observed at discharge were ground-glass opacity (GGO) (125 [83.9%]), fibrous stripe (81 [54.4%]), and thickening of the adjacent pleura (33 [22.1%]). The positive count of GGO, fibrous stripe and thickening of the adjacent pleura gradually decreased, while GGO and fibrous stripe showed obvious resolution during the first week and the third week after discharge, respectively. "Tinted" sign and bronchovascular bundle distortion as two special features were discovered during the evolution. CONCLUSION: Lung lesions in COVID-19 pneumonia patients can be absorbed completely during short-term follow-up with no sequelae. Two weeks after discharge might be the optimal time point for early radiological estimation.