Bilateral Ground-glass Opacities Research Articles

MRSA Community-acquired Pneumonia: Non COVID-19 Related Bilateral Ground-glass Opacities

Methicillin-resistant staph aureus (MRSA) has been known to cause severe hospital-acquired infections with its multi-drug resistant nature. MRSA Infections could quickly escalate into severe sepsis resulting in death, if not recognized and treated abruptly. This pathogen uncommonly causes Community-Acquired Pneumonia (CAP), which can lead to under treatment due to delayed coverage with anti-MRSA antibiotics resulting in poor clinical outcome. We herein describe an unusual case of MRSA CAP during COVID-19 pandemic in an 80-year-old male who was unresponsive and found to be in septic shock, intubated outside the hospital setting, and then brought to intensive care unit for further management. Laboratory and radiographic studies revealed MRSA in sputum culture and extensive bilateral consolidation with bilateral ground glass opacities and pleural effusions on imaging. Our patient was successfully treated with linezolid and extubated within 48 hours with a favorable outcome. High index of suspicion and a timely coverage with anti-MRSA antibiotics would reduce mortality and lead to a better outcome in otherwise fatal infection. Keywords: MRSA; Community-acquired pneumonia; Respiratory failure; Critical care; Case report

Deep Learning-Based Approaches to Improve Classification Parameters for Diagnosing COVID-19 from CT Images.

Patients infected with the COVID-19 virus develop severe pneumonia, which generally leads to death. Radiological evidence has demonstrated that the disease causes interstitial involvement in the lungs and lung opacities, as well as bilateral ground-glass opacities and patchy opacities. In this study, new pipeline suggestions are presented, and their performance is tested to decrease the number of false-negative (FN), false-positive (FP), and total misclassified images (FN + FP) in the diagnosis of COVID-19 (COVID-19/non-COVID-19 and COVID-19 pneumonia/other pneumonia) from CT lung images. A total of 4320 CT lung images, of which 2554 were related to COVID-19 and 1766 to non-COVID-19, were used for the test procedures in COVID-19 and non-COVID-19 classifications. Similarly, a total of 3801 CT lung images, of which 2554 were related to COVID-19 pneumonia and 1247 to other pneumonia, were used for the test procedures in COVID-19 pneumonia and other pneumonia classifications. A 24-layer convolutional neural network (CNN) architecture was used for the classification processes. Within the scope of this study, the results of two experiments were obtained by using CT lung images with and without local binary pattern (LBP) application, and sub-band images were obtained by applying dual-tree complex wavelet transform (DT-CWT) to these images. Next, new classification results were calculated from these two results by using the five pipeline approaches presented in this study. For COVID-19 and non-COVID-19 classification, the highest sensitivity, specificity, accuracy, F-1, and AUC values obtained without using pipeline approaches were 0.9676, 0.9181, 0.9456, 0.9545, and 0.9890, respectively; using pipeline approaches, the values were 0.9832, 0.9622, 0.9577, 0.9642, and 0.9923, respectively. For COVID-19 pneumonia/other pneumonia classification, the highest sensitivity, specificity, accuracy, F-1, and AUC values obtained without using pipeline approaches were 0.9615, 0.7270, 0.8846, 0.9180, and 0.9370, respectively; using pipeline approaches, the values were 0.9915, 0.8140, 0.9071, 0.9327, and 0.9615, respectively. The results of this study show that classification success can be increased by reducing the time to obtain per-image results through using the proposed pipeline approaches.

The eyes see what the mind seeks: a systematic review of abdominal imaging findings in patients with COVID-19.

Objectives:With the increasing recognition of gastrointestinal (GI) manifestation of coronavirus disease-19 (COVID-19), various abdominal imaging findings are increasingly being noted. We scoped the existing literature on the abdominal imaging findings in COVID-19.Methods:A systematic literature search was performed on PubMed, Embase, Google scholar and World Health Organization COVID-19 database.Results:35 studies were included in the final descriptive synthesis. Among the studies reporting positive abdominal imaging findings in patients with COVID-19, majority described imaging abnormalities of the GI tract (16 studies), of which bowel wall thickening was most frequently reported. Other findings noted were abdominal imaging manifestations of bowel ischemia with thrombosis of the splanchnic vasculature, and imaging features suggestive of pancreatitis. Imaging findings suggestive of solid organ infarction were reported in nine studies. An association between imaging evidence of hepatic steatosis and COVID-19 was noted in three studies. Incidental lung base findings on abdominal imaging were noted in 18 studies, where patients presented with predominant GI symptoms. The most common finding was bilateral ground glass opacities (90.7%) with predominant multilobar (91.1%) and peripheral (64.4%) distribution.Conclusion:This systematic review provides insight into the abdominal imaging findings in patients with COVID-19. Knowledge of these imaging manifestations will not only help in further research but also will aid in curtailing transmission of the SARS-CoV-2. Further prospective studies are needed to gain better insight into the pathophysiology of these imaging manifestations.Advances in knowledge:This review highlights the abdominal imaging findings in patients with COVID-19, to gain insight into the disease pathophysiology and gear the abdominal radiologist through the pandemic.

Analysis of 239 ordinary and severe cases of COVID-19: Clinical features and treatment.

This study retrospectively analyzed the clinical characteristics of patients with new coronavirus infection (COVID-19) and summarizes the treatment experience. A total of 239 COVID-19 patients admitted to the Hajar Hospital, Aja University of Medical Science, Tehran, Iran from March 22, 2020 to May 18, 2020 were selected, including 176 cases in the ordinary group and 63 cases in the severe/critical group. We collected and compared the clinical data of the two groups of patients, including general conditions, clinical symptoms, signs, laboratory tests, lung CT imaging and prognosis, and analyzed the treatment plans of the two groups. The mean age of 239 COVID-19 patients was 48.1±17.6 years, including 132 males. Patients in the severe and critically ill groups were older than the normal group, with more males and more underlying diseases. The difference was statistically significant (p < 0.05). The lymphocyte (LYM) counts and albumin (ALB) counts of the severe and critically ill groups were more significantly lower than those of the normal group; while the percentage of neutrophils (NEU), C-reactive protein (CRP), D-dimer, and lactate The increase of lactate dehydrogenase (LDH) and urea nitrogen (BUN) was more significant, and the difference was statistically significant (p < 0.05). Patients in the severe and critically ill groups received more antiviral drugs, glucocorticoids, and nasal catheters than those in the normal group, and the difference was statistically significant (p < 0.05). Also, we observed that the most radiological finding was bilateral ground-glass opacity in both groups, however, the rate of typical abnormalities in both chest CT scan and chest x-ray was significantly higher in sever/critical group except air-bronchogram. Taken together, we showed that combination of oseltamivir and glucocorticosteroid such as dexamethasone was very effective in severe patients.

Characteristics of Inpatients with False-Negative SARS-CoV-2 PCR Test Results

Background: At our institution, the concern for false-negative nasopharyngeal testing for SARS-CoV-2 at the onset of illness led to a general policy of retesting inpatients at 48 hours. For such patients, 2 negative SARS-CoV-2 PCR test results were required prior to discontinuation of COVID-19 control precautions. To assess the utility of routine repeat testing We analyzed patients presenting to our hospital who initially tested negative for SARS-CoV-2 but were found to be positive on repeated testing. Methods: All inpatients with symptoms concerning for COVID-19 were tested via nasopharyngeal sample for SARS-CoV-2 by PCR on admission. Patients with continued symptoms and no alternative diagnosis were retested 48 hours later. Testing was performed using either the Roche cobas SARS-CoV-2 RT-PCR assay or the Cepheid Xpert Xpress SARS-CoV-2 test. Between March 17, 2020, and May 10, 2020, we retrospectively analyzed data from patients with false-negative SARS-CoV-2 PCR test results who were subsequently confirmed positive 48 hours later. We evaluated demographic information, days since symptom onset, symptomatology, chest imaging, vital sign trends, and the overall clinical course of each patient. Results: During the study period, 14,683 tests were performed, almost half (n = 7,124) were performed through the ED and in the inpatient setting. Of 2,283 patients who tested positive for SARS-CoV-2, only 19 (0.01%) initially tested negative. Patients with initial false-negative test results presented with symptoms that ranged from fever and dyspnea to fatigue and vomiting. Notably, few patients presented “early” in their disease (median, 6 days; range, 0–10 days). However, patients with initial false-negative PCR test results did seem to have consistent imaging findings, specifically bilateral bibasilar ground glass opacities on chest radiograph or computed tomography scan. Conclusions: Among inpatients with COVID-19, we found a very low rate of initial false-negative SARS-CoV-2 PCR test results, which were not consistently related to premature testing. We also identified common radiographic findings among patients with initially false-negative test results, which could be useful in triaging patients who may merit retesting. Based on these data, we revised our existing clearance criteria to allow for single-test removal of COVID-19 precautions. Evaluating subsequent reduction in unnecessary testing is difficult given changing community prevalence, increased census, and increased opening to elective procedures. However, given the significant percentage of ED and inpatient testing, removal of repeated testing has likely resulted in a reduction of several thousand unnecessary COVID-19 tests monthly.Funding: NoDisclosures: None

COVID-19 in a Patient Newly Diagnosed with Chronic Lymphocytic Leukemia

Coronavirus disease (COVID-19) pandemic continues to pose challenges.Patients with Chronic Lymphocytic Leukemia (CLL) have many risk factors that predispose them to a severe course of COVID-19– related illness, including co-morbidities, older age, and higher prevalence of immunodeficiency from leukemia. Case presentation: A 70-year-old man had a 2-day history of nonproductive cough, dysnoea and shortness of breath, myalgias/ arthralgias, and headache. He explained that had 6-7 day that not felt well: fatigue, fever over 38.0°C, renching and night sweats. He has been healthy till now. His finger oxygen saturation on air room was 80%. Chest tomography showed bilateral ground glass opacities with basal pulmonary consolidation and bilateral pleural effusions. The complete blood count showed a high leucocytosis and a rise of absolute lymphocyte count. TR-PCR of swab nasopharyngeal for Sars-Cov-2 resulted negative. Antibody anti-Sars-CoV-2 IgM and IgG resulted negative on admission and positive on discharged day. Conclusions: There are limited cases available regarding the presentation of COVID-19 in CLL patients. For these reasons this patient group is of particular concern. Our aim is to describe a patient diagnosed with COVID-19 induced hyperleucocytosisand newly diagnosed CLL. Keywords: COVID-19; Chronic lymphocytic leukemia; Leucocytosis; Lymphocytosis

Differential clinical diagnosis and prevalence rate of allergic rhinitis, asthma and chronic obstructive pulmonary disease among COVID-19 patients.

BackgroundThere is a great need to make a rapid differential clinical diagnosis of COVID‐19 among respiratory disease patients and determining the prevalence rate of these diseases among the COVID‐19 population.MethodApproximately 522 patients with allergic rhinitis, asthma, COPD, and COVID‐19 were analysed for demographic and clinical features. Radiological features were analysed only for COVID‐19 patients.ResultsCOPD and asthma were more common among COVID‐19 patients than allergic rhinitis. All chest CT scans of COVID‐19 patients showed bilateral ground‐glass opacity. Fever, dry cough, diarrhea, loss of sense of smell and taste, shortness of breath, and blue lips were significantly higher in all COVID‐19 patients compared to COPD, asthma, and allergic rhinitis patients.ConclusionThe presence of clinical symptoms such as fever, dry cough, diarrhea, loss of sense of smell and taste, shortness of breath, and blue lips in COVID‐19 patients, can be used for differential diagnosis between COVID‐19 patients and other respiratory diseases. Then, the diagnosis can be confirmed by chest CT scan for COVID‐19 patients without the need for a nasopharyngeal swab or PCR test, especially in epidemic countries. Allergic rhinitis patients are the least exposed to COVID‐19 infection among other respiratory disease patients.

Alkaline phosphatase and score of HRCT as indicators for predicting the severity of COVID-19

BackgroundThe clinical symptoms, blood laboratory data, O2 saturation and high-resolution computed tomography (HRCT) findings are critical factors in diagnosis of COVID-19 infection. MethodsIn this study, 105 hospitalized patients suspected of having COVID-19 were evaluated. Finally, the laboratory and HRCT and related factors data of 83 confirmed cases by HRCT and RT-PCR were analyzed. To compare the median of quantitative variables in the two groups, the Mann-Whitney U test was used. Also, to determine the factors associated with the positiveness of the HRCT result, a univariate logistic model was fitted. Moreover, receiver operating characteristic (ROC) curves were constructed to test the ability of the final model to predict the positiveness of HRCT result. Results61.40% of the patients had a comorbidity disease. 89.20% had fever, 92.00% cough, 91.40% dyspnea. Abnormal CRP was seen in 77.80% of the patients, followed by 66.70% lymphopenia, and 60.30% neutrophilia. Also, ALP (abnormal vs. normal) and score of HRCT assessment variables had a significant effect on the positiveness of HRCT findings. 87.95% had abnormal HRCT with 41% bilateral multi lobar patchy ground glass opacity (GGO). Moreover, there was a statistically significant association between the level of O2 saturation and HRCT results. ConclusionOur findings showed that male patients with middle age and comorbidity disease were more susceptible to the COVID-19 infection. Additionally, clinical features, blood laboratory findings, O2 saturation and HRCT findings are critical factors in the prognosis of COVID-19 infection.

A Review of COVID-19: Data Obtained from Chest CT Imaging and RT-PCR

Context: This review aimed to investigate the computed tomography (CT) imaging features of coronavirus disease 2019 (COVID-19). Evidence Acquisition: Bilateral lung involvement (70%), peripheral distribution (67.5%), multifocal involvement (67.3%) and ground glass opacity (66.1%) were observed in most infected patients. Results: Evaluation of the number of lobes involved in infected patients showed no abnormalities in 7.2% (85/1177) of the patients. Regarding the performance of reverse transcription-polymerase chain reaction (RT-PCR) and chest CT scan, the sensitivity of RT-PCR and chest CT imaging was estimated at 70% (925/1311) and 89% (6605/7396) upon admission, respectively; nevertheless, the sensitivity of CT imaging increased as the time from the symptom onset increased. The CT image acquisition parameters affecting image quality and patient dose were also discussed. Studies suggested that these factors should be adjusted according to the disease stage. Based on our findings, sensitivity was adequately high eight days after the onset of symptoms. Conclusion: Therefore, there is no need for high-resolution chest CT scan after this interval. Using ImpactDose software, the mean effective doses were 4.38 and 5.71 mSv in male and female groups, respectively. The risk of cancer was 36% higher in females than males, as shown by PCXMC program.

Radiological findings of e-cigarette or vaping product use associated lung injury: A systematic review

IntroductionChest radiology provides an opportunity to better understand the diagnostic characteristics of e-cigarette or vaping product use associated lung injury (EVALI). This systematic review aimed to summarize the radiological findings associated with EVALI reported in the literature. MethodsThis systematic review was conducted in accordance with PRISMA guidelines. Electronic searches of MEDLINE®, CINAHL, Embase® and CENTRAL were conducted in February 2020. Included were all English-language studies reporting radiological findings of EVALI. Data was synthesized using descriptive statistics. ResultsThirty studies comprising 184 participants were included. Mean patient age was 24.5 years old. The majority (n = 141, 76.6%) of included patients were male. The most common radiological features reported on chest x-ray were bilateral infiltrates (n = 64, 41.3%) and ground glass opacities (n = 17, 11.0%), and on chest CT were bilateral infiltrates (n = 62, 36.9%), bilateral ground glass opacities (n = 56, 33.3%), subpleural sparing (n = 29, 17.3%), pleural effusions (n = 14, 8.3%), and centrilobular nodularity (n = 13, 7.7%). Of patients with follow-up data reported (n = 81), only 28.4% (n = 23) had complete resolution of symptoms or radiological findings. ConclusionChest radiology is the cornerstone of diagnosis and monitoring of EVALI. A wide variety of radiological findings highlight the need for standardisation of terminology in the radiological descriptions of EVALI. Common findings included bilateral infiltrates and ground glass opacities. Higher quality evidence is warranted to help develop evidenced-based guidelines for the diagnosis and management of EVALI.

Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews

BackgroundNavigating the rapidly growing body of scientific literature on the SARS-CoV-2 pandemic is challenging, and ongoing critical appraisal of this output is essential. We aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic.MethodsNine databases (Medline, EMBASE, Cochrane Library, CINAHL, Web of Sciences, PDQ-Evidence, WHO’s Global Research, LILACS, and Epistemonikos) were searched from December 1, 2019, to March 24, 2020. Systematic reviews analyzing primary studies of COVID-19 were included. Two authors independently undertook screening, selection, extraction (data on clinical symptoms, prevalence, pharmacological and non-pharmacological interventions, diagnostic test assessment, laboratory, and radiological findings), and quality assessment (AMSTAR 2). A meta-analysis was performed of the prevalence of clinical outcomes.ResultsEighteen systematic reviews were included; one was empty (did not identify any relevant study). Using AMSTAR 2, confidence in the results of all 18 reviews was rated as “critically low”. Identified symptoms of COVID-19 were (range values of point estimates): fever (82–95%), cough with or without sputum (58–72%), dyspnea (26–59%), myalgia or muscle fatigue (29–51%), sore throat (10–13%), headache (8–12%) and gastrointestinal complaints (5–9%). Severe symptoms were more common in men. Elevated C-reactive protein and lactate dehydrogenase, and slightly elevated aspartate and alanine aminotransferase, were commonly described. Thrombocytopenia and elevated levels of procalcitonin and cardiac troponin I were associated with severe disease. A frequent finding on chest imaging was uni- or bilateral multilobar ground-glass opacity. A single review investigated the impact of medication (chloroquine) but found no verifiable clinical data. All-cause mortality ranged from 0.3 to 13.9%.ConclusionsIn this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all reviews was “critically low”. Thus, systematic reviews that were published early on in the pandemic were of questionable usefulness. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards.

Telemedicine and Home-Based Treatment of COVID-19 in Resource-Limited Countries. Report of 3 Cases.

Ecuador, despite having taken aggressive and early measures to stop the progression of the pandemic (COVID-19), ended up becoming an epicenter of the pandemic in Latin America, and with the collapse of its health care system. The authors describe three patients who had confirmed COVID-19 and met the criteria for hospital admission but could not be assigned a hospital bed in a resource-limited country. The patients included a 72-year-old male, an 82-year-old female, and a 56-year-old male. They typically presented with fever, dyspnea, loss of taste and smell, diarrhea, and abdominal pain. Oxygen saturation during the initial evaluation ranged from 80-89%. Laboratory results reported lymphopenia and neutrophilia, with leukocytosis in two patients. Inflammatory markers were also elevated for all three patients. CT scan findings showed bilateral ground-glass pulmonary opacities. SARS-CoV-2 was confirmed in all three patients by real time polymerase chain reaction (RT-PCR) testing. Home-based treatment was established. At the time of writing this report, all patients remain asymptomatic and with negative COVID-19 testing. Telemedicine and home-based treatment were essential assets in the care of these severely ill patients living in a low-resource setting where not all patients who have criteria to be admitted into the hospital are able to find a place in a collapsed health care system.

Epidemiological, imaging, laboratory, and clinical characteristics and factors related to mortality in patients with COVID-19: a single-center study.

ObjectivesCoronavirus disease 2019 (COVID-19) is a novel pandemic. Considerable differences in disease severity and the mortality rate have been observed in different parts of the world. The present study investigated the characteristics and outcomes of patients hospitalized with COVID-19 in Iran.MethodsWe established a retrospective cohort to study hospitalized COVID-19 patients in Iran. Epidemiological, imaging, laboratory, and clinical characteristics and outcomes were recorded from medical documents. The chi-square test, t-test, and logistic regression models were used to analyze the data. A p<0.05 was considered to indicate statistical significance.ResultsIn total, 364 cases (207 males and 157 females) were analyzed. The most common symptoms were cough, fever, and dyspnea. Multifocal bilateral ground-glass opacities with peripheral distribution were the predominant imaging finding. The mean age of patients was 54.28±18.81 years. The mean age of patients who died was 71.50±14.60 years. The mortality rate was 17.6%. The total proportion of patients with a comorbidity was 47.5%, and 84.4% of patients who died had a comorbidity. Sex, history of diabetes mellitus, and dyslipidemia were not significantly associated with mortality (p>0.05). However, mortality showed significant relationships with body mass index; age; history of hypertension, chronic kidney disease (CKD), ischemic heart disease, cerebrovascular accident (CVA), pulmonary disease, and cancer; and abnormal high-resolution computed tomography (HRCT) findings (p<0.05 for all). Cancer had the highest odds ratio.ConclusionComorbidities (especially cancer, CKD, and CVA), severe obesity, old age, and abnormal HRCT findings affected the health outcomes of patients hospitalized with COVID-19.

Clinical outcomes and lipid-laden macrophages in Electronic cigarette/Vaping product use-Associated Lung Injury (EVALI) in a South Texas population

Objective: To describe the clinical features, proportion of lipid-laden alveolar macrophages in bronchoalveolar lavage (BAL), and short-term and 6-month to 12-month outcomes of patients with Electronic cigarette/Vaping product use-Associated Lung Injury (EVALI).Methods: Retrospective review of clinical characteristics, radiographs, and BAL samples for all patients with a history of vaping who presented with acute hypoxemic respiratory failure to the University Hospital in San Antonio, Texas from 9/2019 to 6/2020 was performed.Results: We report 16 cases (15 men; median age, 30 years [range 19-75]) of EVALI with a history of vaping Tetrahydrocannabinol (THC), nicotine, or both. The most common presenting symptoms were tachycardia, dyspnea, cough, and fever. All patients required supplemental oxygen, including two who required noninvasive positive pressure ventilation, and five who required mechanical ventilation. All 16 patients had bilateral ground-glass opacities (GGO) with peripheral sparing on chest computerizedtomography (CT). Cultures were negative, except for one patient who tested positive for rhinovirus. COVID-19 PCR was done in one individual which was negative. Cytology demonstrated lipid-laden macrophages on Oil-Red-O stain on fresh (i.e., without fixative) BAL in the majority of patients (N = 12) with a mean lipid-saturation percentage of 78% [range, 44%-100%] and the mean Colombo count of 194 [range, 101-359]. Fifteen patients were treated with systemic corticosteroids. The median length of hospital stay was 10 days. At discharge, three patients required supplemental oxygen. Eight of those who had follow-up imaging showed resolution of GGO. One patient had a relapse of symptoms and was again treated with systemic corticosteroids and mycophenolate, with resolution of symptoms. Fourteen patients who were evaluated after discharge denied vaping post-discharge (two patients were not able to be contacted and did not keep follow-up appointments).Conclusions: Successful diagnosis and management of EVALI requires a high clinical suspicion, thorough evaluation to rule out infectious etiologies, and aggressive treatment with systemic corticosteroids, along with sustained abstinence from vaping.

The Role of High Flow Nasal Cannula in COVID-19 Associated Pneumomediastinum and Pneumothorax.

Background: Pneumomediastinum, subcutaneous emphysema and pneumothorax are not rarely observed during the COVID-19 pandemic. Such complications can worsen gas exchange and the overall prognosis in critical patients. The aim of this study is to investigate what predisposing factors are related to pneumomediastinum and pneumothorax in SARS-CoV2-Acute Respiratory Distress Syndrome (ARDS), what symptoms may predict a severe and potentially fatal complication and what therapeutical approach may provide a better outcome. Methods: In this single center cohort study, we recorded data from 45 critically ill COVID-19 patients who developed one or more complicating events among pneumomediastinum, subcutaneous emphysema and pneumothorax. All patients showed ARDS and underwent non-invasive ventilation (NIV) at baseline. Patients with mild to moderate ARDS and pneumomediastinum/pneumothorax (n = 25) received High Flow Nasal Cannula (HFNC), while patients with severe ARDS and pneumomediastinum/pneumothorax underwent HFNC (n = 10) or invasive mechanical ventilation (IMV) (n = 10). Results: Pneumomediastinum/pneumothorax developed in 10.5% of subjects affected by SARS-coV2-ARDS. Dyspnea affected 40% and cough affected 37% of subjects. High resolution computed tomography of the chest showed bilateral diffuse ground glass opacities (GGO) in 100% of subjects. Traction bronchiolectasis, reticulation, crazy paving and distortion were observed in 64%. Furthermore, 36% showed subcutaneous emphysema. Non-severe ARDS cases received HFNC, and 76% patients recovered from pneumomediastinum/pneumothorax over a median follow up of 5 days. Among severe ARDS cases the recovery rate of pneumomediastinum/pneumothorax was 70% with the HFNC approach, and 10% with IMV. Conclusion: HFNC is a safe and effective ventilatory approach for critical COVID-19 and has a positive role in associated complications such as pneumomediastinum and pneumothorax.

FAVIPIRAVIR AND DEXAMETHASONE IN MANAGEMENT OF SARS-COV2 INFECTION

Background. The clinical presentation of Coronavirus disease 19 (COVID-19) varies from mild symptoms to severe illness including multiorgan dysfunction. Favipiravir is an antiviral agent which has been previously used for treatment of influenza and was recently approved for treatment of mild to moderate COVID-19 in India. Objective. The Objective of this study was to assess the role of Favipiravir and Dexamethasone in patients with COVID-19. Methods. A total of 17 patients were included in this observational study. The included patients were RT-PCR for SARS-Cov-2 positive with increased inflammatory markers. All patients received Antiviral therapy, Anticoagulation (Enoxaparin 0.4mg subcutaneous twice daily), Steroids (Dexamethasone 8mg daily for 5days and 4mg daily for 5 days). Viral clearance (time to RT-PCR negative), time to defervescence after antiviral therapy, time to become independent of Oxygen support was studied. Results. Fever, myalgias, dry cough and dyspnea were the commonest presentation of COVID-19. All of our patients had lymphopenia. In our study 11 (64.7%) patients had bilateral ground glass opacities on CT chest while 6 had consolidation in addition to ground glass opacities. In two patients, who required non-invasive ventilation, Favipiravir was stopped and these patients received Remdesivir for a total of 5 days. In patients who received Favipiravir only, the Median time to RT-PCR negative, defervescence and oxygen independence was 8,3 and 6 days respectively. Conclusion. Our observational study demonstrated improvement in the majority of patients with COVID-19 with use of Favipiravir. Additional studies are needed to compare the efficiency of Favipiravir with Remdesivir.

Life-threatening SARS-CoV-2 Infection in Children: A Single-center Case Series

Introduction: Coronavirus disease 2019 (COVID-19) is known as the most recent pandemic condition declared by the World Health Organization (WHO). It is widely believed that this infection is less frequent and severe in children, but few mortality reports are available in this age group population. Case Presentation: We described nine pediatric patients with probable or confirmed COVID-19 who died due to disease complications. Their age ranged between seven months and 14 years. All had underlying diseases, and three of them had been hospitalized before the COVID-19 diagnosis due to their previous medical conditions. Cough and respiratory symptoms were the most common symptoms observed in these patients. Bilateral ground-glass opacities were common radiologic findings. Conclusions: Although COVID-19 is less common in the pediatric group, all ages are vulnerable to this infection, and mortality may occur, especially in patients with underlying diseases. We emphasize that children with underlying diseases and COVID-19 should be hospitalized and monitored tightly during treatment.

Chest Computed Tomography Findings in a Case Series of Coronavirus Disease 2019 (COVID-19) Patients at Siriraj Hospital

Background: Recent evidence has demonstrated the high sensitivity of chest computed tomography (CT) in coronavirus disease 2019 (COVID-19) case detection. However, considering the cost and infection control issues, the experience of chest CT for COVID-19 diagnosis in Thailand is still limited. Objective: To present the characteristics of chest CT findings in COVID-19 patients at Siriraj Hospital and compare them with other reports. Materials and Methods: The authors retrospectively reviewed the COVID-19 patients’ medical records between April and May 2020. All cases with the presence of chest CT performed during admission were recruited. Clinical data were retrieved from the patients’ medical records. All chest imaging results were reported by consensus between the authors. Results: From 103 cases, four cases with a chest CT scan during the admission were recruited. Consistent with previous reports, the common chest CT findings included a ground-glass opacity and consolidation with bilateral involvement. A round-shaped ground-glass opacity or consolidation was evidenced in half of the cases. The only case with the presence of chest CT scan, which was done 77 days after the onset of COVID-19 symptoms, revealed resolution of the abnormal findings. Conclusion: Chest CT findings in four COVID-19 cases at Siriraj Hospital are consistent with previous reports. Common findings include bilateral ground-glass opacity and consolidation. Keywords: COVID-19, SARS-CoV-2, Computed tomography, Case series

Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State Associated With COVID 19

Background: Cases of patients with combined DKA and HHS associated to COVID-19 are scarce but showed Hispanics patients tended to be associated with higher mortality. Clinical Case: A 51-year-old Mexican man with past medical history of T2DM presented to our hospital with 1-week history of fever, dyspnea, polydipsia, and nausea. Initial vital signs were notable for fever (axillary temperature 39°C) and low oxygen saturation (90% on room air). His examination was notable for a BMI of 31.2 kg/m2. Blood tests showed hyperglycemia (663 mg/dl, n 70–100 mg/dL), hypernatremia (146 mEq/L, n 135–145 mEq/L), hyperchloremia (113 mEq/L, n 95–110 mEq/L), elevated C-Reactive Protein [CRP] (18.7 mg/dl, n < 0.7 mg/dl), elevated lactate dehydrogenase [LDH] (672 U/L, n 100–170 U/L), high D-dimer (3420 ng/ml, n <400 ng/ml), elevated WBC count (13,200 cell/mm3, n 4600–10200 cells/mm3), high neutrophil count (11300 cells/mm3, n 2000–6900 cells/mm3) and low lymphocyte count (200 cells/mm3, n 600–3400 cells/mm3). Arterial blood gas analysis showed metabolic acidosis (pH 7.2 [n 7.35–7.45], bicarbonate 8mmol/L [22–28 mmol/L], anion gap 23.5 [8–16]) with ketones (100 mg/dl, n <5 mg/dl) in the urine analysis. Calculated serum osmolarity resulted of 328 mOsm/kg (n 278–305 mOsm/kg). Electrocardiogram showed no alterations. Chest X-ray revealed bilateral ground-glass opacities with bilateral infiltrates. Blood and urine cultures were negative. The patient tested positive for SARS-CoV-2. Intravenous fluids, insulin infusion with ceftriaxone i.v. (2 g daily) and clarithromycin p.o. (1 g daily) were initiated but did not result in clinical improvement, continuing with fever, hyperglycemia, metabolic acidosis and worsening of respiratory status. At first day of hospitalization, he presented acute respiratory distress syndrome and was intubated and sedated. He developed multi-organ failure and expired after 3 days of mechanical ventilation. Conclusion: DM is a predisposing factor leading to severe COVID-19 disease. Patient showed similar features reported in cases who died of combined DKA and HHS associated with COVID-19: male, Hispanic, poor blood glucose control, mechanical ventilation, elevated CRP with high LDH and D-dimer. In this patient, obesity was an additional feature that led to severe COVID- 19. Reference: Hoe Chan K, Thimmareddygari D, Ramahi A, Atallah L, Baranetsky NG, Slim J (2020) Clinical characteristics and outcome in patients with combined diabetic ketoacidosis and hyperosmolar hyperglycemic state associated with COVID-19: a retrospective, hospital-based observational case series. Diabetes Res Clin Pract 166:108279

Chest computed tomography imaging features in patients with coronavirus disease 2019 (COVID-19).

ObjectiveTo analyze computed tomography (CT) features of symptomatic patients with coronavirus disease 2019 (COVID-19).MethodsNinety-five symptomatic patients with COVID-19 confirmed by reverse-transcription polymerase chain reaction from 1 May to 14 July 2020 were retrospectively enrolled. Follow-up CT findings and their distributions were analyzed and compared from symptom onset to late-stage disease.ResultsAmong all patients, 15.8% had unilateral lung disease and 84.2% had bilateral disease with slight right lower lobe predilection (47.4%). Regarding lesion density, 49.4% of patients had pure ground glass opacity (GGO) and 50.5% had GGO with consolidation. Typical early-stage patterns were bilateral lesions in 73.6% of patients, diffuse lesions (41.0%), and GGO (65.2%). Pleural effusion occurred in 13.6% and mediastinal lymphadenopathy in 11.5%. During intermediate-stage disease, 47.4% of patients showed GGO as the disease progressed; however, consolidation was the predominant finding (52.6%).ConclusionCOVID-19 pneumonia manifested on lung CT scans with bilateral, peripheral, and right lower lobe predominance and was characterized by diffuse bilateral GGO progressing to or coexisting with consolidation within 1 to 3 weeks. The most frequent CT lesion in the early, intermediate, and late phases was GGO. Consolidation appeared in the intermediate phase and gradually increased, ending with reticular and lung fibrosis-like patterns.