[Cavitary lung lesions in COVID-19 associated pneumonia: a single-center study of 40 cases]. / Polostnye obrazovaniya legkikh pri COVID-19-assotsiirovannoi pnevmonii.

OBJECTIVE: To demonstrate clinical features and outcomes in patients with cavitary lung lesions and COVID-19 associated pneumonia. MATERIAL AND METHODS: A retrospective analysis of electronic medical records of 8261 patients with COVID-19 was performed. We selected 40 patients meeting the inclusion criteria. Sex, age, hospital-stay, lung tissue lesion, comorbidities, treatment, methods of respiratory support, complications and outcomes were evaluated. RESULTS: Cavitary lung lesions were more common in men (67.5%). Age of patients ranged from 28 to 88 (mean 64.9±13.7) years. Hospital-stay in patients with cavitary lung lesions was 9-58 (median 27.5) days. There were 18 complications in 14 (35%) patients. Pneumothorax, isolated pneumomediastinum, pleural empyema, hemoptysis and sigmoid colon perforation were considered as complications of cavitary lung lesions. Nine (22.5%) patients died (5 of them with complications). Three patients died after surgical treatment. Long-term results were analyzed in 8 (25.8%) patients. Patients were followed-up for 3 months after discharge. Shrinkage of lesions occurred after 7-60 (mean 23) days, and complete obliteration of cavities came after 32 (range 14-90) days. CONCLUSION: Cavitary lung lesions are a rare complication of COVID-19 pneumonia. There was no significant correlation of complications with age, sex, therapy, volume of lung lesions and non-invasive ventilation (NIV). Despite more common fatal outcomes in older patients undergoing NIV, the last one was prescribed exclusively due to disease progression and respiratory failure. Further research on this problem is necessary to identify possible risk factors of cavitary lung lesions.

[Risk factors of pulmonary cavitation in COVID-19 pneumonia]. / Faktory riska poyavleniya polostnykh obrazovanii legkikh pri COVID-19-pnevmonii.

OBJECTIVE: To identify the risk factors of pulmonary cavitation in COVID-19 pneumonia. MATERIAL AND METHODS: A retrospective study included 8261 patients with COVID-19 between April 2020 and March 2022. Inclusion criteria: age >18 years, COVID-19 confirmed by polymerase chain reaction. Two cohorts of patients were formed: 40 patients with pulmonary cavitation and 40 patients without these lesions. Both groups were comparable in age, lung lesion volume and oxygenation. Sex, age, length of hospital-stay, CT grade of lung lesion, comorbidities, treatment, respiratory support, oxygen saturation and in-hospital outcomes were evaluated. The highest lung lesion volume during hospitalization was assessed. CT was performed upon admission and approximately every 5 days for evaluation of treatment. Statistical analysis was performed using the IBM SPSS Statistics software (IBM Corporation, USA). RESULTS: Patients with pulmonary cavitation significantly differed in age, SpO2, lung lesion volume, more common non-invasive ventilation and prolonged hospital-stay. Cardiovascular diseases were more common in both groups. Univariate logistic regression analysis revealed age, cardiovascular diseases, CT-based severity of lung damage, absence of biological therapy and non-invasive ventilation as risk factors of pulmonary cavitation. According to multivariate logistic regression analysis, these predictors were CT-based severity of lung damage and absence of biological therapy. Univariate logistic regression analysis showed that pulmonary cavitation had no significant effect on mortality (OR=2.613, 95% CI: 0.732-9.322, p=0.139). CONCLUSION: The risk of pulmonary cavitation in COVID-19 is directly related to advanced lung damage and untimely or absent biological therapy with IL-6 inhibitors. Pulmonary cavitation in COVID-19 is not a typical manifestation of disease and can be caused by some factors: fungal infection, secondary bacterial infection, tuberculosis and pulmonary infarction. Further study of this problem is required to develop diagnostic algorithms and treatment tactics.

Lung Adenocarcinoma Mimicking a Bilateral Cavitary Pneumonia.

Teaching Point: Failure to recognize unusual radiological presentations of some lung adenocarcinomas can lead to misdiagnosis and/or delay appropriate treatment.

Cavidades pulmonares en Lupus Eritematoso Sistémico / Lung cavities in Systemic Lupus Erythematosus

Las lesiones pulmonares cavitadas en pacientes con Lupus Eritematoso Sistémico (LES) han sido descriptas en asociación con neumonitis por citomegalovirus, o secundarias a infecciones fúngicas. Haciendo una revisión en la literatura, se han descripto 13 casos de pacientes con estas lesiones. Presentamos cuatro pacientes con diagnóstico de LES, que durante la evolución de su enfermedad desarrollan cavidades pulmonares.

Cavitary lung lesions in patients with SLE have been described in association with cytomegalovirus pneumonitis, or secondary to fungal infections. Making a review in the literature, 13 cases of patients with these lesions have been described. We present four patients diagnosed with SLE, whom developed lung cavities during the evolution of the disease.

Cavidades pulmonares en Lupus Eritematoso Sistémico / Pulmonary cavities in Systemic Lupus Erythematosus

Las lesiones pulmonares cavitadas en pacientes con Lupus Eritematoso Sistémico (LES) han sido descriptas en asociación con neumonitis por citomegalovirus, o secundarias a infecciones fúngicas. Haciendo una revisión en la literatura, se han descripto 13 casos de pacientes con estas lesiones. Presentamos cuatro pacientes con diagnóstico de LES, que durante la evolución de su enfermedad desarrollan cavidades pulmonares.

Cavitary lung lesions in patients with SLE have been described in association with cytomegalovirus pneumonitis, or secondary to fungal infections. Making a review in the literature, 13 cases of patients with these lesions have been described. We present four patients diagnosed with SLE, whom developed lung cavities during the evolution of the disease.

Lung cavities in chronic thromboembolic pulmonary hypertension

OBJECTIVES: Chronic thromboembolic pulmonary hypertension (CTEPH) is a unique form of pulmonary hypertension (PH) that arises from obstruction of the pulmonary vessels by recanalized thromboembolic material. CTEPH has a wide range of radiologic presentations. Commonly, it presents as main pulmonary artery enlargement, peripheral vascular obstructions, bronchial artery dilations, and mosaic attenuation patterns. Nevertheless, other uncommon presentations have been described, such as lung cavities. These lesions may be solely related to chronic lung parenchyma ischemia but may also be a consequence of concomitant chronic infectious conditions. The objective of this study was to evaluate the different etiologies that cause lung cavities in CTEPH patients. METHODS: A retrospective data analysis of the medical records of CTEPH patients in a single reference PH center that contained or mentioned lung cavities was conducted between 2013 and 2016. RESULTS: Seven CTEPH patients with lung cavities were identified. The cavities had different sizes, locations, and wall thicknesses. In two patients, the cavities were attributed to pulmonary infarction; in 5 patients, an infectious etiology was identified. CONCLUSION: Despite the possibility of being solely associated with chronic lung parenchyma ischemia, most cases of lung cavities in CTEPH patients were associated with chronic granulomatous diseases, reinforcing the need for active investigation of infectious agents in this setting.

Frequency of Circulating CD4+Ki67+HLA-DR- T Regulatory Cells Prior to Treatment for Multidrug Resistant Tuberculosis Can Differentiate the Severity of Disease and Predict Time to Culture Conversion.

Identifying a blood circulating cellular biomarker that can be used to assess severity of disease and predict the time to culture conversion (TCC) in patients with multidrug resistant tuberculosis (MDR-TB) would facilitate monitoring response to treatment and may be of value in the design of future drug trials. We report on the frequency of blood Ki67+HLA-DR- CD4+ T regulatory (Treg) cells in predicting microbiological outcome before initiating second-line treatment for MDR-TB. Fifty-one patients with MDR-TB were enrolled and followed over 18 months; a subset of patients was sputum culture (SC) negative at baseline (n = 9). SC positive patients were divided into two groups, based on median TCC: rapid responders (≤71 days TCC; n = 21) and slow responders (>71 days TCC; n = 21). Whole blood at baseline, months 2 and 6 was stimulated with M tuberculosis (Mtb) antigens and Treg cells were then identified as CD3+CD4+CD25hiFoxP3+CD127-CD69- and further delineated as Ki67+HLA-DR- Treg. The frequency of these cells was significantly enlarged at baseline in SC positive relative to SC negative and smear positive relative to smear negative patients and in those with lung cavitation. This difference was further supported by unsupervised hierarchical clustering showing a significant grouping at baseline of total and early differentiated memory Treg cells in slow responders. Conversely, there was a clustering of a lower proportion of Treg cells and activated IFNγ-expressing T cells at baseline in the rapid responders. Examining changes over time revealed a more gradual reduction of Treg cells in slow responders relative to rapid responders to treatment. Receiver operating curve analysis showed that baseline Mtb-stimulated Ki67+HLA-DR- Treg cells could predict the TCC of MDR-TB treatment response with 81.2% sensitivity and 85% specificity (AUC of 0.87, p < 0.0001), but this was not the case after 2 months of treatment. In conclusion, our data show that the frequency of a highly defined Mtb-stimulated blood Treg cell population at baseline can discriminate MDR-TB disease severity and predict time to culture clearance.

Performance of computed tomography versus chest radiography in patients with pulmonary tuberculosis with and without diabetes at a tertiary hospital in Riyadh, Saudi Arabia.

BACKGROUND: Prior research suggests that diabetes mellitus (DM) is associated with increasing risk for developing cavitary lung disease in patients with pulmonary tuberculosis (TB). Additionally, chest computed tomography (CT) scan may be more sensitive than chest X-ray in detecting cavitary disease in such patients. The aim of this study was to compare the performance of chest CT to chest X-ray in detecting cavitary lung disease and to compare the frequency of cavities between TB patients with DM and without DM. PATIENTS AND METHODS: We conducted a retrospective cohort study at King Fahad Medical City, Riyadh, Saudi Arabia, from January 2004 to December 2015. We included patients aged 18 years and older with a positive sputum culture for Mycobacterium tuberculosis, and their medical charts were reviewed from admission to discharge. RESULTS: Of the 133 patients who met the inclusion criteria, 38 (28.6%) patients were known to have DM and were compared with 95 (71.4%) patients without DM. DM patients with glycated hemoglobin (HbA1c) >6.5% had significantly more cavitary lesions when compared to all patients (with or without DM) with HbA1c <6.4% and/or random blood sugar <200 mg/dL. Furthermore, CT was able to detect lung cavities in 58.8% of the patients who had negative chest X-ray findings for cavities. CONCLUSION: The presence of lung cavities was significantly associated with the presence of DM and levels of HbA1c in patients with pulmonary TB. CT scan in those with normal radiography increased the detection of cavities.

Tuberculosis de tipo adulto en los niños / Adult-type tuberculosis in children

One of the fascinating aspects of childhood tuberculosis (TB) is the diverse spectrum of pathology, which necessitates accurate disease classification. This manuscript provides a brief overview of the disease diversity observed in children with TB, with particular emphasis on adult-type TB. Cavitary disease in children may result from three distinct pathologic processes; 1) poor containment within the Ghon focus (mainly very young and/or immune compromised children), 2) aspiration of virulent bacilli following eruption of a diseased lymph node into an airway with resultant caseating pneumonia and parenchymal destruction (mainly children < 5 yrs of age), and 3) from adulttype disease (mainly children > 10 yrs of age). The exact pathological mechanism underlying adult-type disease remains uncertain. The combination of a destructive cell mediated immune response together with increased organism survival and proliferation in the lung apices, may initiate a vicious circle of parenchymal destruction. This hypothesis may explain the sudden emergence of adult-type disease around puberty, as well as the typical anatomical location of the lung cavities. Most children with adult-type disease are sputum smear-positive and can be diagnosed with routine sputum smear microscopy at primary health care level. Due to the high organism load the same treatment rationale used in adults with sputum smear-positive TB would apply, which justifies the use of four drugs during the initial intensive phase. These children pose a considerable transmission risk, particularly in congregate settings such as schools, and screening of close contacts should also be considered

Uno de los aspectos fascinantes de la tuberculosis (TB) infantil es el amplio espectro de las alteraciones histopatológicas, lo que requiere una clasificación precisa de los hallazgos. Este manuscrito proporciona un breve panorama general de la diversidad de presentaciones clínicas observadas en los niños con TB y hace hincapié particularmente en la TB que imita las formas del adulto. La enfermedad cavitaria en los niños puede ser el resultado de tres procesos anatomopatológicos distintos: 1) la escasa limitación dentro del foco de Ghon (principalmente en los niños muy pequeños o inmunocomprometidos), 2) la aspiración de bacilos virulentos luego de la erupción de una adenopatía en una vía aérea con neumonía caseosa consiguiente y destrucción del parénquima (principalmente en los menores de 5 años) y 3) la enfermedad de tipo adulto (principalmente en los niños mayores de 10 años). Es incierto aún el mecanismo fisiopatológico exacto subyacente a la enfermedad de tipo adulto. La combinación de una intensa respuesta inmune mediada por células junto con la mayor supervivencia y proliferación del microorganismo en los vértices pulmonares puede iniciar un círculo vicioso de destrucción parenquimatosa. Esta hipótesis puede explicar la aparición súbita de la enfermedad de tipo adulto alrededor de la pubertad, así como la localización anatómica típica de las cavidades pulmonares. La mayoría de los niños con enfermedad de tipo adulto tienen frotis de esputo positivos y el diagnóstico se puede realizar con la microscopia de rutina del frotis de esputo en la atención primaria. Debido a la gran carga de microorganismos se debe aplicar el mismo fundamento terapéutico utilizado en los adultos con TB con frotis de esputo positivo, lo cual justifica el uso de cuatro drogas durante la fase intensiva inicial. Estos niños plantean un riesgo considerable de transmisión, sobre todo en comunidades cerradas como las escuelas y también se debe considerar la pesquisa de los contactos cercanos