COVID-19 and severe pulmonary alveolar proteinosis (PAP): A case report.

Background: Pulmonary alveolar proteinosis (PAP) is a rare lung disease that mainly presents with dyspnea. PAP diagnosis can be easily missed in the background of a coronavirus disease 2019 (COVID-19) infection, due to the similarity of their presentation and radiological findings. We present a case report of a post-COVID-19 patient, who later developed severe PAP. Case presentation: A 55-year-old male patient presented to the emergency department with progressive exertional dyspnea and hypoxia following a COVID-19 infection. Chest X-ray showed severe bilateral infiltrates. Patient received multiple courses of broad-spectrum antibiotics and prolonged course of corticosteroids without improvement. "Crazy paving" appearance in a follow up chest computed tomography raised the suspicion of PAP of what was initially thought to be a post-COVID-19 syndrome presentation. A diagnostic segmental bronchioalveolar lavage with a lung biopsy revealed a proteinaceous material filling the alveoli, with a positive periodic acid-Schiff (PAS) stain. Due to severe hypoxia, therapeutic segmental followed by whole lung lavage was performed with significant improvement. Conclusion: Diagnosing PAP is challenging due to the rarity of the disease. An accurate diagnosis of PAP requires a combination of medical history, imaging, and bronchoalveolar lavage staining positive for PAS. Decision whether to treat with a segmental or whole lung lavage is individualized to each patient. Further studies are needed to confirm whether COVID-19 or long-term use of steroids might be contributing to PAP.

Skin Manifestations Among Patients Admitted with COVID-19: A Cross-Sectional Study at a University-Based Tertiary Hospital in Jordan.

Background: COVID-19 pandemic hit the entire world with severe health and economic consequences. Although the infection primarily affected the respiratory system, it was soon recognized that COVID-19 has a multi-systemic component with various manifestations including cutaneous involvement. Objective: The main objective of this study is to assess the incidence and patterns of cutaneous manifestations among moderate-to-severe COVID-19 patients who required hospitalization and whether there was a prognostic indication for cutaneous involvement and the outcome in terms of recovery or death. Methods: This is a cross-sectional observational study that included inpatients who were diagnosed with a moderate or severe COVID-19 infection. The demographic and clinical data of patients were assessed including age, sex, smoking, and comorbidities. All patients were examined clinically for the presence of skin manifestations. Patients were followed for the outcome of COVID-19 infection. Results: A total of 821 patients (356 females and 465 males) aged 4-95 years were included. More than half of patients (54.6%) aged >60 years. A total of 678 patients (82.6%) had at least one comorbid condition, mostly hypertension and diabetes mellitus. Sixty-two patients (7.55%) developed rashes; 5.24% cutaneous and 2.31% oral. The rashes were then grouped into five major types: group A, Exanthema: morbilliform, papulovesicular, varicella-like. Group B, Vascular: Chilblain-like lesions, purpuric/petechial, livedoid lesions. Group C, Reactive erythemas: Urticaria, Erythema multiforme. Group D, other skin rashes including flare-up of pre-existing disease, and O for oral involvement. Most patients (70%) developed rash after admission. The most frequent skin rashes were reactive erythema (23.3%), followed by vascular (20.9%), exanthema (16.3%), and other rashes with flare-ups of pre-existing diseases (39.5%). Smoking and loss of taste were associated with the appearance of various skin rashes. However, no prognostic implications were found between cutaneous manifestations and outcome. Conclusion: COVID-19 infection may present with various skin manifestations including worsening of pre-existing skin diseases.

Subclinical high-resolution chest CT scan features in psoriasis.

BACKGROUND: Although psoriasis is considered a systemic disease, no clear association has been established between psoriasis and lung diseases. This study aims to detect and describe subclinical pulmonary involvement in psoriasis patients with various degrees of cutaneous manifestations. METHODS: Adult psoriasis patients with no known active pulmonary disease or respiratory symptoms were screened for subclinical pulmonary manifestations and possible parenchymal changes using high-resolution computed tomography (HRCT) scan of the chest. Patients were classified according to the severity of skin manifestations. The clinical characteristics and radiographic findings of these patients were evaluated. RESULTS: Fifty-nine patients with psoriasis were included, among which 47 (79.7%) had abnormal HRCT scan features. Micronodules were the most common detected lung lesions (66.1%), followed by nonspecific interstitial changes (32.2%), including pleuro-parenchymal band/atelectasis, scarring, and focal ground-glass opacities. Other HRCT findings included emphysematous changes and calcified granulomas. Abnormal HRCT findings correlated with older age and duration of psoriasis but not with the severity of skin manifestations. CONCLUSIONS: Micronodules and minor focal nonspecific interstitial changes were the most detected lung alterations in patients with psoriasis. These findings of the pilot study highlight a possible pulmonary involvement in patients with psoriasis. Larger multicenter studies are needed to clarify these findings further. LIMITATIONS: A major limitation of the study, is the lack of a control group with similar radiologic findings of different conditions done in the same geographical region.

Pulmonary Barotrauma in COVID-19 Patients: Invasive versus Noninvasive Positive Pressure Ventilation.

PURPOSE: This study aims to determine the incidence and outcome of COVID-19 patients who required positive pressure ventilation (PPV) and subsequently developed pulmonary barotrauma (PBT). Also, to investigate the risk factors and predictors of these complications to better understand the disease pathogenesis. PATIENTS AND METHODS: This retrospective analysis enrolled all adult COVID-19 patients admitted through the period from October 1, 2020, to December 31, 2020. All patients who received any form of PPV were included. Patients were then divided into two groups based on PBT development, including subcutaneous emphysema, pneumothorax, and pneumomediastinum. Medical records of all patients were reviewed. Patients' demographics, laboratory data on admission, respiratory support modes, surgical interventions, and outcomes were collected and analyzed. RESULTS: In the specified period, 1095 patients were hospitalized due to COVID-19 illness. A total of 239 (21.8%) of all admitted patients received PPV. PBT accounted for 21.3% (51/239) of the study cohort. While both groups were equally exposed to the same modes of PPV, receiving invasive ventilation significantly correlated with decreased PBT odds (OR = 0.891; 95% CI, 0.803-0.988; p=0.029). PBT patients were significantly younger (p<0.001). Diabetes mellitus was found to have a protective effect on developing PBT (OR = 0.867; 95% CI, 0.782-0.962), while PO2/FIO2 ratio was inversely associated with higher odds of developing PBT in both univariate and multivariate analyses (p=0.03 and p=0.019, respectively). CONCLUSION: COVID-19-infected patients are at a higher risk of developing PBT. Invasive positive pressure ventilation was associated with less PBT compared to noninvasive ventilation and delaying intubation does not seem to reduce the risk of pulmonary barotrauma.

Viral Clearance Course of COVID-19 Outbreaks.

BACKGROUND: Coronavirus disease 2019 (COVID-19) viral course and behavior remain unpredictable. This study describes incubation time and viral clearance of COVID-19 hospitalized cases in Northern Jordan. METHODS: All COVID-19 confirmed cases hospitalized from March 15 to June 09, 2020, were included. Nasopharyngeal swabs were collected, and COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) was performed every two days in all cases. The viral cure was defined when two negative RT-PCR tests were obtained ≥ 24 hours apart. Viral clearance time (VCT) reflects the time from the first positive nasopharyngeal swab to the first of two consecutive negative tests. RESULTS: In this cohort, a total of 157 patients were included. Most cases resulted from two major outbreaks. The median incubation period was 6 days (IQR, 3-10) and ranged from 1 to 17 days. The median VCT was 13 days (IQR, 7-2) and ranged from 1 to 40 days. Symptomatic presentation and abnormal chest radiograph were predictors for a prolonged VCT (p=0.015 and p=0.014, respectively). The median time of resolution of symptoms was 7 days (IQR, 3-10 days). Most symptomatic cases (91.7%) remained RT-PCR positive for up to 20 days after symptoms resolution, with a median of 13.5 days. VCT significantly correlated with the incubation period (p=0.013). CONCLUSION: Viral cure lagged for as long as 20 days after resolution of symptoms. Continuing with social-distancing, frequent hand hygiene, and wearing facial mask remains essential and is recommended even after clinical resolution of symptoms.

Depression and Coping Among COVID-19-Infected Individuals After 10 Days of Mandatory in-Hospital Quarantine, Irbid, Jordan.

BACKGROUND: In-hospital mandatory quarantine of asymptomatic and symptomatic COVID-19-infected individuals was part of the national control strategy used to prevent the spread of the COVID-19 outbreak in Jordan. This study aims to evaluate depression, associated stressors, and various coping methods used among adult quarantined COVID-19-infected individuals. METHODS: This cross-sectional study included all COVID-19-infected individuals who were obligatorily quarantined at King Abdullah University Hospital, Irbid, Jordan from March 15 to April 20, 2020. Symptoms of depression were assessed using the 9-item Patient Health Questionnaire after 10 days of quarantine. In addition, several questions regarding the patients' sights with the health-care system, and coping methods were added. Demographic characteristics, clinical presentation, and comorbidities were collected from the medical records. RESULTS: Out of 91 quarantined COVID-19 patients, a total of 66 completed the survey, with a participation rate of 72.5%. The majority were relatively young; the mean ± SD age was 35.8 ± 16.2 years (range 18-79), 59.1% were females and 47% were asymptomatic. A considerable proportion of patients (44%) reported symptoms of depression, with 21% were at high risk of major depressive disorder. Depression symptoms were significantly more common among females than males [PHQ-9 score ≥10: 13 (92.9%) vs 1 (7.1%), respectively; p=0.004]. The majority of patients (71.2%) reported having problems with health-care services. Insufficient involvement in making treatment decisions was the most commonly reported concern (59.1%). Patients who reported problems in maintaining privacy, reaching out to their physicians, or receiving conflicting information from the medical staff, had more symptoms of depression compared with the satisfied ones (p<0.05). On the other hand, those who were receiving sufficient support from the family, friends, or medical staff during quarantine, were less likely to have depression symptoms (p<0.05). Furthermore, symptoms of depression were less in patients who stayed in touch with others using phone calls, texting, or social media (p=0.024). CONCLUSION: Symptoms of depression were common among both symptomatic and asymptomatic quarantined COVID-19 patients. The support of family, friends, and medical staff was an essential alleviating factor. Facilitating adequate communication may promote the mental well-being of COVID-19-infected patients and help in reducing the risk of depression during the in-hospital quarantine.

COVID-19 outbreak in Jordan: Epidemiological features, clinical characteristics, and laboratory findings.

BACKGROUND: In March 2020, an outbreak of coronavirus 19 (COVID-19) was detected in the North of Jordan. This retrospective study is the first from Jordan to report the epidemiologic, clinical, laboratory, and radiologic characteristics of COVID-19 infected patients. METHODS: All patients with laboratory-confirmed COVID-19 infection by RT-PCR in the North of Jordan admitted between March 15 and April 2, 2020 were included. The clinical features, radiological, and laboratory findings were reviewed. RESULTS: Of 81 patients affected, 79 (97.5%) shared a common exposure to four recent travelers from endemic areas. The mean age was 40 years. Although about half (44 [54.3%]) were females, symptomatic patients were mostly females (75%). The most common presenting symptoms were nasal congestion, sore throat and dry cough. Less than one-third (31%) had chronic diseases. Although 84% of patients reported receiving Bacille Calmette-Guérin (BCG) vaccination, more asymptomatic patients had BCG than symptomatic (p = 0.017). Almost all patients (97.5%) had an elevated D-dimer level. Erythrocyte sedimentation rate (ESR) and c-reactive protein were elevated in 50% and 42.7% of patients, respectively. High ESR found to be the predictor of abnormal chest radiograph observed in 13 (16%) patients with OR of 14.26 (95% CI 1.37-147.97, p = 0.026). CONCLUSIONS: An outbreak of COVID-19 infection in northern Jordan affected more females and relatively young individuals and caused mainly mild illnesses. The strict outbreak response measures applied at early stages probably contributed to the lenient nature of this outbreak, but the contribution of other factors to such variability in COVID-19 presentation is yet to be explained.

Incidence, Risk Factors, and Outcome of Acute Kidney Injury in the Intensive Care Unit: A Single-Center Study from Jordan.

BACKGROUND: Acute kidney injury (AKI) is a common serious problem affecting critically ill patients in intensive care unit (ICU). It increases their morbidity, mortality, length of ICU stay, and long-term risk of chronic kidney disease (CKD). METHODS: A retrospective study was carried out in a tertiary hospital in Jordan. Medical records of patients admitted to the medical ICU between 2013 and 2015 were reviewed. We aimed to identify the incidence, risk factors, and outcomes of AKI. Acute kidney injury network (AKIN) classification was used to define and stage AKI. RESULTS: 2530 patients were admitted to medical ICU, and the incidence of AKI was 31.6%, mainly in stage 1 (59.4%). In multivariate analysis, increasing age (odds ratio (OR) = 1.2 (95% CI 1.1-1.3), P = 0.0001) and higher APACHE II score (OR = 1.5 (95% CI 1.2-1.7), P = 0.001) were predictors of AKI, with 20.4% of patients started on hemodialysis. At the time of discharge, 58% of patients with AKI died compared to 51.3% of patients without AKI (P = 0.05). 88% of patients with AKIN 3 died by the time of discharge compared to patients with AKIN 2 and 1 (75.3% and 61.2% respectively, P = 0.001). CONCLUSION: AKI is common in ICU patients, and it increases mortality and morbidity. Close attention for earlier detection and addressing risk factors for AKI is needed to decrease incidence, complications, and mortality.

Association of genetic variants with level of asthma control in the Arab population.

BACKGROUND: Rates of asthma in Jordan have been doubled in the past decade, but this increased prevalence was not met with improved asthma control protocols. The aim of the present study was to assess whether there was any significant association between the level of asthma control and certain single-nucleotide polymorphisms (SNPs) in five genes: (ADRB2; rs1042713 and rs1042714), (CRHR1; rs1876828, rs242939, and rs242941), (STIP1; rs2236647), (ADH5, rs1154400), and (ARG1; rs2781659). These SNPs were selected based on their involvement in enzymes and receptors that are related to asthma pathways and subsequent response to medication and based on a high degree of linkage disequilibrium. PATIENTS AND METHODS: A cross-sectional genetic association study was conducted from June 2016 to June 2017 in the two major hospitals in Jordan. The present study involved sampling from adult asthmatic patients of Arab descent who were selected from two phenotypic groups, ie, controlled and uncontrolled asthma. The blood samples and medical data were collected from the participants. DNA samples were extracted, quantified, and genotyped according to standard operating procedure. Allelic and haplotypic analyses were performed using the Haploview®. RESULTS: A total of 245 Arab asthmatic patients were enrolled in this study. Genotyping analysis revealed that the two SNPs (rs1042713 and rs1042714) in ADRB2 gene, along with their related haplotypes, were nominally significantly associated with asthma control in the Jordanian population. The A-allele of rs1042713 and the C-allele of rs1042714 were more common in the uncontrolled asthma group than in the controlled asthma group (P=0.048 and P=0.017, respectively). CONCLUSION: This was the first study that identified the nominal significant association between the level of asthma control and genetic variants in ADRB2 gene in Arab population. Further studies in other Arab region with larger sample size are recommended to confirm the relationship.

Prevalence of undiagnosed COPD in male patients with coronary artery disease: a cross-sectional study in Jordan.

Purpose: COPD and coronary artery disease (CAD) are common chronic diseases with shared risk factors. COPD continues to be largely underdiagnosed and undertreated. We aimed to describe the prevalence and predictors of undiagnosed COPD in Jordanian men with CAD. Patients and methods: In a cross-sectional study conducted at a referral center in Jordan, male patients who underwent coronary angiography for suspected CAD and reported ≥10 pack-year of cigarette smoking were recruited. Pre- and post-bronchodilator spirometry was undertaken for all participants, and COPD was defined as post-bronchodilator FEV1/FVC <70%. The finding of ≥50% coronary luminal narrowing confirmed the presence of CAD. Results: Spirometry was undertaken for 376 men with mean age of 56.02±10.55 years, and 72.6% were active cigarettes smokers with a mean pack-year of 55.89±34.25. A CAD diagnosis was confirmed in 300 (79.8%) men. Spirometric criteria for COPD were met in 76 (15.7%) patients, of whom 91.5% were not previously diagnosed. COPD-related symptoms were common: chronic cough (44.4%), dyspnea (66.2%), and wheezes (27.9%). COPD was more common in patients with (18.0%) compared to patients without (6.6%) CAD (P=0.014). Multivariate logistic regression showed that the risk of COPD was higher in patients with CAD (OR 3.16, 95% CI, 1.10-9.09, P=0.033) and in those with chronic bronchitis (OR 13.07, 95% CI, 6.69-25.52, P<0.001). Conclusion: There was a high prevalence of COPD among male patients with CAD and most were underdiagnosed despite having respiratory symptoms. Male smokers with CAD and respiratory symptoms should be evaluated for airflow limitation and the presence of COPD.

Incidence, Characteristics, and Survival Trend of Cardiopulmonary Resuscitation Following In-hospital Compared to Out-of-hospital Cardiac Arrest in Northern Jordan.

BACKGROUND: Cardiac arrest remains a leading cause of mortality worldwide. Early cardiopulmonary resuscitation (CPR) is the cornerstone intervention to optimize the survival rates. OBJECTIVES: The main aim of this study was to determine and compare the incidence, characteristics, risk factors, and outcomes of CPR in a referral university hospital following in-hospital cardiac arrests (IHCAs) and out-of-hospital cardiac arrest (OHCA) in Northern Jordan. PATIENTS AND METHODS: Retrospective observational study of adults referred to King Abdulla University Hospital who received CPR between January 2014 and January 2015. Data were obtained from the medical recorded of included patients. The primary outcome was survival to hospital discharge. Chi-square and logistic regression analyses were performed to identify risk factors associated with survival to discharge. RESULTS: A total of 79 OHCA and 257 IHCA were included in the study. The overall survival rate for OHCA was 2.97%. The survival rate increased to 4.3% if CPR performed before arriving the hospital. Only 22% of the OHCA cases had CPR performed mainly due to lack of knowledge and skills of bystanders. The survival rate for IHCA was 14.88%. In this study, patient survival was not associated with age, smoking habit, diabetes mellitus, cancer status, hypertension, or heart failure. CONCLUSION: This is the first study to describe the incidence and outcome of adult IHCA and OHCA in Jordan. The findings will serve as a benchmark to evaluate future impact of changes in service delivery, organization, and treatment for OHCA and IHCA. Furthermore, findings will urge the regulatory bodies to establish well-structured Emergency Medical Service system. Educational programs at the national level to improve public awareness of CPR intervention are crucial to improve survival rates.

Candidate gene analysis of asthma in a population of Arab descent: a case-control study in Jordan.

AIM: To evaluate whether SNPs (n = 15) in ten candidate genes (ADRB2, ADH5, ARGI, CRHR1, STIP1, LTA4H, LTC4S, ALOX5, ABCC1 and OATP2B1) are associated with asthma in Jordanian population of Arab descent. METHODS: A case-control study included 245 adult asthmatics and 249 controls. RESULTS: Significant genetic association was identified at the rs2236647 (T/C) SNP in STIP1 and risk of asthma (p < 0.001). The C allele and CC genotype of this SNP were significantly higher in asthmatics compared with controls. The rs1141370 SNP (Val34Met) in ADRB2 is not polymorphic in our cohort. CONCLUSION: The rs2236647 SNP could act as a reliable tool to identify individuals at risk of developing asthma and provision of early intervention in population of Arab descent.

Asthma insights from Jordan: cross-sectional observational study.

OBJECTIVE: The burden of uncontrolled asthma on patients in Jordan is largely unknown. This study assessed different aspects of asthma clinical features: the level of asthma control, its correlation with quality of life, and possible predictors of asthma control. METHODS: Face-to-face interviews with asthmatic patients (≥16 years old) in north Jordan from 2013 to 2014 were conducted. Outcomes measures were assessed using the asthma control test (ACT), the mini asthma quality of life questionnaire (mini-AQLQ), and the Generic health-related quality of life (EQ-5D). The relationship between asthma control and quality of life was examined using Spearman's correlation coefficient. Predictors of asthma control were determined using multivariable logistic regression adjusted for confounders. RESULTS: A total of 255 patients were recruited (mean age 45.16 years, 74.5% female). Approximately one-third of subjects (30.6%; n = 78) had controlled asthma (ACT ≥ 20). A strong correlation between asthma control and both mini-AQLQ and EQ-5D scores was identified (p < 0.001). Subjects who required to step-up treatment (OR = 0.12, 95% CI: 0.02-0.63, p = 0.01) and with acute asthma exacerbation (OR = 0.32, 95% CI: 0.18-0.58, p < 0.001) were independently associated with poor asthma control. CONCLUSIONS: Most of the recruited patients have not achieved optimal asthma control and was associated with low quality of life. The study highlights that even in low-income countries, a simple assessment tool such as the ACT can be utilized to screen and categorize asthma control. This approach would facilitate a better treatment plan and eventually improve asthma control and quality of life in asthma patients.

Resolution of intracardiac and pulmonary thrombi without anticoagulation in a patient with Behçet's disease: a case report.

Intracardiac and pulmonary thrombi are rare but serious manifestations of Behçet's disease, the treatment of such cases is a challenge to the treating physician and use of anticoagulants can hold a great risk to some patients. We report a patient who was found to have multiple right intraventricular and bilateral pulmonary artery thrombi and was clinically diagnosed with Behçet's disease. Early in the course of his treatment, the patient developed massive haemoptysis which precluded the further use of anticoagulants. The patient was treated with immunosuppressants alone and had complete resolution of his symptoms and documented resolution of the thrombi. In a review of the literature, only 3 out of around 50 patients reported to have intracardiac thrombi complicating Behçet's disease were treated without anticoagulants (1, 2) even though there is no clear evidence to support the benefit of anticoagulation to treat arterial or thrombotic lesions (3). We conclude that intracardiac thrombi in patients with Behçet's disease may resolve with immunosuppressants without anticoagulation, which is especially important in patients with contraindication to anticoagulation.