A practical update on the management of patients with COVID-19.

While vaccines against COVID-19 are being rolled out, an ongoing need remains for therapies to treat patients who have symptomatic COVID-19 before vaccination or in whom breakthrough infection develops. Dexamethasone and interleukin-6 inhibitors have been the mainstay of treatment for severe to critical COVID-19 requiring hospitalisation. However, in the previous few months, several therapies have been approved in the UK for hospitalised and non-hospitalised patients with COVID-19. In particular, the development of neutralising monoclonal antibodies and novel antivirals represents a welcome expansion in the armamentarium against COVID-19, not only therapeutically to reduce mortality but also because they can be used in mild or moderate disease to prevent hospitalisation. This update is based on guidance from NHS England as well as the World Health Organization, and provides practical support and guidance to all clinicians involved or interested in the management of COVID-19 patients, whether based in community, outpatient or inpatient settings.

Pneumomediastinum in the COVID-19 era: to drain or not to drain?

Pneumomediastinum (PNM) is a rare clinical finding, usually with a benign course, which is managed conservatively in the majority of cases. However, during the COVID-19 pandemic, an increased incidence of PNM has been observed. Several reports of PNM cases in COVID-19 have been reported in the literature and were managed either conservatively or surgically. In this study, we present our institutional experience of COVID-19 associated PNM, propose a management algorithm, and review the current literature. In total, 43 Case Series were identified, including a total of 747 patients, of whom 374/747 (50.1%) were intubated at the time of diagnosis, 168/747 (22.5%) underwent surgical drain insertion at admission, 562/747 (75.2%) received conservative treatment (observation or mechanical ventilation. Inpatient mortality was 51.8% (387/747), while 45.1% of the population recovered and/or was discharged (337/747). In conclusion, with increased incidence of PNM in COVID-19 patients reported in the literature, it is still difficult to assign a true causal relationship between PNM and mortality. We can, however, see that PMN plays an important role in disease prognosis.  Due to increased complexity, high mortality, and associated complications, conservative management may not be sufficient, and a surgical approach is needed.

A case of Bartonellosis presenting as a puzzling multisystem disorder complicated by nosocomial COVID-19 infection.

The most commonly considered infection with a Bartonella species is cat-scratch disease caused by Bartonella henselae Here, we discuss a unique case of a 60-year-old man who presented with Bartonella infection complicated by nosocomial COVID-19. He was admitted with a history of chest pain, persistent fever, rash and influenza-like symptoms. Positive Bartonella serology confirmed diagnosis and the patient developed complications of pericardial effusion in addition to COVID-19 infection, requiring non-invasive ventilation and admission to the intensive care unit. We discuss his symptoms, investigations, treatment and outcomes, while also highlighting the challenges of assessing patients presenting with fever of unknown origin during the COVID-19 pandemic.

Early prognostication of COVID-19 to guide hospitalisation versus outpatient monitoring using a point-of-test risk prediction score.

INTRODUCTION: Risk factors of adverse outcomes in COVID-19 are defined but stratification of mortality using non-laboratory measured scores, particularly at the time of prehospital SARS-CoV-2 testing, is lacking. METHODS: Multivariate regression with bootstrapping was used to identify independent mortality predictors in patients admitted to an acute hospital with a confirmed diagnosis of COVID-19. Predictions were externally validated in a large random sample of the ISARIC cohort (N=14 231) and a smaller cohort from Aintree (N=290). RESULTS: 983 patients (median age 70, IQR 53-83; in-hospital mortality 29.9%) were recruited over an 11-week study period. Through sequential modelling, a five-predictor score termed SOARS (SpO2, Obesity, Age, Respiratory rate, Stroke history) was developed to correlate COVID-19 severity across low, moderate and high strata of mortality risk. The score discriminated well for in-hospital death, with area under the receiver operating characteristic values of 0.82, 0.80 and 0.74 in the derivation, Aintree and ISARIC validation cohorts, respectively. Its predictive accuracy (calibration) in both external cohorts was consistently higher in patients with milder disease (SOARS 0-1), the same individuals who could be identified for safe outpatient monitoring. Prediction of a non-fatal outcome in this group was accompanied by high score sensitivity (99.2%) and negative predictive value (95.9%). CONCLUSION: The SOARS score uses constitutive and readily assessed individual characteristics to predict the risk of COVID-19 death. Deployment of the score could potentially inform clinical triage in preadmission settings where expedient and reliable decision-making is key. The resurgence of SARS-CoV-2 transmission provides an opportunity to further validate and update its performance.

Rapid onsite evaluation uses a very small proportion of total material aspirated at endobronchial or endoscopic ultrasound in the investigation of suspected thoracic malignancy.

INTRODUCTION: The objectives were: to measure the proportion of aspirated material used to make direct slides for rapid onsite evaluation (ROSE) at endobronchial (EBUS) and endoscopic ultrasound (EUS) in suspected thoracic malignancy; and to correlate pass weights with ROSE category and needle size. METHOD: All EBUS and EUS cases for possible thoracic malignancy October 2018-May 2019 were included. All material from each pass was expelled into a Petri dish. One drop of material was placed on each of two slides; one used for ROSE, the other fixed and remaining material processed to cell block. Dish and slides were weighed before and after this procedure on a sensitive balance and weight of aspirate and slide material calculated. When ROSE identified malignancy, slide production ceased but target sampling for ancillary studies continued. RESULTS: ROSE accuracy was 96.8%. Mean percentage by target of aspirated material used to make direct slides for ROSE was 1.9% in malignant cases and 3.6% in non-malignant cases (P = .027 for difference). Mean percentage by pass was 5.9%. Mean weight of a single aspirate was 128.8 mg. Mean weight of aspirates insufficient on ROSE (175.7 mg) was significantly higher than the mean weight of benign or malignant aspirates (117.1 and 114.0 mg, respectively). Mean weight of aspirates using 22G needles (132.6 mg) was significantly higher than that for 25G needles (87.1 mg). CONCLUSION: Material made into direct slides at EBUS and EUS and used in part for ROSE uses a tiny proportion of aspirated material with over 98% processed to cell block and available for ancillary testing in malignant cases.

Pulmonary MALToma Synchronous with Metastatic Prostate Adenocarcinoma: A Diagnostic Challenge.

OBJECTIVE: We describe the novel case of a patient presenting with pulmonary mucosa-associated lymphoid tissue lymphoma (pMALToma) synchronous with metastatic prostate adenocarcinoma. MATERIALS AND METHODS: We report the clinical, laboratory, radiological and histological findings of the above patient. RESULTS: While the patient's metastatic prostate adenocarcinoma responded well to chemo-radio-hormonal therapy, a persistent area of lung consolidation was noted and further investigated, leading to the diagnosis of concurrent pMALToma. CONCLUSION: It is important to pursue further investigation when there appears to be persistent change or altered disease response in malignancy if there is evidence for disease response elsewhere, as there may be two synchronous primary cancers. LEARNING POINTS: This is a novel case where pulmonary mucosa-associated lymphoid tissue lymphoma (pMALToma), a rare disease entity, presented synchronously and asymptomatically in a patient with metastatic prostate adenocarcinoma.From an instructive errors perspective, it is important to consider synchronous primary malignancy and pursue further investigations, as appropriate, when there appears to be persistent change or altered disease response if there is evidence for disease response elsewhere.

Successful endobronchial ultrasound-guided transbronchial needle aspiration of tumour thrombus in the left pulmonary vein to achieve histological diagnosis.

A symptomatic 66-year-old gentleman presented with a large left upper lobe mass, thought likely to be malignant. Further imaging suggested direct tumour extension into the left pulmonary vein. During a subsequent EBUS (endobronchial ultrasound) histological diagnosis was not achieved from sampling higher order lymph nodes, thus intra-procedurally the decision to sample, by Transbronchial Needle Aspiration (TBNA), an area thought to relate to tumour thrombus in the left pulmonary vein was taken. A diagnosis of a non-small cell lung cancer was made on histological testing of the tumour thrombus sample. Considering the bleeding risk, direct probe contact with the endobronchial wall was maintained for several minutes but no bleeding was observed. There were no complications as a result of the procedure. It may be safe to sample tumour thrombus from within a pulmonary vein via EBUS-TBNA to achieve positive histology.

A Young Woman With Severe Chest Pain After Undergoing Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for a Large Mediastinal Mass.

A 33-year-old woman with chest pain and hemoptysis was found to have a large mediastinal mass. As the radiology imagings were inconclusive, she underwent diagnostic endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). After the procedure she developed mediastinitis, which required video-assisted thoracoscopic surgery excision and intravenous antibiotics. Bronchogenic cysts are rare congenital anomalies. Traditionally, surgical resection has been recommended as the first-line treatment option for both symptomatic and asymptomatic bronchogenic cysts due to concerns of late complications, including malignant transformation. Recently, there have been a number of case reports of bronchogenic cysts been diagnosed and treated successfully using EBUS-TBNA. We present a case in which EBUS-TBNA was performed for a definitive diagnosis of cystic lesion in the mediastinum.