Bilateral Lung Infiltrates Research Articles

Acute exacerbation of fibrotic hypersensitivity pneumonitis: incidence and outcomes

BackgroundPatients with fibrotic hypersensitivity pneumonitis (HP) show variable clinical courses, and some experience rapid deterioration (RD), including acute exacerbation (AE). However, little is known about AE in fibrotic HP. Here, we retrospectively examined the incidence, risk factors, and outcomes of AE in fibrotic HP.MethodsThe incidence rates of AE were calculated in 101 patients with biopsy-proven HP. AE was defined as the worsening of dyspnoea within 30 days, with new bilateral lung infiltration and no evidence of infection or other causes of dyspnoea.ResultsDuring follow-up (median: 30 months), 18 (17.8%) patients experienced AE. The 1, 3, and 5 year incidence rates of AE were 6.0, 13.6, and 22.8%, respectively. Lower diffusing capacity of the lung for carbon monoxide (DLCO) and a radiologic usual interstitial pneumonia (UIP)-like pattern were risk factors for AE. In-hospital mortality after AE was 44.4%. Median survival from diagnosis was significantly shorter in patients with AE (26.0 months) than in those with no-AE RD (55.0 months; p = 0.008) or no RD (not reached; p < 0.001). AE remained a significant predictor of all-cause mortality (hazard ratio, 8.641; 95% confidence interval, 3.388–22.040; p < 0.001) after adjustment for age, body mass index, lung function, lymphocyte levels in bronchoalveolar lavage fluid, and the presence of a UIP-like pattern.ConclusionsAE was not uncommon among patients with fibrotic HP and significantly affected prognosis. A lower DLCO value and radiologic UIP-like pattern at diagnosis were associated with the development AE in patients with fibrotic HP.

Multidisciplinary corroboration in differentiation syndrome: a case report

BackgroundDifferentiation syndrome (DS) is a life-threatening complication that may be seen in patients with acute promyelocytic leukaemia undergoing induction therapy with all-trans retinoic acid or arsenic trioxide. It can lead to severe inflammatory response syndrome and shock if adequate measures are not taken immediately. The radiological features of lung nodules with changes in ground-glass opacity can represent DS. The principal unique feature of the case reported here is that the diagnosis of DS was based on imaging results in the absence of a low total leukocyte count.Case presentationA 14-year-old Indian girl diagnosed with acute promyelocytic leukaemia currently undergoing a chemotherapy regimen that included all-trans retinoic acid/arsenic trioxide was sent to the radiology department for investigation of respiratory distress which she had developed soon after the initiation of chemotherapy. Her chest radiograph showed bilateral lower zone lung infiltrates. Computed tomography (CT) revealed changes in ground-glass opacity in the lower lobes with multiple lung nodules. Differential diagnosis included bacterial, viral or fungal infections, leukemic infiltrates, drug toxicity, pulmonary haemorrhage or leukostasis. She was started on dexamethasone immediately after stopping the chemotherapy with all-trans retinoic acid/arsenic trioxide and given ventilatory support. Her condition subsequently improved and her follow-up chest radiograph and CT scan showed a significant reduction of abnormal lung findings. Based on the clinical improvement and the resolution of findings on imaging following the withdrawal of all-trans retinoic acid/arsenic trioxide, we made the diagnosis of DS.ConclusionsThough a rather unusual possibility, the treatment history of the patient enabled a rather crucial diagnosis in the nick of time and imaging played a pivotal role. This case further iterates the importance of keeping DS in mind when dealing with similar patients in the future.

Recovery from COVID-19 Pneumonia in a Heart Transplant Recipient

IntroductionSolid-organ transplant patients have a high risk of severe infection related to Severe Acute Respiratory Syndrome Coronavirus-2. There are limited data on COVID-19 presentation and clinical outcome in a cardiac transplant recipient.Case ReportA 54-year old woman a heart transplant recipient presented with symptoms of fatigue, excessive sleepiness and cough with phlegm for one week. She did not report any fever or shortness of breath. She had a heart transplant six months prior complicated by antibody-mediated rejection. She was treated with plasmapheresis, intravenous immune globulin, and high dose methylprednisolone. She could not have further scheduled RV biopsies due to the lockdown. She remained on a high dose of immune suppressive medication till her current presentation. Her medication included Prednisolone 20mg daily, Mycophenolate Mofetil (MMF) 1g bid, Tacrolimus 7 mg bid for a target FK level 10-15. On her current presentation to the hospital, she was found to be hypoxic, tachypnic, tachycardic with a BP 130/70. Her chest x-ray showed bilateral infiltrates. She had leukopenia 3.5 and lymphopenia 0.2, CRP 25, ferritin 1106, LDH 632, and IL6 87. She was started empirically on oseltamivir, vancomycin and piperacillin/tazobactam. Her COVID-19 PCR result was positive. Subsequently, she was started on Favipiravir loading of 1600 mg for two doses and a maintenance dose of 600 mg twice daily for 7 days. The MMF and tacrolimus were discontinued. The prednisone was switched to hydrocortisone 50mg IV q6h. Despite treatment, she had reduced level of consciousness and progressive bilateral lung infiltrates requiering mechanical ventilation. The multidisciplinary team discussed enrolling patients in the convalescent plasma study. The patient's family was informed and they agreed and consented to proceed with plasma therapy. Two units of compatible ABO plasma therapy was given for two consecutive days. Intravenous dexamethasone was started. She was extubated successfully after ten days. Given her marked clinical improvement, she was started on MMF 1g bid, and tacrolimus adjusted to the target FK level of 5. The patient was discharged home after three weeks of admission.SummaryThis case represents a recent heart transplant recipient who presented with COVID-19 pneumonia. Her treatment involved convalescent plasma transfusion, Favipiravir, dexamethasone, and reduction of immune suppression.

Association of menopausal status with COVID-19 outcomes: a propensity score matching analysis

BackgroundDespite the growing number of studies on the coronavirus disease-19 (COVID-19), little is known about the association of menopausal status with COVID-19 outcomes.Materials and methodsIn this retrospective study, we included 336 COVID-19 inpatients between February 15, 2020 and April 30, 2020 at the Taikang Tongji Hospital (Wuhan), China. Electronic medical records including patient demographics, laboratory results, and chest computed tomography (CT) images were reviewed.ResultsIn total, 300 patients with complete clinical outcomes were included for analysis. The mean age was 65.3 years, and most patients were women (n = 167, 55.7%). Over 50% of patients presented with comorbidities, with hypertension (63.5%) being the most common comorbidity. After propensity score matching, results showed that men had significantly higher odds than premenopausal women for developing severe disease type (23.7% vs. 0%, OR 17.12, 95% CI 1.00–293.60; p = 0.003) and bilateral lung infiltration (86.1% vs. 64.7%, OR 3.39, 95% CI 1.08–10.64; p = 0.04), but not for mortality (2.0% vs. 0%, OR 0.88, 95% CI 0.04–19.12, p = 1.00). However, non-significant difference was observed among men and postmenopausal women in the percentage of severe disease type (32.7% vs. 41.7%, OR 0.68, 95% CI 0.37–1.24, p = 0.21), bilateral lung infiltration (86.1% vs. 91.7%, OR 0.56, 95% CI 0.22–1.47, p = 0.24), and mortality (2.0% vs. 6.0%, OR 0.32, 95% CI 0.06–1.69, p = 0.25).ConclusionsMen had higher disease severity than premenopausal women, while the differences disappeared between postmenopausal women and men. These findings support aggressive treatment for the poor prognosis of postmenopausal women in clinical practice.

Tracheostomy and Improvement in Utilization of Hospital Resources During SARS-CoV-2 Pandemic Surge

The SARS-CoV-2 pandemic has affected millions across the world. Significant patient surges have caused severe resource allocation challenges in personal protective equipment, medications, and staffing. The virus produces bilateral lung infiltrates causing significant oxygen depletion and respiratory failure thus increasing the need for ventilators. The patients who require ventilation are often requiring prolonged ventilation and depleting hospital resources. Tracheostomy is often utilized in patients requiring prolonged ventilation, and early tracheostomy in critical care patients has been shown in some studies to improve a variety of factors including intensive care unit (ICU) length of stay, ventilation weaning, and decreased sedation medication utilization. In a patient surge setting, as long as adequate personal protective equipment (PPE) is available to minimize spread to healthcare workers, early tracheostomy may be a beneficial management of these patients. Decreasing sedative medication utilization may help prevent shortages in future waves of infection and improve patient-provider communication as patients are more alert. Tracheostomy care is easier than endotracheal intubation and may have decreased viral aerosolization risk, particularly if repeat intubation is necessary after a weaning trial. Additionally, tracheostomy patients can be monitored with less staff, decreasing total healthcare worker exposure to infection. To manage risk of exposure, coordination of ventilation controlled by an anesthesiologist or a critical care physician with a surgeon during the procedure can minimize aerosolization to the team. Risk management and resource allocation is of the utmost importance in any global crisis and procedures must be appropriately planned and benefits to patients, as well as minimized exposure to healthcare providers, must be considered. Early tracheostomy could be a beneficial procedure for severe SARS-CoV-2 patients to minimize long-term virus aerosolization and exposure for healthcare workers while decreasing sedation, allowing for earlier transfer out of the ICU, and improving hospital resource utilization.

Outcomes After Vascular Surgery Procedures in Patients with COVID-19 Infection: A National Multicenter Cohort Study (COVID-VAS)

ObjectivesTo analyze the outcome of vascular procedures performed in patients with COVID-19 infection during the 2020 pandemic.MethodsThis is a multicenter, prospective observational cohort study. We analyzed data from 75 patients with COVID-19 infection undergoing vascular surgery procedures in 17 hospitals across Spain and Andorra between March and May 2020. The primary end point was 30-day mortality. Clinical Trials registry number NCT04333693.ResultsThe mean age was 70.9 (45–94) and 58 (77.0%) patients were male. Around 70.7% had postoperative complications, 36.0% of patients experienced respiratory failure, 22.7% acute renal failure, and 22.7% acute respiratory distress syndrome (ARDS). All-cause 30-days mortality rate was 37.3%. Multivariate analysis identified age >65 years (P = 0.009), American Society of Anesthesiologists (ASA) classification IV (P = 0.004), preoperative lymphocyte count <0.6 (×109/L) (P = 0.001) and lactate dehydrogenase (LDH) >500 (UI/L) (P = 0.004), need for invasive ventilation (P = 0.043), postoperative acute renal failure (P = 0.001), ARDS (P = 0.003) and major amputation (P = 0.009) as independent variables associated with mortality. Preoperative coma (P = 0.001), quick Sepsis Related Organ Failure Assessment (qSOFA) score ≥2 (P = 0.043), lymphocytes <0.6 (×109/L) (P = 0.019) leucocytes >11.5 (×109/L) (P = 0.007) and serum ferritin >1800 mg/dL (P = 0.004), bilateral lung infiltrates on thorax computed tomography (P = 0.025), and postoperative acute renal failure (P = 0.009) increased the risk of postoperative ARDS. qSOFA score ≥2 was the only risk factor associated with postoperative sepsis (P = 0.041).ConclusionsPatients with COVID-19 infection undergoing vascular surgery procedures showed poor 30-days survival. Age >65 years, preoperative lymphocytes <0.6 (x109/L) and LDH >500 (UI/L), and postoperative acute renal failure, ARDS and need for major amputation were identified as prognostic factors of 30-days mortality.

SARS-CoV-2 Seroconversion and Viral Clearance in Patients Hospitalized With COVID-19: Viral Load Predicts Antibody Response.

BackgroundThe interdependencies of viral replication and the host immune response in patients with coronavirus disease 2019 (COVID-19) remain to be defined. We investigated the viral determinants of antibody response, the predictors of nonseroconversion, and the role of antibodies on viral dynamics.MethodsThis was a prospective study in patients hospitalized with COVID-19 that was microbiologically confirmed by real-time polymerase chain reaction (RT-PCR). Serial nasopharyngeal and oropharyngeal swabs and plasma samples were obtained for measuring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA and antibodies (total and S-IgG/N-IgG), respectively.ResultsOf 132 patients included, 99 (75%) showed positive antibody titers after a median (Q1–Q3) of 11 (8–14) days. The median (Q1–Q3) follow-up was 74.5 (63.0–87.0) days. In an adjusted linear regression model, time to seropositivity was inversely associated with peak log SARS-CoV-2 viral load (P = .009) and positively with time to viral clearance (P = .004). Adjusted predictors of S-IgG levels were time to viral clearance (P < .001), bilateral lung infiltrates on admission (P = .011), and the time-dependent SARS-CoV-2 RNA (P < .001) and SARS-CoV-2 RNA area under the curve (P = .001). Thirty-three (25%) patients showed undetectable antibody titers. Patients who did not seroconvert had higher cycle threshold values of RT-PCR (38.0 vs 28.0; P < .001), had shorter time to viral clearance (3.0 vs 41.0; P < .001), and were more likely to have SARS-CoV-2 only detected on fecal samples (P < .001). Nonseroconvertors had also lower levels of blood inflammatory biomarkers on admission and lower disease severity.ConclusionsViral replication determines the magnitude of antibody response to SARS-CoV-2, which, in turn, contributes to viral clearance. COVID-19 patients who do not seroconvert exhibit a differential virological and clinical profile.

Awake prone positioning versus non invasive ventilation for COVID-19 patients with acute hypoxemic respiratory failure

ABSTRACT Background: Oxygenation failure one of the main covid-19 presentation in pandemic. Prone position (PP) and non-invasive ventilation (NIV) have been traditionally used in acute respiratory distress syndrome (ARDS) to improve oxygenation and avoiding invasive ventilation complications. Awake proning and noninvasive ventilation are being used as a therapy in COVID-19 hypoxic failure to improve outcomes. Methods: A prospective study of 30 COVID patients admitted in our Hospital critical care isolation. Co-operative hemodynamically stable patients, SaO2 ˂90%, PaO2/FiO2 ˂200, respiratory rate ˃ 24, bilateral lung infiltration on CT chest into two groups (15 pts in each) Oxygen was administered through non-rebreathing mask(NRB) mask O210-15 L/min with awake PP or NIV for 1-2 h each session, 3 h apart during waking hours for the first 3 days. Primary target improve oxygenation (SaO2 > 95% and P/f > 200 mm Hg), avoid intubation. ICU days and hospital stay are the secondary end points. Other COVID therapies were used according to our hospital protocol. Results: The mean SaO2 at admission 79 ± 8.47% in PP, 82 ± 7.05% in NIV, after PP or NIV applying the mean saO2 and paO2 was significantly increased (mean SaO2 93 ± 5.9%, mean PaO2 107 ± 12 mmHg)PP, (mean sop2 95 ± 4.2%, mean PaO2 129 ± 11 mmHg) NIV, the mean pacO2 was decreased significantly in NIV (39.34 ± 5.12 mmHg) compare to PP (43.41 ± 3.2 mmHg) p value ˂0.001 with no significant results regarding the PH (7.40 ± 0.02&7PP group .33 ± 0.06 NIV group), ICU mortality 20% in each group in whom need intubation, with no significant value in ICU or hospital stay . Conclusion: Awake prone positioning and non-invasive ventilation showed marked improvement in SaO2 and PaO2 in COVID-19 patients with improvement in clinical symptoms with reduced rate of intubation with superiority of NIV in hypercapnic patients.

Eosinophilic Granulomatosis with Polyangiitis and Atopy: A Case Report

A 36-year-old male, diagnosed with atopic dermatitis and allergy to egg white when he was a baby, was diagnosed in adolescence with Bird-Egg Syndrome and seasonal rhinoconjunctivitis with bronchial asthma. Five years later, he developed rhinosinusitis, nasosinusal polyposis and persistent bronchial asthma. At the age of 27, this individual presented with eosinophilic esophagogastroduodenitis and peripheral eosinophilia with a total IgE of 1,989 KU/mL and repeatedly tested negative for antineutrophil cytoplasmic antibodies. When he was 31-year-old, the patient was admitted to the hospital due to an exacerbation of his asthma, the onset of fever, bilateral migratory lung infiltrates and maculopapular lesions in the ankles (leukocytoclastic vasculitis). He was also diagnosed with motor-sensory polyneuritis. Finally, this patient met the criteria of allergic granulomatosis with polyangiitis and was treated with Omalizumab (monthly) with effective recovery.

Diabetes and Covid-19 among hospitalized patients in Saudi Arabia: a single-centre retrospective study

BackgroundInformation on the clinical characteristics and outcomes of hospitalized Covid-19 patients with or without diabetes mellitus (DM) is limited in the Arab region. This study aims to fill this gap.MethodsIn this single-center retrospective study, medical records of hospitalized adults with confirmed Covid-19 [RT-PCR positive for SARS-CoV2] at King Saud University Medical City (KSUMC)-King Khaled University Hospital (KKUH), Riyadh, Saudi Arabia from May to July 2020 were analyzed. Clinical, radiological and serological information, as well as outcomes were recorded and analyzed.ResultsA total of 439 patients were included (median age 55 years; 68.3% men). The most prevalent comorbidities were vitamin D deficiency (74.7%), DM (68.3%), hypertension (42.6%) and obesity (42.2%). During hospitalization, 77 out of the 439 patients (17.5%) died. DM patients have a significantly higher death rate (20.5% versus 12.3%; p = 0.04) and lower survival time (p = 0.016) than non-DM. Multivariate cox proportional hazards regression model revealed that age [Hazards ratio, HR 3.0 (95% confidence interval, CI 1.7–5.3); p < 0.001], congestive heart failure [adjusted HR 3.5 (CI 1.4–8.3); p = 0.006], smoking [adjusted HR 5.8 (CI 2.0–17.2); p < 0.001], β-blocker use [adjusted HR 1.7 (CI 1.0–2.9); p = 0.04], bilateral lung infiltrates [adjusted HR 1.9 (CI 1.1–3.3); p = 0.02], creatinine > 90 µmol/l [adjusted HR 2.1 (CI 1.3–3.5); p = 0.004] and 25(OH)D < 12.5 nmol/l [adjusted HR 7.0 (CI 1.7–28.2); p = 0.007] were significant predictors of mortality among hospitalized Covid-19 patients. Random blood glucose ≥ 11.1 mmol/l was significantly associated with intensive care admission [adjusted HR 1.5 (CI 1.0–2.2); p = 0.04], as well as smoking, β-blocker use, neutrophil > 7.5, creatinine > 90 µmol/l and alanine aminotransferase > 65U/l.ConclusionThe prevalence of DM is high among hospitalized Covid-19 patients in Riyadh, Saudi Arabia. While DM patients have a higher mortality rate than their non-DM counterparts, other factors such as old age, congestive heart failure, smoking, β-blocker use, presence of bilateral lung infiltrates, elevated creatinine and severe vitamin D deficiency, appear to be more significant predictors of fatal outcome. Patients with acute metabolic dysfunctions, including hyperglycemia on admission are more likely to receive intensive care.

Abstract S10-01: COVID-19 severity and outcomes in hospitalized patients with cancer at a New York City tertiary medical center: A matched cohort study

Abstract Background: New York City has been at the epicenter of the SARS-CoV-2 (COVID-19) pandemic. Immunocompromised cancer patients may be more vulnerable to COVID-related morbidity and mortality. The objectives of this study were to determine if patients with cancer have worse outcomes compared to their noncancer counterparts and to identify potential demographic and clinical predictors of morbidity and mortality among cancer patients. Methods: We used data from a retrospective observational cohort of adult patients who tested positive for COVID-19 at New York-Presbyterian hospitals between March 3 and April 25, 2020. Patients with active cancer were matched 1:4 to noncancer controls on age, gender, and diabetes status. Using Kaplan-Meier curves and the log-rank test, we compared morbidity (intensive care unit admission and intubation) and mortality outcomes between cancer patients and controls. We identified demographic and clinical predictors of worse outcomes using Cox Proportional Hazard models. Hazard ratios and 95% confidence intervals were calculated for all estimates. Results: We included 445 COVID-19 positive adult patients of whom 89 had active malignancy. Among cancer patients, the median age was 72 years, 54% were male, and 52% were non-white. Presenting symptoms were similar between cancer and noncancer groups. Nearly half of cancer patients were on active treatment including cytotoxic and immunosuppressive therapy, and 40.9% of patients received cytotoxic treatment within 90 days of admission. Both patients with and without cancer received hydroxychloroquine in similar proportions (64% vs. 65.5%), and more cancer patients received remdesivir (7.9% vs. 3.7%). Overall, age (HR 1.14; 95% CI 1.00-1.29; p=0.049), male sex (HR 1.43; 95% CI 1.04-1.96, p=0.07), dyspnea on presentation (HR 1.81, 95% CI 1.3-2.58; p=0.0005), and bilateral lung infiltrates (HR 1.94; 95% CI 1.30-2.89; p=0.001) were associated with worse outcomes. Observed complications were similar for cancer and noncancer patients, including myocardial infarction (3.4% vs. 4.2%), vasopressor requirements (24.7% vs. 26.2%), bacteremia (9% vs. 10.4%), and venous thromboembolic events (7.9% vs. 7.3%), respectively. There were no statistically significant differences in morbidity or mortality between cancer and noncancer patients (p=0.287). Conclusion: We demonstrate that COVID-19 hospitalized patients with active malignancies have comparable morbidity and mortality to patients without cancer. In contrast to previous findings, we observed no differences in risk of ICU admission, intubation, or death between cancer and noncancer patients. Our findings suggest that active malignancy may not be a contributive risk factor in comparison to other significant comorbidities that may be more responsible for the unfavorable prognosis of COVID-19 in cancer patients. We should consider the consequences of limiting care for cancer patients on cancer-specific outcomes and mortality in the context of COVID-19. Citation Format: Gagandeep Brar, Laura C. Pinheiro, Michael Shusterman, Brandon Swed, Evgeniya Reshentnyak, Orysya Soroka, Frank Chen, Samuel Yamshon, John Vaughn, Peter Martin, Doru Paul, Manuel Hidalgo, Manish A. Shah. COVID-19 severity and outcomes in hospitalized patients with cancer at a New York City tertiary medical center: A matched cohort study [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S10-01.

COVID-19 and Thrombocytopenia: Heparin or Sepsis-Induced?

About 40% of SARS-CoV-2 positive patients are asymptomatic but infectious. More common symptoms are fever, dry cough and dyspnea but some patients might experience also myalgia, diarrhea, anosmia and ageusia. Severe cases present a severe pneumonia that could exitate in an acute respiratory distress syndrome (ARDS) characterized by acute hypoxemic respiratory failure and bilateral lung infiltrates.

The SARS-CoV-2 Coronavirus and the COVID-19 Outbreak

ABSTRACTThe SARS-CoV-2, a newly identified β-coronavirus, is the causative agent of the third large-scale pandemic from the last two decades. The outbreak started in December 2019 in Wuhan City, Hubei province in China. The patients presented clinical symptoms of dry cough, fever, dyspnea, and bilateral lung infiltrates on imaging. By February 2020, The World Health Organization (WHO) named the disease as Coronavirus Disease 2019 (COVID-19). The Coronavirus Study Group (CSG) of the International Committee on Taxonomy of Viruses (ICTV) recognized and designated this virus as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The SARS-CoV-2 uses the same host receptor, angiotensin-converting enzyme 2 (ACE2), used by SARS-CoV to infect humans. One hypothesis of SARSCoV-2 origin indicates that it is likely that bats serve as reservoir hosts for SARSCoV-2, being the intermediate host not yet determined. The predominant route of transmission of SARS-CoV-2 is from human to human. As of May 10th 2020, the number of worldwide confirmed COVID-19 cases is over 4 million, while the number of global deaths is around 279.000 people. The United States of America (USA) has the highest number of COVID-19 cases with over 1.3 million cases followed by Spain, Italy, United Kingdom, Russia, France and Germany with over 223.000, 218.000, 215.000, 209.000, 176.000, and 171.000 cases, respectively.

Experiences from the epicenter: an observational report on converting a post anesthesia care unit to a COVID-19 intensive care unit

Experiences from the epicenter: an observational report on converting a post anesthesia care unit to a COVID-19 intensive care unit

Osseous manifestations of sarcoidosis.

Sarcoidosis is a systemic multisystem inflammatory disease of unknown etiology. The disease is characterized by formation of non-caseating granulomas. The most common presentation is bilateral hilar lymphadenopathy and lung infiltration, but the disease is very heterogeneous, with an unpredictable clinical course. Musculoskeletal manifestations are common. Bone involvement is less frequent, and usually occurs in patients with chronic multisystem course of the disease. They are most commonly found in the phalanges of hands and feet, and are usually bilateral. The skull, long bones, ribs, pelvis, and axial skeleton may also be affected.Osseous involvement may be asymptomatic but in some cases can cause a severe disability. Imaging techniques are important for diagnosis. Radiological investigations revealed sclerotic or destructive lesions (involving also joints), cystic and punched out lesions and cortical abnormalities. Biopsy is required for differential diagnosis with respect to malignancy. Treatment is a part of systemic therapy and is not needed in all cases. Glucocorticoids and TNF-α antagonists are used for management.

Description of patients with severe COVID-19 treated in a national referral hospital in Peru.

In order to describe manifestations from patients with coronavirus disease 2019 (COVID-19), sociodemographic variables such as, previous medical history, clinical and radiological manifestations, treatments and evolution of patients were evaluated. This took place from March 6th to 25th, 2020, in the "Edgardo Rebagliati Martins" National Hospital in Lima. Seventeen patients were registered: 76% were male, with an average age of 53.5 years (range 25-94); 23.5% had returned from abroad; 41.2% were referred from other health facilities; 41.2% were admitted to mechanical ventilation; 29.4% (5 patients) died. The risk factors detected were: advanced age, arterial hypertension and obesity. The main symptoms detected were: cough, fever and dyspnea. Frequent laboratory findings were: elevated C-reactive protein and lymphopenia. The predominant radiological presentation was bilateral interstitial lung infiltrate. A first experience in the management of patients diagnosed with severe COVID-19 in Peru is reported.

Real-Life Study of Mepolizumab in Idiopathic Chronic Eosinophilic Pneumonia.

Idiopathic chronic eosinophilic pneumonia (ICEP) is an orphan lung disease characterized by concomitant systemic and local eosinophilia, along with bilateral lung infiltrates. Symptoms include dyspnea of subacute/chronic onset, cough, and general systemic signs. Although all patients do respond to oral corticosteroids, relapse rate is very high, which highlights the need for alternative therapies in case of relapsing ICEP. Mepolizumab is a fully humanized antibody directed against interleukin 5, a key growth factor of eosinophils. In the present study, we retrospectively studied the effect of off-label use of mepolizumab for relapsing ICEP. All data from patients treated with mepolizumab for relapsing ICEP were included in our database and diagnoses were reviewed. We analyzed the effect of treatment on relapse rate, oral corticosteroids (OCS) use, and lung lesions on high-resolution computed tomography (HRCT). We included ten patients in the final analysis, with a median follow-up of 9months after initiation of mepolizumab. Beside its expected effect on circulating eosinophils, treatment with mepolizumab was associated with a significant reduction of annual rate of exacerbations and a reduced consumption of corticosteroids. We also observed a remission of lung lesions on follow-up HRCT. In this open-label retrospective study, treatment of ICEP with mepolizumab was associated with a reduction of relapses, OCS use, and the disappearance of lung infiltrates.

A Case of Pulmonary Histoplasmosis Presenting with Hypercalcemia and Altered Mental Status in a Patient Following Allogeneic Hematopoietic Stem Cell Transplantation

Patient: Male, 75-year-oldFinal Diagnosis: Pulmonary histoplasmosisSymptoms: Altered mental status • cough • shortness of breathMedication: —Clinical Procedure: —Specialty: PulmonologyObjective:Rare co-existance of disease or pathologyBackground:Histoplasmosis results from the inhalation of spores from the fungus, Histoplasma capsulatum. A case is presented of pulmonary histoplasmosis associated with altered mental state and hypercalcemia following allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia (AML).Case Report:A 75-year-old man with a five-day history of AML treated with allogeneic hematopoietic stem cell transplantation, presented with weakness, fatigue, and slow mentation. Computed tomography (CT) of the brain was unremarkable. Laboratory investigations showed serum albumin of 2.9 g/dL, calcium of 11.6 mg/dL, ionized calcium of 1.55 mmol/L, parathyroid hormone (PTH) <6.3 pg/mL, and 25-hydroxy vitamin D of 14.4 ng/mL. Treatment began with intravenous cefepime 1 gm bid, normal saline, and the bisphosphonate, pamidronate, administered as a single dose. Three days later, his clinical status declined. He developed a dry productive cough, his oxygen saturation (O2 Sat) was 90%, and his mental status worsened. Chest CT showed diffuse bilateral lung infiltrates with ground glass opacities. Bronchioalveolar lavage and transbronchial biopsy were negative for Pneumocystis jiroveci pneumonia (PJP). The CMV viral load was 195 IU/mL. Urinalysis for Histoplasma antigen and the Fungitell® assay were positive. Treatment commenced with intravenous voriconazole (250 mg, bid) and ganciclovir (5 mg/kg, bid). A left lower lobe transbronchial lung biopsy was positive for Histoplasma capsulatum and negative for CMV.Conclusions:This case report has highlighted the need for awareness of the diagnosis of histoplasmosis in patients with allogeneic hematopoietic stem cell transplantation who present with an altered mental state in the setting of hypercalcemia.

An Update on Initial Epidemiological Profile, Clinical Course, and Outcome of COVID-19 Patients at a Tertiary Care Center in India.

Background and Aim:Coronavirus disease 2019 (COVID-19) has become a global pandemic with the spectrum of disease from asymptomatic or mild disease to severe cases requiring intensive care unit (ICU) admission. In India, it started with milder presentation affecting younger population. Later on, an increase in disease severity was observed involving older age group as well. However, there is a paucity of published data regarding patients requiring ICU care in India. This case series describes the initial experience of an ICU in India regarding epidemiological profile, clinical course, and outcome of critically ill COVID-19 patients.Methods:This case series included 27 consecutive laboratory-confirmed COVID-19 patients who were admitted in a tertiary care ICU over 14 days period, followed up till their discharge from ICU. Demographic and clinical data, including laboratory and radiological findings, were compiled with special attention to co-morbidities of the patients. The management of these patients was done as per the institutional protocol for critically ill COVID-19 patients.Results:The median age of the patients was 50 years with no difference in gender. Comorbid conditions were seen in 85% of the patients with diabetes (43.7%) and hypertension (37.5%) as the most common conditions. The median duration of symptoms before admission was 6 days with fever as the most common clinical symptom at presentation. Chest roentogram showed bilateral lung infiltrates in 88.8% of the patients. Mild, moderate, and severe hypoxia were observed in 3, 8, and 16 patients, respectively. Ten patients were managed with oxygen therapy. Seventeen patients (62.9%) required ventilatory support. Mortality rate among patients admitted to our ICU was 59.2%.Conclusions:This case series shows middle-aged patients with comorbid diseases present with severe COVID-19 disease and have poor outcome.

Pneumocystis Jiroveci Mimicking COVID-19 Pneumonia in a Patient who Receiving Ipilimumab and Nivolumab Combination Therapy: A Case Report

The novel coronavirus SARS-CoV-2 , which first appeared in December 2019, threatened the world within a few months. Being preoccupied with the risk of this disease might mislead the clinicians and prevent them from providing the best care to their patients who are also exposed to other risks and conditions. In this article, we present a metastatic melanoma patient, who presented with fever, respiratory symptoms and a diffuse bilateral lung infiltration with ground-glass opacities treated with immunotherapy. He was first suspected of having COVID-19 pneumonia, but then Pneumocystis Jiroveci pneumonia was correctly diagnosed and this had to be decided in a timely manner so as not to lose the patient. Keywords: Cancer, COVID-19, checkpoint inhibitors, computed X-ray tomography; ground glass opacities, pneumocystis