Areas Of Consolidation Research Articles

Clinical Characteristics of Chlamydia psittaci Pneumonia Confirmed by Metagenomic Next-Generation Sequencing

Chlamydia psittaci pneumonia has atypical clinical manifestations and the diagnosis may be missed by traditional methods of microbiological diagnosis. Twelve cases of Chlamydia psittaci pneumonia diagnosed by metagenomic next-generation sequencing (mNGS) in Huizhou Central People's Hospital in China between January 2020 and August 2021 were reviewed and analyzed, retrospectively, using hospital records, the clinical characteristics, treatment, and prognosis. Ten of the 12 cases (83%) were associated with a definite history of bird/poultry contact. Common symptoms included high fever, cough, fatigue, anorexia (12/12, 100%), dyspnea (11/12, 92%), and changes in the level of consciousness and headache (5/12, 42%). There was a marked increase in C-reactive protein and D-dimer levels, but white blood cells and neutrophils were normal or slightly increased. Nine patients (75%) had liver enzyme abnormalities, and six (50%) had cardiac insufficiency and myocardial injury. There was no correlation between the mNGS sequence number of Chlamydia psittaci and the pneumonia severity. The chest imaging manifestations were mainly large areas of consolidation, predominantly in the lower lung lobes. Monotherapies or combinations of doxycycline, moxifloxacin/levofloxacin, and azithromycin were effective for treating Chlamydia psittaci pneumonia. The use of mNGS increases the probability of diagnosing Chlamydia psittaci pneumonia, and good prognosis can be achieved with timely use of appropriate antibiotics.

Clinicoradiological Correlation of Covid19 Patients in Western Uttar Pradesh, India: A Descriptive Study

Abstract: A pilot study of 150 patients at premier medical institute of western Uttar Pradesh, INDIA. The purpose of this pictorial review article is to describe the most common manifestations and patterns of lung abnormality on CXR in COVID-19 in order to equip the medical community in its efforts to combat this pandemic. The varied spectra of COVID-19 presentation included fever, cough, shortness of breath, sore throat etc. Diabetes mellitus, hypertension, COPD/K-Chest and CAD were found as major comorbid conditions. Symptomatic presentation of COVID-19 was observed to be higher in patients with co morbid disease, especially if multiple. HRCT chest in COVID-19 patients had a major diagnostic and prognostic importance as positive CT findings were more prominent in symptomatic patients and co-morbid patients. Clinical symptoms of patients directly correlated with CT severity index. CT imaging was found to be useful in predicting clinical recovery of patients or progression of disease. Introduction: COVID-19 (coronavirus disease 2019) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), declared as a pandemic on 11th March 2020. The chest imaging findings are nonspecific and most commonly show atypical or organizing pneumonia, often with a bilateral, peripheral and bi-basal predominant distribution. Our study is concerned with the data of COVID positive patients admitted in the institute for the period of March 16- May 17, 2020. Aims and Objectives 1) To correlate clinical and radiological spectra of covid positive patients and their final outcome. 2) To describe the spectrum of lung parenchyma changes in the symptomatic as well as asymptomatic in COVID- 19 patients. Review of literature: This case report series presents a summary of key findings frequently associated with COVID-19, which will assist radiologists and clinicians in preliminary clinical evaluation (PCE). Materials and Methods: The data for the study is sourced from clinically suspected patients from the Covid Ward, LLRM Medical College, Meerut,(U.P.),INDIA which were subjected to chest radiography on 60mAh portable X-Ray machine. The patients are followed up to correlate the findings with clinical outcome. The study has been conducted on a minimum of 150 patients with portable Chest X-Ray machine. Observations & Discussion: The most frequent findings encountered are airspace opacities are viz- Hazy pulmonary opacities, Bilateral lower lobe consolidations, Peripheral air space opacities, Uncommon CXR findings, Diffuse air space disease. Conclusion: Based on our study, few inferences have been deduced; A significant proportion of the clinically symptomatic cases shows characteristic radiological changes on chest X-ray and also how chest radiography can be used as a tool not to substitute but supplement RTPCR in evaluation of COVID positive cases. Keywords: Patchy areas of consolidation, shortness of breath, high resolution CT Scan, RTPCR.

701 ECMO assistance during TAVI in high-risk patient with recent COVID-19 pneumonia

Methods and resultsA 87 years old woman, with history of dyslipidemia and permanent Atrial Fibrillation, already undergone full SARS-CoV2 vaccination few months before, referred to our E.R. with complain of dyspnoea and chest pain. COVID-19 molecular test resulted positive and CT Scan of the chest confirmed the presence of several areas of ground-glass opacity and consolidation together with bilateral pleural effusion (right 6 cm with pulmonary atelectasis; left 2 cm), not requiring drainage. Moreover, it showed severe calcification of both the aortic valve and root. Transthoracic echocardiogram showed eccentric LV hypertrophy with diffuse hypokinesia (EF 20–25%), ectatic ascending aorta (45 mm) with severe LF-LG aortic stenosis (AVAi 0.19 cm2) and moderate regurgitation, moderate-severe mitral regurgitation. During hospitalization in the COVID-19 Unit, despite O2 therapy she experienced worsening of the respiratory status with concomitant pulmonary oedema, hypotension and acute kidney injury, requiring administration of i.v. dobutamine and high dose diuretics. After gradual stabilization and COVID-19 negativization on 10th molecular test, she was transferred to our Coronary Care Unit. Coronary angiography showed absence of significant stenoses in the main vessels. In the following days the patient underwent a new clinical deterioration with dyspnoea, hypotension (BP 85/50 mmHg), oliguria and ankle swelling, requiring Ventimask O2 therapy and Dobutamine infusion. Transtoracic echocardiogram confirmed EF of 25% with PASP 30 mmHg. We decided to perform a ‘Rescue’ TAVI procedure, facilitated by extra-corporeal cardiac and respiratory support. CT Angiography of the chest, performed with low-dose contrast injection under amines infusion, showed severly calcific aortic valve with large sizes of the ring (Virtual Basal Ring area 620 mm2, perimeter 91 mm), measures compatible with the largest sizes of TAVI prostheses. After Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) cannulation, we performed the implantation of a 34 mm Evolut R (Medtronic) TAVI prosthesis, post-dilated with 24 mm balloon for under-expansion due to massive calcification. During both self-expandable TAVI delivery and balloon inflation the patient underwent two phases of cardiac arrest, during which the ECMO flow provided a proper circulatory support.ConclusionsSince percutaneous valve replacement the patient’s recovery was fast with rapid ECMO removal and discontinuation of inotropic therapy. Few weeks after discharge, at first follow-up examination, the patient appeared asymptomatic, in excellent clinical conditions. 701 Figure

December 2021 Pulmonary Case of the Month: Interstitial Lung Disease with Red Knuckles

No abstract available. Article truncated after 150 words. History of Present Illness A 56-year-old man was referred for a second opinion on recent onset of diffuse parenchymal lung disease. He had started noting mild dyspnea with yard work approximately in March 2021. His symptoms progressed over the next month with increasing shortness of breath and some fever. He presented to outside emergency department on April 17, 2021 and chest CT showing patchy ground-glass opacities with some areas of irregular consolidation (Figure 1). He was subsequently seen by an outside pulmonologist and started empirically on prednisone (50 mg/day). An outside lung biopsy had been performed which showed nonspecific interstitial pneumonitis. There was some improvement in his symptoms and his prednisone dose was reduced to 20 mg/day; however, his symptoms subsequently worsened with saturations noted to drop to 85% with any ambulation. He also had swelling of his left face and a biopsy of the parotid gland with the findings …

Assessment of forest visitors’ route preferences – Impact encounters across a range of forest environments

Studies of visitors' preferences for forest environments play a central role for the understanding of recreational behaviour. The encounter of other agents, such as wildlife or other visitors, has proven important for preferences, and this is something visitors may affect themselves. Thus, this study focusses on forest visitors’ preferences for forest environments and potential encounters with other agents. 1089 respondents have been asked to consider a choice for change of direction at trail junctions, during a visit to the forest, by ranking five cards representing possible path segments. Each segment constituted a given forest environment (represented by text and a photo) and agent types and numbers (text and an icon), and the direction (text only) – relative to a preferred direction. Results show that on average respondents will detour from their preferred direction, disregarding the forest environment, to experience wildlife. At the other end of the scale, larger groups of mountain bikers or runners can make respondents detour in all forest environments, except for the most preferred ones, to avoid an encounter. Based on a latent class analysis three classes are identified with distinct preferences. 20% of the respondents are unlikely to detour no matter the possible forest environment or agent types. 30% are not affected by encountering other agents, but are to a slight but significant extent affected by the forest environment. The majority, constituting 50% of the population, is strongly influenced by forest environments and even more by potential encounters with other agents. Results largely confirm earlier studies using an ordinal scale, but in addition, we estimate the mutual strength of the preferences and thereby allowing for better guidance of how to manage for forest recreation. In our study, a large group of people state that encountering other types of visitors or wild life matters a lot, and often overrules, the diverse utility of different forest environments. This highlights the necessity of focusing on the management trade-offs between nature conservation and recreational use. One implications of our study relates to path network planning. In areas with less preferred forest environments (e.g. as present in afforestation areas), path segregation may be more important than in the more preferred (e.g. older, more consolidated) areas, where encounters with other visitors have less negative influence on visitors utility.

Diagnostic value of 12-zone lung ultrasound protocol for diagnosing COVID-19-associated pneumonia in outpatients.

Introduction: In the SARS-CoV-2 pandemic, lung ultrasound can be of decisive importance for planning further treatment approach in patients with infection. There is still no clear priority for the choice of lung ultrasound protocol in an outpatient setting. Aim: The objective of the study was to evaluate the applicability of 12-zone protocol lung ultrasound for the diagnosis of COVID-19 associated pneumonia in outpatients. Materials and methods: We examined 39 outpatients meeting the diagnostic criteria of COVID-19 infection (17 men and 22 women) aged 31–75 years (median 49 years). All patients underwent lung ultrasound immediately after chest computed tomography performed by a blinded specialist. Correlation analysis of the results of a quantitative assessment of the detected signs, assessment of the diagnostic significance of lung ultrasound for identifying signs of pneumonia were performed. Results: Pneumonia was diagnosed by computed tomography in 25 (64%; 95% CI 47–79) out of 39 patients. At the same time, ultrasound signs of interstitial abnormalities were detected in 31 patients. Multiple (narrow) B-lines, confluent (wide) B-lines, as well as areas of subpleural consolidation and “white lung” were the most common lung ultrasound abnormalities. When evaluating the method, the optimal sensitivity/specificity ratio was obtained for a value of ≥2 points, the area under the curve = 0.970 (95% CI 0.858–0.999; p <0.0001). The score of lung ultrasound significantly correlated with computed tomography quantitative assessment (r = 0.928, p <0.001). Conclusion: Despite some limitations, lung ultrasound can be extremely useful in primary care settings, also in the case of a significant number of admitted patients, to detect features of COVID-19 associated pneumonia.

Treatment of COVID-19 Patients: Insights into the Use of Bone Marrow-Derived Mesenchymal Stem Cells

Patients with SARS-CoV-2 may be affected by the acute respiratory distress syndrome (ARDS), which has been associated with high mortality rate. As no specific drugs are available for ARDS, mesenchymal stem cells (MSC) seems to be a promising cell therapy due to immunomodulatory effects on reducing and healing inflammation-induced lung and other tissue injuries. The goal of this Phase I clinical trial was to explore the safety and efficacy of bone marrow-derived MSC (BM-MSC) infusions in patients with COVID-19 ARDS. The inclusions criteria were age between 18 to 70 years and PaO2/FiO2≤200mmHg. The BM-MSC infusions were as follow: one to 3 infusions intravenous doses of BM-MSC of 1x10 6 cells/kg; each dose could be administered with an interval between 3 to 7 days. The primary endpoint was safety (adverse events) within 6 hours; cardiac arrest or death within 24 hours post-infusion. The secondary endpoint includes patient survival at 30 days after the first infusion.Six patients were included in the trial and treated with at least one infusion of BM-MSC. The median age was 60,3 years (54 to 69), 5 were male. The median time between the worsening of respiratory distress and the BM-MSC infusion was 10 days (3 to 31 days). The median of PaO2/FiO2 before infusion was 151.86 (127.80-164.44) and median PaCO2 was 63,85 (39 to 117). One patient was treated with 3 MSC doses, two patients with 2 doses and 3 patients one dose. No serious adverse effects were observed within 24 hours post-infusion; only one death was observed following 30 days of cell administration. None of them showed adverse events during BM-MSC infusion. Only one patient showed signs of pulmonary infection one week after first BM-MSC infusion. This patient was at increased risk for infection due to prolonged intubation and a high dose of corticosteroid. Therefore, it was not possible to conclude its association with BM-MSC treatment.Only two patients showed clinical improvement after BM-MSC infusion. Patient 1 had BM-MSC infusion 72 hours after worsening of respiratory parameters, and thorax CT suggested the hypothesis of cryptogenic organizing pneumonia, which led to decision of using methylprednisolone 125mg I.V. for 3 days and carry on with MSC infusion. We observed a decrease in CRP levels from 126 to 67 mg/dL on day 1 after the first infusion, and PaO2/FiO2 ratio improved from 155 to 297 mmHg on day 5. He received the second dose within 7 days interval and by day 11 of the first infusion a new thorax TC showed complete resolution of alveolar consolidation areas in both lungs (Figure 1A and 1B). Patient 2 had BM-MSC administration 11 days after respiratory worsening and also presented improvement of PaO2/FiO2 ratio (148 to 215 mmHg after 2 days of infusion) and had thorax CT images suggesting cryptogenic organizing pneumonia with administration of methylprednisolone 250mg I.V. Nevertheless, the second dose was not administered due to ventilator-associated pneumonia and urinary infection.Four patients showed a non-sustained increase of PaO2/FiO2 ratio, with higher median PCO2 levels of 69,3 mmHg (range, 61,2 to 117) comparing to 39 and 47,3 mmHg of patients 1 and 2, respectively. PCO2 parameter could be a marker to indicate a worse response to MSC treatment, since it could point out chronic phases of COVID-19 disease. The patients died due to COVID-19 complications.No difference in inflammatory markers, such as interleukin 6, C-protein reactive test, procalcitonin, ferritin was observed before and after treatment.Inclusion criteria did not defined interval between respiratory worsening and first BM-MSC infusion. Four patients had chronic phase of COVID-19 without inflammatory markers and hypercapnia. It could be related to severity of pulmonary disease, such as reported in chronic obstructive pulmonary disease. Two patients were discharged after MSC treatment and they received methylprednisolone to treat cryptogenic organizing pneumonia. There are only a few clinical trials and observational studies evaluating the use of high-dose of glucocorticoid for severe COVID-19 pneumonia. Therefore, it is not possible to conclude that use of glucocorticoid has contributed to favorable outcomes.In conclusion, BM-MSC showed to be a secure therapeutic option for severe COVID-19 pneumonia, possibly with superior benefit in acute phases and lower PCO2 levels. Further studies involving a large cohort or randomized controlled trials are warranted. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Point-of-care contrast enhanced lung ultrasound and COVID-19.

Bedside lung ultrasound has been indispensable during the coronavirus disease 2019 (COVID-19) pandemic, allowing us to rapidly assess critically unwell patients. We demonstrate the unique application of contrast-enhanced ultrasound with the aim of further understanding this disease. Patient demographics were recorded alongside recent cross-sectional imaging and inflammatory markers. Ultrasound was conducted by experienced operators in a portable setting. Conventional six-point lung ultrasound method was used to evaluate B-lines, small (subpleural) consolidation and the pleura. Areas of small consolidation were targeted after intravenous administration of ultrasound contrast. The areas of small consolidations, a potential sign of pneumonia on B-mode lung ultrasound, usually enhance on contrast-enhanced ultrasound. Our study revealed these areas to be avascular, indicating an underlying thrombotic/infarction process. Findings were present in 100% of the patients we examined. We have also shown that the degree of infarction correlates with CT severity (r = 0.4) and inflammatory markers, and that these areas improve as patients recover. We confirmed the theory of immune thrombus by identifying the presence of microthrombi in the lungs of 100% of our patients, despite 79% having had a recent negative CT pulmonary angiogram study. contrast-enhanced ultrasound can be utilised to add confidence to an uncertain COVID-19 diagnosis and for prognosticating and monitoring progress in confirmed COVID-19 patients. Contrast-enhanced ultrasound is clearly very different to CT, the gold standard, and while there are specific pathologies that can only be detected on CT, contrast-enhanced ultrasound has many advantages, most notability the ability to pick up microthrombi at the periphery of the lungs.

Successful recovery from COVID-19 pneumonia with awake early self-proning

BackgroundSince COVID-19 global pandemic, “early awake proning in non-intubated patients with COVID-19” has been suggested as anecdotal evidence. Hereby, we report an awake and non-intubated patient with COVID-19 pneumonia who was successfully managed with early self-proning.Case presentationA 68-year-old male presented to the emergency department with a respiratory distress. He was non-smoker and denied any significant past medical history. His chest computed tomography scan showed “ground glass opacities” and “consolidation areas” located especially in the peripheral sites of both lungs which were consistent with a coronavirus pneumonia and reverse transcription polymerase chain reaction amplification by a nasopharyngeal swab sample for SARS-Cov-2 was also positive. His initial therapy with hdroxychloroquine and favipiravir was started. Due to deterioration of the patient’s oxygenation, he was transferred to the intensive care unit for further treatment with non-invasive mechanical ventilation on supine position and intermittent “awake early self-proning positioning” was applied. Additionally, antibiotherapy, anticoagulant therapy, and convalescent plasma therapy were also administered to the patient. On the 17th day of the ICU admission, he was transferred back to the ward. And the patient was discharged from the hospital on the 19th day of his initial admission.ConclusionsAlthough some case reports and small case series initially noted potential improvement in oxygenation by awake proning, further research is required to evaluate the exact benefits and proper applications of prone positioning in awake patients with COVID-19 pneumonia.

Tuberculous pleural effusion in a patient with sympathetic ophthalmia on immunosuppression:\xa0a case report

BackgroundTuberculous pleural effusion (TPE) is paucibacillary, making its diagnosis difficult based on laboratory investigations alone. We present a case of a patient with a TPE who was initially misdiagnosed to have azathioprine-induced lung injury. The diagnosis of TPE was arrived at with the help of clinical assessment, laboratory and radiological investigations.Case presentationA 25-year-old chronic smoker with sympathetic ophthalmia on long-term immunosuppression, latent tuberculosis infection and a significant family history of tuberculosis presented with a three-week history of productive cough, low-grade fever, night sweats and weight loss. Examination of the lungs showed reduced breath sounds at the right lower zone. Chest x-ray showed minimal right pleural effusion with a small area of right upper lobe consolidation. The pleural fluid was exudative with predominant mononuclear leukocytes. Direct smears of sputum and pleural fluid; polymerase chain reaction of pleural fluid; and sputum, pleural fluid and blood cultures were negative for M. tuberculosis (MTB) and other organisms. As he did not respond to a course of broad-spectrum antibiotics, he was then treated as a case of azathioprine-induced lung injury. However, his condition did not improve despite the cessation of azathioprine. A contrast-enhanced computed tomography of the thorax showed right upper lobe consolidation with tree-in-bud changes, bilateral lung atelectasis, subpleural nodule, mild right pleural effusion and mediastinal lymphadenopathy. Bronchoalveolar lavage was negative for malignant cells and microorganisms including, MTB. However, no pleural biopsy was done. He was empirically treated with anti-tubercular therapy for 9 months duration and showed complete recovery.ConclusionA high index of suspicion for TPE is required in individuals with immunosuppression living in regions endemic to tuberculosis. Targeted investigations and sound clinical judgement allow early diagnosis and prompt treatment initiation to prevent morbidity and mortality.

Rural community-based nurses' self-reported knowledge and skills in the provision of psychosocial care to palliative and end-of-life clients and carers.

This study examined rural community-based nurses' self-reported knowledge and skills in the provision of psychosocial care to rural residing palliative and end-of-life clients and carers. We further sought to determine correlates of knowledge gaps to inform workforce education and planning. Nurses from a rural area of Victoria, Australia, were invited to complete an electronic questionnaire rating their knowledge against 6 national palliative care standards and 10 screening and assessment tools. A 5-point scale of (1) No experience to (5) Can teach others was used to rate knowledge. Results were classified into three categories: practice gaps, areas of consolidation, and strengths. Descriptive and logistical regression was used to analyze data. A total of 122 of 165 nurses (response rate = 74%) completed the survey. Of these nurses, 87% were Registered Nurses, 43% had ≥10 years' experience in palliative care, and 40% had palliative care training. The majority of practices across the standards and screening and assessment tools were rated as knowledge strengths (N = 55/67, 82%). Gaps and areas of consolidation were in the use of client and carer assessment tools, the care of specific populations such as children, supporting carers with appropriate referrals, resources, and grief, and facilitating the processes of reporting a death to the coroner. Lack of formal training and lower years of experience were found to be associated with practice gaps. Our study found rural nurses were confident in their knowledge and skills in the majority of psychosocial care. As generalist nurses make up the majority of the rural nursing workforce, further research should be undertaken on what educational strategies are needed to support and upskill rural community-based nurses to undertake formal training in palliative care.

COVID-19 in pregnancy: placental pathological patterns and effect on perinatal outcome in five cases

IntroductionCOVID-19, the disease caused by the novel coronavirus SARS-CoV-2, is a severe systemic thrombotic syndrome that emerged in 2019, with an ensuing pandemic.To evaluate the impact of this disease on placental tissue and perinatal outcome, histological, immunohistochemical and ultrastructural analyses of placental tissue were performed for five cases of pregnant women with COVID-19.Case reportsAll five pregnant women in this series developed COVID-19 in late pregnancy. Two patients experienced respiratory distress, and computed tomography revealed signs of pneumonia, with bilateral involvement, multiple lobular and subsegmental areas of consolidation and ground-glass opacities.Histological studies of placental tissue revealed the presence of slight signs of maternal vascular underperfusion (MVUs) or foetal vascular underperfusion (FVUs) lesions and mild inflammatory lesions. CD15 immunoreactivity in the placental tissue was low in all cases, demonstrating that in these cases there was not severe foetal hypoxia/asphyxia risk for newborns or distal vascular immaturity.In all cases examined, ultrastructural analyses showed spherical-like coronavirus particles with an electron intermediate-density core as well as projections from the surface as spike-like structures in the syncytiotrophoblasts. At term, all of the women delivered newborns who were negative for SARS-CoV-2 by nasopharyngeal testing in their first day of life. All newborns were exclusively breastfed and were discharged on the 3rd day of life.ConclusionsIn conclusion, placental patterns in pregnancy due to COVID-19 in the late stage of gestation indicate no evidence of vertical trans-placental SARS-CoV-2 transmission or a significant impact on the perinatal outcome of newborns, in both mild and more severe cases.

A RARE CASE OF RADIATION-PRIMED CRYPTOGENIC ORGANIZING PNEUMONIA

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cryptogenic organizing pneumonia (COP) has rarely been associated with radiotherapy for breast cancer since the advent of planned irradiation field therapy. Here we present a case of a woman diagnosed with radiation-primed COP, diagnosed on lung biopsy. CASE PRESENTATION: A 78-year-old female with a medical history of asthma and three year old history of invasive ductal carcinoma of the right breast post lumpectomy, radiotherapy and adjuvant Taxol and Herceptin chemotherapy presented to the hospital with symptoms of progressive dyspnea. CT Chest at the time of admission revealed patchy areas of ground-glass and peripheral nodular consolidation with cavitation superimposed on postradiation fibrosis. She was diagnosed with pneumonia and discharged on a 5 day course of Amoxicillin-Clavulanic Acid.She continued to have persistent dyspnea, dry cough and was retreated with a 7 day course of Levofloxican. She symptoms persisted and a repeat CT Chest performed a month later demonstrated persistent pulmonary opacities concerning for cryptogenic organizing pneumonia and she underwent a CT-guided biopsy. Pathology revealed acute lung injury consistent with organizing pneumonia and cultures were negative for bacteria, fungi or acid-fast bacilli. She was treated with 1 mg/kg of prednisone daily, adjusted body weight, for a total of 3 months and experienced complete resolution of symptoms. DISCUSSION: Radiotherapy is the core treatment of breast cancer with planned field irradiation allows for minimal risk of side effects e.g. pneumonia and fibrosis. Pneumonia typically presents 4 to 12 weeks after radiotherapy; it's characterized by dyspnea, dry cough and alveolar opacities restricted to the treatment port [1]. In rare cases, bilateral lymphocytic alveolitis can develop, in spite of a limited radiation treatment area and it's radiological and histological pattern emulates cryptogenic organizing pneumonia (COP) [2]. Corticosteroid treatment in COP often results in rapid correction of both clinical symptoms and radiological signs; the precise dose and duration of treatment has not yet been defined [1].In our case, the patient presented with the typical signs of pneumonia and failed multiple rounds of treatment with antibiotics. The correct diagnosis was only established months later, after her symptoms persisted and a pathological tissue sample and negative cultures enabled a conclusive diagnosis of radiation-primed COP. Her clinical response to systemic corticosteroid provided further confirmation of her diagnosis. CONCLUSIONS: A high index of suspicion is required in order to diagnose radiation-primed cryptogenic organizing pneumonia. Clinicians must be aware of its chronic and persistent presentation if left untreated, as early diagnosis will prevent significant physical and psychological morbidity. REFERENCE #1: Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society [published correction appears in Thorax. 2008 Nov;63(11):1029. multiple author names added]. Thorax. 2008;63 Suppl 5:v1-v58. doi:10.1136/thx.2008.101691 REFERENCE #2: Roberts CM, Foulcher E, Zaunders JJ, Bryant DH, Freund J, Cairns D, Penny R, Morgan GW, Breit SN. Radiation pneumonitis: a possible lymphocyte-mediated hypersensitivity reaction. Ann Intern Med. 1993;118:696–700. DISCLOSURES: No relevant relationships by Suhayb Ranjha, source=Web Response

AROMATHERAPY MAY NOT BE SO RELAXING AFTER ALL: A CASE OF ACUTE EOSINOPHILIC PNEUMONIA

TOPIC: Diffuse Lung Disease TYPE: Global Case Reports INTRODUCTION: Acute eosinophilic pneumonia (AEP) is a rare entity of eosinophilic lung diseases, with around 200 cases reported worldwide (1). The cause is unknown, but it has mostly been linked to cigarette smoking inhalation. We present a unique case of AEP associated with a history of deep inhalation of fragrance oil. CASE PRESENTATION: Our patient is a 19-year-old medically free female who presented to the emergency department (ED) complaining of acute cough, fever, and dyspnea which started one day after deeply inhaling fragrance oil while trying to open the bottle with her mouth. She was febrile, in respiratory distress with an Oxygen saturation of 51%. The patient was managed as a case of possible COVID infection. She was intubated and admitted to the ICU. She received Dexamethasone for 3 days. Afterward, she was extubated and discharged home on room air the next day. Four days later, she presented to the ED with a similar picture. Chest x-ray (figure 1) showed bilateral patchy opacities. Computed tomography of the chest (CT) showed bilateral areas of consolidation and ground-glass opacities (figure 2). She was started empirically on antibiotics and a single dose of Hydrocortisone intravenously prior to CT scan as premedication protocol for Intravenous Contrast. Clinical, biochemical, and radiological improvement were noticed the next day. On the fourth day of admission, she became febrile and required more oxygen with an increase in neutrophils. At this point, she was started on Methylprednisone for a suspected diagnosis of acute eosinophilic pneumonia. The patient's condition improved with steroids. Bronchoalveolar lavage fluid analysis showed a WBC count of 614 cells /cumm with eosinophils of 84%. The patient was discharged home on prednisone 50mg which was tapered off within six weeks. On a follow-up clinic visit, the patient had complete resolution of her symptoms and her chest X-ray showed no lung infiltrates (figure 1 and 2). DISCUSSION: Acute eosinophilic pneumonia (AEP) is a rare disease with few reported cases worldwide. It usually presents similarly to pneumonia and acute respiratory distress syndrome. The cause of AEP is unknown but it has been suggested to be the result of an acute hypersensitivity reaction to an unknown allergen in a previously healthy individual (2) such as smoking. Our patient is the first case of AEP to occur after deep and sudden inhalation of fragrance oi which was made up of essence, scent stabilizer, deionized water, and ethyl alcohol. Our patient fulfills all the clinical criteria for AEP diagnosis.The mainstay of treatment in AEP is corticosteroids and patients usually have a rapid response as clinical recovery happens after 3 days of steroids (3). Prognosis in AEP is excellent with rapid initiation of steroids (1). CONCLUSIONS: We reported a unique case of AEP that occurred post fragrance oil inhalation and was resolved rapidly and completely with steroids. REFERENCE #1: Pizzuto, M., Seychell, M., Caruana Montaldo, B., & Mizzi, A. (2019). Idiopathic acute eosinophilic pneumonia. BMJ Case Reports, 12(9), e231095. REFERENCE #2: Badesch, D. B., King, T. E., & Schwarz, M. I. (1989). Acute Eosinophilic Pneumonia: A Hypersensitivity Phenomenon? American Review of Respiratory Disease, 139(1), 249–252. REFERENCE #3: Rhee, C. K., Min, K. H., Yim, N. Y., Lee, J. E., Lee, N. R., Chung, M. P., & Jeon, K. (2013). Clinical characteristics and corticosteroid treatment of acute eosinophilic pneumonia. The European respiratory journal, 41(2), 402–409. DISCLOSURES: No relevant relationships by Riyad Al-Lehebi, source=Web Response no disclosure on file for Mais AlSardi; No relevant relationships by Shaya Alshaya, source=Web Response

THE BENEFITS OF CORTICOSTEROIDS IN COVID-19 WITH ORGANIZING PNEUMONIA-LIKE PATTERN: A CLINICAL REPORT OF SUCCESSFUL TREATMENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Since the outbreak of COVID-19 (disease caused by severe acute respiratory syndrome coronavirus 2 - SARS-CoV-2), the world faces a major public health crisis.Organizing pneumonia (OP) is a relatively rare condition, that can be idiopathic or, more commonly, result from infections, drugs or autoimmunity (secondary OP) #1. Viral induced OP throughout the severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and H1N1 viral pandemics was well documented #2. The reported imaging findings of COVID-19 suggest that secondary OP may be occurring even more often #2. CASE PRESENTATION: 74-y-old man, evaluated in the emergency room for dry cough and asthenia with 1 week of evolution. He presented with hypoxemic respiratory failure (PaO2/FiO2 ratio: 276), and tested positive for SARS-CoV-2, being admitted in the COVID department. Treatment with Dexamethasone 6mg was started but a week later (day 14 of illness) there was a clinical deterioration, with worsening of the respiratory insufficiency (PaO2/FiO2 ratio: 175), requiring introduction of non-invasive mechanical ventilation with high oxygen rates. A clinical and gasometrical improvement (PaO2/FiO2 ratio: 230»253) was then observed with slow reduction and weaning from corticosteroids at D10 of dexamethasone. At day 20 of the disease, there was a new clinical and gasometrical worsening (PaO2/FiO2: 162), and it was decided to restart dexamethasone 6mg. No clinical improvement was observed in the following days and a chest computed tomography (CT) was performed, revealing multiple peripheral areas of consolidation and bilateral ground glass opacities, suggestive of an OP-like pattern. Given these findings, the case was discussed in a multidisciplinary team reunion, who considered the diagnosis of OP secondary to COVID-19 infection. It was decided to initiate 'pulse-dose' methylprednisolone 1000mg IV for 3 days and posteriorly the dosage of steroids was tapered every 3 days. There was an abrupt reduction in oxygen and ventilatory support needs and he was discharge requiring only 1L of oxygen and showing significant radiological improvement. After 3 months of follow-up, chest CT scan revealed dramatic improvements regarding previous findings. DISCUSSION: The definitive role of SARS-CoV-2 infection in diffuse lung injury is still unclear, but it is expected that it might induce host immune responses that damage the lungs. Corticosteroids, as immunosuppressive and anti-inflammatory agents, can reduce lung damage by regulating various inflammatory responses #3. CONCLUSIONS: This case suggests that corticosteroids may be an option to consider in COVID-19 pneumonia with an OP-like pattern. Secondary OP often requires prolonged corticosteroid treatment. It is important to increase recognition of this diagnosis, in order to start the appropriate treatment, which may lead to a reduction of the harmful consequences of COVID-19. REFERENCE #1: Drakopanagiotakis F, Paschalaki K, Abu-Hijleh M, Aswad B, Karagianidis N, Kastanakis E, Braman SS, Polychronopoulos V. Cryptogenic and secondary organizing pneumonia: clinical presentation, radiographic findings, treatment response, and prognosis. Chest. 2011 Apr;139(4):893-900. doi: 10.1378/chest.10-0883. Epub 2010 Aug 19. PMID: 20724743. REFERENCE #2: Kory P, Kanne JP. SARS-CoV-2 organising pneumonia: 'Has there been a widespread failure to identify and treat this prevalent condition in COVID-19?'. BMJ Open Resp Res 2020;7:e000724. doi:10.1136/ bmjresp-2020-000724 REFERENCE #3: Fauci AS. Mechanisms of the immunosuppressive and anti-inflammatory effects of glucocorticosteroids. J Immunopharmacol. 1978;1:1-25. DISCLOSURES: No relevant relationships by Mariana Argel, source=Web Response No relevant relationships by Joana Correia, source=Web Response No relevant relationships by Marta Sousa, source=Web Response No relevant relationships by Antonio Torres, source=Web Response

Modern concepts of the prevalence, pathomorphology and diagnosis of granulomatosis with polyangiitis with pulmonary involvement (literature review)

Granulomatosis with polyangiitis (GPA) (Wegener's granulomatosis) is a rare systemic autoimmune disease from the group of vasculitis associated with anti-neutrophil cytoplasmic antibodies (ANCAs). GPA is proceeding with granulomatous inflammation, mainly of the upper and lower respiratory tract and low-immune necrotizing vasculitis that affects small- and medium-size vessels in lungs, kidneys, skin. The disease is an extremely rare long-term systemic disorder, is rarely the object of research, the literature data are few and unsystematic.Purpose. The purpose of the literature review was to study the published materials, analyze the received information and define tasks for further study of this pathology, primarily from the standpoint of radiation diagnostics.Materials and methods. The search was carried out in bibliographic databases MedLine, PubMed, if necessary, links to external full-text sources were used. 36 of the most significant publications were selected and worked out, including 8 domestic and 28 foreign. One of the selection criteria for articles was the availability of information about the radiological diagnosis of GPA in them.Results. Most authors focus their attention on clinical manifestations and features of treatment, not paying sufficient attention to diagnostic methods. Many studies have been carried out on a small sample of patients or are limited to individual clinical observations; there is practically no information on changes in the computed tomographic picture of the lungs in GPA in dynamics. The most complete semiotics of lung damage according to CT data is presented in the article by F. Martinez et al. (2012).Conclusions. It was found that in case of lung lesions by GPA, nodules, nodes and masses are more often determined, in half of cases – with cavities of decay, less often areas of ground-glass opacity and consolidation are detected. However, at present there is no unified approach to the interpretation of the radiological semiotics of the disease and the determination of the diagnostic value of individual computed tomographic patterns of lung damage. This requires their further detailed study for the correct and timely diagnosis of such a rare, but complex and potentially life-threatening disease.

Opportunities to reduce the radiation exposure during computed tomography to assess the changes in the lungs in patients with COVID-19: use of adaptive statistical iterative reconstruction

BACKGROUND: Several COVID-19 patients are subjected to multiple imaging examinations during hospitalization, the cumulative effect of which can significantly increase the total dose of radiation received. The effective radiation dose can be reduced by lowering the current and voltage of the X-ray tube, but this reduces image quality. One possible solution is to use adaptive statistical iterative reconstruction technology on the raw CT data. Recently, data on the efficacy of low-dose CT (LDCT) in the diagnosis of COVID-19 have appeared in the literature. AIM: To analyze the quality and diagnostic value of LDCT images of the lungs after applying an iterative processing algorithm and to assess the possibility of reducing the radiation load on the patient when diagnosing COVID-19. MATERIALS AND METHODS: Patients from the Infectious Diseases Department of the Moscow State University Hospital participated in the prospective study. CT examinations were performed at the time of patient admission and discharge and were repeated as needed during hospitalization. In the first study, a standard CT protocol with a tube voltage of 120 kV and automatic current modulation in the range of 200400 mA was used; in repeated CT scans, the LDKT protocol was used with reduced tube voltage parameters (100 or 110 kV) and automatic current modulation in the range of 40120 mA. To assess the diagnostic value of LDCT in comparison with standard CT, a survey was conducted among doctors from the Department of Radiation Diagnostics at Moscow State University Hospital. The questionnaire included a comparison of the two methods for identifying the following pathological processes: ground-glass opacities, compaction of the lung tissue with reticular changes, areas of lung tissue consolidation, and lymphadenopathy. RESULTS: The study included 151 patients. The average age was 5814.2 years, with men accounting for 53.6% of the population. During LDCT the radiation load was reduced by 2.96 times on average, CTDI by 2.6 times, DLP by 3.1 times, the current on the tube by 1.83 times, and the voltage on the tube by 1.2 times. The results indicate that the effectiveness of detecting the main signs of viral pneumonia and assessing the dynamics of the patients condition does not differ significantly from CT performed according to the standard protocol. CONCLUSIONS: The results of a comparison of standard and low-dose CT show that there is no significant loss of diagnostic information and image quality as the radiation load is reduced. Thus, chest LDCT can be used to successfully diagnose COVID-19 in routine practice.

Comparing radiological presentations of first and second strains of COVID-19 infections in a low-resource country

IntroductionThe novel corona virus popularly referred to as COVID-19 disease and SARS-CoV-2 was first detected in Wuhan, China in December 2019. It was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. In Ghana, the first two cases of COVID-19 infection were recorded on March 13, 2020 with a strain imported from Europe. In December 2020, a new strain from South Africa was detected in Ghana which was associated with higher transmission rates, severity of the disease, and higher number of recorded deaths. Our study aimed to record notable differences and similarities between infections due to the initial, and second strains of COVID-19 infections detected in Ghana during the last 12-months. MethodThis was a retrospective study involving 50 patients infected with the first strain, and another 50 patients infected with the second strain of the SARS-CoV-2 virus. Microsoft Excel-2013 was the analytical tool. ResultsThe data analysis supported publications suggesting that the new strain of the virus caused more severe infections, which were manifested on high resolution CT (HRCT) scans as more widespread alveolar disease, most commonly presenting as large areas of consolidation. ConclusionDespite numerous similarities in terms of the manifestation of COVID-19 infection on HRCT scans, notable difference supporting the notion of increased virulence and severity of disease were also recorded. The study findings demonstrate the need for heightened and sustained preventive measures needed to reduce, and eventually curb COVID-19 infection and mortality rates associated with the introduction of new virulent strains.

Participatory Management to Improve Accessibility in Consolidated Urban Environments

There is a wide range of regulations on universal accessibility, but our cities are still inaccessible in many cases. Most accessibility problems in cities occur in consolidated areas that were developed prior to the development of current accessibility regulations. This leads to consider the importance of focusing more effort on managing the improvement of the accessibility of existing public urban environments. As such, the objective of this research is to design a conceptual model for accessibility management in consolidated urban environments. Unlike other research focusing on city users to collect information on accessibility problems or to provide services to improve wayfinding, this method has a focus on urban accessibility managers. The model is based on the assessment of the level of accessibility of urban environments together with the assessment of management processes in which city users are actively involved. It consists of a set of basic indicators for the identification of accessible pedestrian routes, and provides a dynamic accessibility index for the evaluation of their efficient management by the responsible governments. The inclusion of this assessment framework in the management process itself enables the necessary improvement actions to be identified and taken in time. ICT (Information and Communication Technologies) provide the communication channel between the responsible governments and city users, making this a more dynamic and efficient management model based on assessment possible.

Ribavirin Aerosol in the Treatment of SARS-CoV-2: A Case Series.

Ribavirin is an inosine monophosphate dehydrogenase inhibitor with demonstrated activity against coronaviruses, including SARS-CoV-2. Five hospitalized patients with COVID-19 (confirmed by positive tests for SARS-CoV-2) received treatment with ribavirin for inhalation solution (ribavirin aerosol) as part of a compassionate use program. Patients included four men and one woman, with an age range of 29–72 years. Patients were managed according to international and Italian treatment guidelines for COVID-19. In addition, therapy with ribavirin aerosol 100 mg/mL was administered for 30 min twice daily for 6 days (i.e., 12 doses) in all patients. In order to address concerns about a possible increase in viral dispersal with the use of a nebulizer, healthcare providers remained outside the patient room during ribavirin aerosol administration. Pretreatment chest computed tomography (CT) scans showed pseudonodular areas of parenchymal thickening in the upper right lobe with associated ground glass opacities, multiple areas of parenchymal consolidation in both lower lobes with associated ground glass opacities, bilateral parenchymal thickening and multiple associated ground glass areas, or focal ground glass areas in the upper lobes bilaterally, which were almost completely resolved (three patients) or moderately cleared (one patient) on imaging at the end of ribavirin treatment. For a fifth patient, CT scans showed a stable pulmonary picture at the end of ribavirin treatment. No adverse reactions to ribavirin treatment were observed in any of the five patients. All patients recovered fully, and nasopharyngeal swabs obtained after hospital discharge tested negative for SARS-CoV-2. Ribavirin aerosol appears to be efficacious in the treatment of patients with COVID-19. A controlled trial of ribavirin aerosol is ongoing and will provide additional data across a broader patient population.