Multiple Ground-glass Opacities Research Articles

Electromagnetic Navigation Bronchoscopy-Guided Microwave Ablation Combined With Uniportal Video-Assisted Thoracoscopic Surgery for Multiple Ground Glass Opacities

BackgroundAn increasing number of patients are being diagnosed with multiple ground glass opacities (GGOs), but a consensus on the treatment of these patients is still lacking. The aim of this study was to investigate the safety and feasibility of a novel technique, electromagnetic navigation bronchoscopy (ENB)-guided microwave ablation combined with uniportal video-assisted thoracoscopic surgery in patients with multiple GGOs. MethodsThe clinical, radiographic, surgical, and pathologic data of patients with multiple GGOs who underwent ENB-guided microwave ablation combined with uniportal video-assisted thoracoscopic surgery from October 2018 to December 2019 were reviewed. ResultsEleven patients with multiple GGOs underwent ENB-guided microwave ablation combined with uniportal video-assisted thoracoscopic surgery; they included 6 men and 5 women with a mean age of 61.3 ± 5.1 years (range, 53 to 68). Thirty-seven lesions were observed in the 11 patients, 21 of which were microwave ablated and 16 of which were surgically resected. Only 1 patient had postoperative pneumothorax and subcutaneous emphysema and was successfully discharged from the hospital after symptomatic treatment. The success rate and the efficiency of microwave ablation under ENB guidance were both 100%, with no other serious complications or procedure-related deaths occurring. No local metastasis or recurrence occurred in any patients during the follow-up period. ConclusionsElectromagnetic navigation bronchoscopy-guided microwave ablation combined with uniportal video-assisted thoracoscopic surgery is safe and feasible in patients with multiple GGOs suspected of having multiple primary lung cancers, and may represent an alternative approach for more patients, particularly patients who cannot tolerate the simultaneous resection of multiple tumors.

A longitudinal follow-up of COVID-19 patients in the convalescent phase showed recovery in radiological results, the dynamics of lymphocytes, and a decrease in the level of IgG antibody: a single-centre, observational study.

BackgroundGiven the high prevalence of coronavirus disease 2019 (COVID-19) globally, and the increased number of patients being discharged, it is necessary to understand the health consequences of COVID-19 to formulate and manage public policy concerning convalescent patients.MethodsA longitudinal follow-up investigation of 25 patients from a tertiary hospital in Henan provincial was conducted 8 weeks after discharge. Of these patients, 15 attended a second follow-up appointment 8 weeks after that. A throat swab reverse transcription-polymerase chain reaction (RT-PCR) analysis for SARS-CoV-2 and chest computerized tomography (CT) scans were implemented at the first follow-up appointment, and a total of 40 blood samples (25 from the first and 15 from the second follow-up appointment) were collected. Patients’ levels of Immunoglobulin G (IgG) antibody against S-Receptor binding domain (S-RBD) and Nucleocapsid Protein (NP) of SARS-CoV-2 and the subpopulation of lymphocytes were evaluated using an enzyme-linked immunoassay (ELISA) test and flow cytometry, respectively.ResultsAt the first follow-up appointment, 10 of the 25 patients (40.0%) showed complete radiological resolution. Of these patients, 80.0% were classified as moderate, and 80.0% were younger (those whose age was ≤ the median age of all the patients). The predominant patterns of abnormalities included an irregular line (12/25, 48.0%), ground-glass opacity (GGO) (44.0%), and multiple GGOs (28.0%). At the first follow-up appointment, 40.0% (10/25) of patients still had lymphopenia. Of the 15 patients who were followed-up with twice, the ratio of lymphopenia was 80% (12/15), 60.0% (9/15), and 46.7% (7/15) at 0, 8, and 16 weeks after discharge, respectively. This was mainly due to a decrease in the cluster of differentiation (CD) 4+ T lymphocyte, which was observed in 60% (9/15), 60% (9/15), and 46.7% (7/15) of total patients at 0, 8, and 16 weeks after discharge, respectively. All of the patients were S-RBD and NP IgG antibody positive at the first follow-up appointment. 40.0% (6/15) and 66.7% (10/15) of patients showed a decrease over 50.0% in the level of NP and S-RBD IgG antibodies, respectively, at the second follow-up appointment. The NP and S-RBD IgG antibodies’ levels declined to 44.6% (P=0.044) and 28.1% (P=0.18), respectively. 0 and 26.7% (4/15) of patients turned from NP and S-RBD IgG antibody positive to negative, respectively.ConclusionsAbout half of the patients still showed at least 1 abnormality in chest CT scans 8 weeks after discharge and lymphopenia 16 weeks after discharge. The level of the IgG antibody had declined by the follow-up appointment. Notably, the S-RBD IgG antibody declined more dramatically than that of NP. These results may have implications in the making of policies related to disease prevention, the long-term management of discharged patients, and vaccines’ development.

Comparison of Perioperative Outcomes Between Precise and Routine Segmentectomy for Patients With Early-Stage Lung Cancer Presenting as Ground-Glass Opacities: A Propensity Score-Matched Study

IntroductionSegmentectomy is widely used for early-stage lung cancer presenting as single or multiple ground-glass opacities (GGOs). Precise segmentectomy is the recommended procedure in China. However, clinically, most routine segmentectomies are performed using only high-resolution computed tomography (CT). The aim of this study was to evaluate the effect of two segmentectomy approaches for GGOs in the lung.MethodsFrom January 2020 to September 2020, 55 precise segmentectomies performed with real-time guidance using 3D reconstruction and 343 routine segmentectomies for patients with single or multiple GGOs were performed as uniportal procedures. To reduce bias related to outcomes, preoperative clinical factors were used for propensity score matching (1:1); 55 precision and 55 routine segmentectomies were selected and further analyzed. Perioperative outcomes, namely operation time, blood loss, resection margins, number of removed lymph nodes, postoperative pulmonary function (1 month after surgery), length of postoperative stay, and postoperative complications were compared between the two groups.ResultsPatients constituted 43 men and 67 women, with an age range of 25–68 years (median: 53 years). No significant differences were seen between the groups regarding blood loss, complications, histological type, and postoperative pulmonary function, and there were no 30-day postoperative deaths in either group. The median operation time for the Precision group (74 min) was longer than in the Routine group (55 min) (p <0.01), and the number of removed lymph nodes in the Precision group (5 ± 1.1) was higher than in the Routine group (3 ± 0.8) (p <0.01). Chest tube duration days and postoperative stay days were similar in both groups; however, the rate of air leakage on postoperative day 1 was higher in the Precision group (p = 0.020). All patients in the Precision group had adequate resection margins. Four patients (7.3%) undergoing complex segmentectomy in the Routine group had inadequate resection margins and required resection of additional lung tissue.ConclusionRoutine segmentectomy can significantly shorten the operation time and might prevent postoperative air leakage in uniportal segmentectomy for lung GGOs. However, precision segmentectomy may be more precise for complex cases, ensuring adequate resection margins and lymph node dissection.

Clinical features of 141 fatal cases of coronavirus disease in Jinyintan Hospital in Wuhan, China

Objective: To describe the epidemiological characteristics and clinical features of patients with fatal coronavirus disease (COVID-19), in order to provide evidence for clinical diagnosis and treatment. Methods: In this retrospective study, we analyzed data on 141 fatal cases of confirmed COVID-19 that occurred among patients in Jinyintan Hospital in Wuhan, China, from January 20 to March 6, 2020. We analyzed their epidemiological characteristics, clinical and radiological features, laboratory results, and treatment. Results: Of the 141 patients (49 females, 92 males), the median age was 77 years (range: 24-92 years). The most likely source of exposure included the Huanan seafood market (n=3, 2%), family members (n=6, 4%), and hospital-acquired infection (n=8, 6%). The remaining 116 patients (72%) had no known source of exposure. Of the patients, 101 (72%) had chronic diseases. The most common comorbidities were hypertension, diabetes and coronary heart disease. The most common clinical manifestations were fever (n=121, 85%), dry cough (n=77, 54%), shortness of breath (n=23, 16%), and chest pain (n=15, 10%). Less common clinical manifestations included fatigue (n=7, 4%), headache (n=3, 2%), disorders of consciousness (n=2, 1%), diarrhea (n=2, 1%) and lumbago (n=1, 0.7%). In terms of laboratory tests, the absolute value of lymphocytes in most patients was reduced (n=132, 94%), but C-reactive protein (n=141, 100%), procalcitonin(n=121, 89%), serum amyloid (n=140, 99%) were significantly increased. The most common findings on imaging of the lungs were bilateral multiple mottling and ground-glass opacity (n=101, 72%), mainly in the lower lobes (n=15, 10%), with lesions being more common on the right. Other imaging findings included diffuse consolidation (n=4, 3%), ground-glass opacity and consolidation (n=20, 14%), and pneumothorax (n=1, 0.7%). All patients were treated with antibiotics and antiviral drugs. Other treatments included immunoglobulin (n=49, 35%), corticosteroids (n=45, 32%), continuous renal replacement therapy (n=24, 17%), and extracorporeal membrane oxygenation (n=12, 9%). All patients were treated with oxygen therapy. The mode of administration included invasive mechanical ventilation (n=61, 43%), noninvasive mechanical ventilation (n=65, 46%), and nasal catheter oxygen inhalation (n=15, 11%). The direct causes of death were acute respiratory distress syndrome (n=90, 64%), multiple organ failure (n=24, 17%), sudden cardiac arrest (n=11, 8%), viral myocarditis (n=8, 5%), acute myocardial infarction (n=4, 3%), cerebrovascular accident (n=3, 2%), and acute gastrointestinal bleeding (n=1, 0.7%). Conclusions: Risk factors for death due to COVID-19 included older age, male sex, and the presence of comorbidities. The most common direct causes of death were acute respiratory distress syndrome, multiple organ failure, sudden cardiac arrest, and viral myocarditis.

Clinico-radiologic Characteristics of Pulmonary Visceral Larva Migrans Caused by Ascaris suum.

Objective Visceral larva migrans (VLM) caused by Ascaris suum is a major health problem in pig farming regions. The clinical characteristics of pulmonary VLM caused by A. suum, however, are unclear. We assessed the clinico-radiologic features of this disease. Methods Medical records, including the results of chest radiography and high-resolution computed tomography (HRCT), were retrospectively reviewed from January 2000 through June 2019, at the University of Miyazaki Hospital and Kyoritsuiin Hospital in Miyazaki Prefecture, Japan. Results Seven patients with VLM caused by A. suum were identified. All seven patients had a unique habit of consuming raw foods, such as organic vegetables, chicken, turkey, wild boar, and venison. All but one patient, who had eosinophilic pneumonia with a fever and severe fatigue, had only mild or no respiratory symptoms. All 7 patients had remarkable eosinophilia (median, 1,960 /μL) and high serum IgE levels (median, 1,346 IU/mL). Chest HRCT revealed multiple nodules and multiple nodular ground-glass opacities in 57% and 29% of the patients, respectively. The pulmonary lesions were located predominantly in subpleural areas. All seven patients were treated with albendazole, which led to improvement within two to three months. Neither eggs nor parasites were detected in the feces or sputum of any patient. Conclusion Consumption of raw organic vegetables or raw meat is a possible route of A. suum infection. Infected patients exhibit mild respiratory symptoms, and multiple nodules with a halo in the subpleural area are a common finding on chest HRCT. Treatment with albendazole was effective in these cases.

COVID-19 in a pediatric cohort\u2014retrospective review of chest computer tomography findings

BackgroundRadiological features of the novel 2019 coronavirus disease (COVID-19) have been mainly described in adults. Available literature states that imaging findings in children are similar but less pronounced. The aim of this study is to describe and illustrate the chest computer tomography (CT) features of pediatric COVID-19.ResultsThis retrospective study was based on the review of all the chest CTs performed in pediatric patients with confirmed COVID-19 disease between March 8th and May 26th 2020 (n = 24). The presence of comorbidities and coinfection was assessed, as well as timing of CT examination in relation to the onset of symptoms. CT findings were categorized as typical, indeterminate, atypical, and negative for COVID-19 according to International Expert Consensus Statement on Chest Imaging in Pediatric COVID-19 Patient Management. This study found that CT findings were abnormal in 17 (71%) patients, with 5 (21%), 9 (38%), and 3 (13%) patients considered to have typical, indeterminate, and atypical findings, respectively. The most common CT patterns were multiple ground-glass opacities (58%), followed by consolidations (50%). Six patients showed predominantly peripheral distribution of parenchymal abnormalities. A halo sign was identified in 3 patients and a perilobular pattern was identified in one of the cases with typical findings.ConclusionsChest CT findings in children infected with SARS-CoV-2 can be subtle or absent. Besides recognizing typical findings, radiologists should be able to identify features that favor different or concomitant diagnosis.

Venous Thromboembolism as an Initial Manifestation of COVID-19 in a Heart Transplant Patient

IntroductionThe disease caused by the coronavirus 2019 (COVID-19) is mainly characterized by symptoms related to the upper respiratory tract associated with fever and constitutional symptoms, progressing in the most severe cases to pneumonia and severe acute respiratory syndrome (SARS). However, due to the increasing number of cases, atypical presentations have been found. Among them, thromboembolic manifestations stand out, since the virus itself seems to predispose to changes in the coagulation system.Case ReportA 62-year-old male patient who underwent cardiac transplantation 6 months ago, secondary to chagasic cardiomyopathy, had pain and edema in his left foot for 1 week. Upon admission, he was eupneic, afebrile, heart rate of 96bpm, blood pressure of 120 × 70mmhg, with edema and erythema on his left foot. Chagas reactivation, cellulite or deep vein thrombosis were the diagnostic hypotheses suggested. Soft tissue ultrasound and venous doppler of the left lower limb were compatible with deep venous thrombosis and superficial thrombophlebitis. Skin lesion biopsy confirmed Chagas reactivation. Antibiotic therapy with cefazolin, full anticoagulation with enoxaparin and treatment with benzonidazole were introduced. In the second day of hospitalization, patient presented myalgia and dry cough, in addition to an increased C-reactive protein and multiple ground-glass opacities on computed tomography of the chest, suggestive of COVID-19. This finding was corroborated by a positive result of RT-PCR for SARS-COV2. The patient evolved with SARS, requiring progressive use of vasoactive drugs, mechanical ventilation and pronation.SummaryIt is currently known that COVID-19 increases the risk of thromboembolic events, especially in hospitalized patients, reaching an incidence of 25%, even in the presence of effective prophylaxis. Several mechanisms have been proposed for this association, but not with robust evidence. Despite these increased cases, there are no reports in the literature of initial presentation with a thromboembolic event in a heart transplant patient, emphasizing the importance of clinical suspicion and appropriate investigation.

Bronchiectasis is one of the indicators of severe coronavirus disease 2019 pneumonia.

Bronchiectasis is one of the indicators of severe coronavirus disease 2019 pneumonia.

COVID-19 integrated imaging: our experience and literature review.

PurposeTo investigate the imaging features of emerging COVID-19 pneumonia on chest ultrasound, radiographs and computed tomography examinations performed at admission. In addition, we provide a review of the literature and compare our results with recent evidence regarding the imaging characteristics of this novel disease.Material and methodsFrom March 17, 2020 to April 25, 2020, 23 patients with real-time polymerase chain reaction (RT-PCR) assay confirmed COVID-19 were identified. All 23 patients were evaluated and admitted at San Giuseppe Moscati Hospital in Aversa, Italy. Multi-modality imaging findings were evaluated and compared. Literature research was conducted through a methodical search on PubMed.ResultsTwenty-three patients were included in the study. Chest transthoracic ultrasound (US), chest X-ray (CXR), and computed tomography (CT) were performed respectively in 11, 16 and 21 patients. Chest US findings were consistent with diffuse B lines (91%), subpleural consolidations (45%), and thickened pleural line (18%). CXR showed prevalent manifestations of consolidations (50%) and hazy increased opacities (37%). Typical CT features are bilateral and multilobar ground-glass opacities (GGO). Indeed GGO were present in 100% of our patients. Consolidations were visible in 76% of our study population. Notably both GGO and consolidations had a peripheral distribution in all our patients. Other CT imaging features included crazy-paving pattern, fibrous stripes, subpleural lines, architectural distortion, air bronchogram sign, vascular thickening and nodules. Our literature review identified thirty original studies supporting our imaging chest findings.ConclusionsAt admission, COVID-19 pneumonia can manifest in chest imaging as B-lines and consolidations on US, hazy opacities and consolidations on CXR, multiple GGO and consolidations on CT scan.

High cholesterol in COVID-19 leading to lung consolidation and bronchiectasis.

A 60-years-old male with high cholesterol and a Modified Medical Research Council (mMRC) dyspnoea score of 2 was admitted with a history of fever, cough, dyspnoea. Initial chest radiograph (A) showed bronchiectasis in right base with pneumonia in the left base. A diagnosis of COVID-19 was confirmed with positive SARS-CoV-2 RT-PCR on nasal swab. There were some typical findings on CT images. According to the CT images (B), the case was classified as of stage I consolidation with multiple peripheral ground glass opacities with interlobular septal thickening were seen in anterior and inferior lingular segment of left upper lobe, posterior basal segment of left lower lobe, posterior segment of right upper lobe, and medial segment of right middle lobe. Initially he was on IV steroids and therapeutic doses of heparin. He was maintaining his oxygen saturation to 96%. Ten (10) days after hospitalization and normalization of all inflammatory markers, he has Modified Medical Research Council (mMRC) dyspnoea score 1 and oxygen-independent. The patient was asked for follow up in 6 weeks. Due to the mMRC of 1 and short history, it is assumed that the fibrosis was not present prior to the COVID-19 diagnosis. The early use of antifibrotics may prevent this devastating complication, but it is difficult to predict who is likely to progress to pulmonary fibrosis. Early rehabilitation protocol for post-acute COVID-19 patients can minimize dyspnea and shortness of breath even for minimal activities.

SARS-CoV-2 atypical viral pneumonia with 25/25 computed tomography score.

A-36-year old female patient came to the emergency department with the complains of fever with chills, along with progressing breathing difficulty since 8 days. She was advised rapid antigen test on 22/04/2021 and a sample was taken for reverse transcription polymerase chain reaction (RT PCR), both came out to be positive for SARS-CoV-2. Following this, her high-resolution computed tomography (HRCT) thorax (A) was done which reveals multiple ill-defined patchy ground-glass opacities with consolidation, septal thickening, and fibrotic changes in bilateral lung fields as described above signs suggestive of COVID-19 changes with atypical viral pneumonia. The computed tomography (CT) severity score was 25/25 (severe) with CORAD grade 6. The patient was immediately admitted to the isolation ICU. High flow O2 support was started as SpO2 on admission was 44% on room air. Despite high flow of O2, patient was breathless and SpO2 was 57%. She was hence taken on BiPAP with a 14-8 setting with O2 support. Along with medical management, physiotherapy treatment was administered. After 22 days the RT PCR was reported negative and was shifted to high dependency unit and advised chest X-ray (B) which suggestive of bilateral opacities seen in bilateral lobes and right hemi diaphragm is pulled up. She received regular physiotherapy and was gradually wean off from ventilator and was maintaining saturation at the flow rate of 15 litre O2/min. Early administration of rehabilitation program will help in prevent further complications among such patients.

Cardiac Injury in COVID-19: A Systematic Review.

Coronavirus 2019 (COVID-19) is responsible for the current pandemic which has already resulted in considerable mortality worldwide. This systematic review was conducted to summarize the results of the published articles assessing the incidence of heart diseases in patients infected with COVID-19. The electronic databases Scopus, Web of Science, Pubmed, Science Direct, and ProQuest were used to search for potentially relevant articles. Articles published from Dec 2019 to April 2020 were included. All cross-sectional, retrospective or prospective observational cohort and case-control studies were selected which reported the incidence or prevalence of myocardial injury, myocardial infarction, or cardiovascular disease in patients with confirmed COVID-19 infection. Based on the inclusion criteria, 12 articles were selected. The incidence of cardiac injury was reported in 8 articles and 8 articles focused on the cardiovascular outcomes of COVID-19 infection. The incidence of new cardiac injury was reported to be 7.2-77% in live and dead patients, respectively. The results showed that patients with cardiac injury had worse outcomes including higher mortality than those without cardiac injury. The most common cardiac injury outcomes were shock and malignant arrhythmias. The most common radiographic findings in patients with cardiac injury were multiple mottling and ground-glass opacities in the lungs (64.6%). A significant number of patients with cardiac injury required noninvasive mechanical ventilation (46.3%) or invasive mechanical ventilation (22.0%). Acute respiratory distress syndrome was seen in 58.5%, acute kidney injury in 8.5%, electrolyte disturbances in 15.9%, hypoproteinemia in 13.4%, and coagulation disorders in 7.3% of patients with cardiac injuries. In addition, survival days were negatively correlated with cardiac troponin I levels (r=-0.42, 95%, p=0.005). The results of this review showed that myocardial injury in patients with COVID 19 has a poor prognosis. Hence, cardiac investigation and management in these patients are crucial.

Post COVID-19 lung fibrosis and pleural effusion in geriatric patient.

An 81-year-old male who has hypertension in the last 15 years coming to our hospital with a chief complaint of severe breathlessness, chest pain with a history of fever spike in the last 20 days. When he underwent real-time reverse transcription-polymerase chain reaction (RT-PCR) test, the test comes positive with SARS COVID-19. Routine test high-resolution computed tomography (HRCT) showed approximately 75% of the left side and 50% of right lung involvement with CO-RAD 6 and HRCT severity score 20. HRCT showed multiple ill-defined patchy ground-glass opacity with consolidation and septal thickening in the bilateral lung field. There is a finding of fibrotic changes with tractional bronchiectasis in bilateral lung field with minimal pleural effusion.

Potential impact of the COVID-19 in HIV-infected individuals: a systematic review Impact of the COVID-19 in HIV-Infected Individuals.

Although much has been studied about the SARS-Cov-2 virus, its effects, and the effectiveness of possible treatments, little is known about its interaction with other infectious diseases. The aim is to study its clinical features and morbidity, and mortality outcomes of COVID-19 patients with HIV/AIDS coinfection. MEDLINE, Web of Science, Embase, CINAHL, LILACS, Scopus, ClinicalTrials.gov, and Cochrane. Atudies in any language, published after 2019, were describing COVID-19 patients with HIV/AIDS. JBI Levels of Evidence, Joanna Briggs Institute. As shown in the PRISMA flow diagram, two authors separately screened the search results from the obtained titles and abstracts. Chest CT was observed in patients with pneumonia by SARS-CoV-2 with findings of multiple ground-glass opacities (GGO) in the lungs, there is a need for supplemental oxygenation. One patient developed encephalopathy and complicated tonic-clonic seizures; four patients were transplanted (two, liver; two, kidneys), one patient developed severe SARS-CoV-2 pneumonia and 30 patients died (mortality rate, 11%). HIV did not show any relevance directly with the occurrence of COVID-19. Some studies suggest that HIV-1 infection through induction levels of IFN-I, may to some extent, stop the apparent SARS-CoV-2 infection, thus leading to undetectable RNA. Moreover, some authors suggest retroviral therapy routinely used to control HIV infection could be used to prevent COVID-19 infection.

Differential diagnosis of high altitude pulmonary edema and COVID-19 with computed tomography feature

To investigate the computed tomography (CT) characteristics and differential diagnosis of high altitude pulmonary edema (HAPE) and COVID-19, CT findings of 52 cases of HAPE confirmed in Medical Station of Sanshili Barracks, PLA 950 Hospital from May 1, 2020 to May 30, 2020 were collected retrospectively. The size, number, location, distribution, density and morphology of the pulmonary lesions of these CT data were analyzed and compared with some already existed COVID-19 CT images which come from two files, "Radiological diagnosis of COVID-19: expert recommendation from the Chinese Society of Radiology (First edition)" and "A rapid advice guideline for the diagnosis and treatment of 2019 novel corona-virus (2019-nCoV) infected pneumonia (standard version)". The simple or multiple ground-glass opacity (GGO) lesions are located both in the HAPE and COVID-19 at the early stage, but only the thickening of interlobular septa, called "crazy paving pattern" belongs to COVID-19. At the next period, some increased cloudy shadows are located in HAPE, while lesions of COVID-19 are more likely to develop parallel to the direction of the pleura, and some of the lesions show the bronchial inflation. At the most serious stage, both the shadows in HAPE and COVID-19 become white, but the lesions of HAPE in the right lung are more serious than that of left lung. In summary, some cloudy shadows are the feature of HAPE CT image, and "crazy paving pattern" and "pleural parallel sign" belong to the COVID-19 CT, which can be used for differential diagnosis.

Herpes Zoster Duplex Unilateralis as a manifestation of severe lymphopenia in COVID19

To the editor in chief, SARS-CoV2 (severe acute respiratory syndrome coronavirus-2), a novel coronavirus was first reported in December of 2019 from Wuhan, China as an aetiological agent causing a new infectious respiratory disease (coronavirus disease 2019- COVID-19). The main clinical manifestations of COVID-19 are fever, cough, fatigue, dyspnoea and muscle aches. Herpes zoster is characterized by several groups of painful vesicles on an erythematous base with a distribution in a unilateral dermatome involving the skin and/or mucosa. Herpes zoster is caused by varicella zoster virus which remains dormant in the sensory root ganglion contained by the immune system particularly CD lymphocytes (Wollina, 2017). This characteristic presentation is seen in an immunocompetent host. Severe forms of Herpes zoster not respecting the borders of a dermatome have been described. They are (a) Disseminated Herpes zoster that is, lesions extending over three contiguous dermatomes or lesions going outside the original dermatome. (b) Herpes zoster Duplex—here the lesions involve two non-contiguous dermatomes. If the dermatome involved are unilateral then it is known as Herpes Zoster Duplex Unilateralis and if present bilaterally then—Herpes Zoster Duplex Bilateralis (Jung et al., 2000). The non-contiguous variants are rare in both immunocompetent and immunocompromised host and represent a viraemic spread of VZV due to decrease in lymphocyte count and/or function. Classical Dermatomal Herpes Zoster has been described as a marker of subclinical COVID19 infection (Tartari et al., 2020). We are presenting a case of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve (V1) and left Thoracic 10 (T10) dermatome in a patient of COVID19 with severe lymphopenia. A 62-year-old otherwise healthy male presented with highly painful vesicular lesions on an erythematous base involving the left ophthalmic division of trigeminal nerve (Day 6) and left thoracic 10 (T10) (Day 8) dermatome occurring 2 days apart. The vesicles ranged from 0.3 mm to 1 cm in size and had necrotic element at some places. Hutchinson sign was positive. A diagnosis of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve and left Thoracic 10 (T10) dermatome was observed. The patient had fever (101–103°F) with malaise for preceding 5 days of appearance of vesicles. His COVID19 RT PCR test was positive (Day 8), however, evaluation for HIV status, diabetes, any immunosuppressive state and malignancy was negative. HRCT thorax showed multiple ground glass opacities in both the lungs with CT severity score being 18/30. His LDH levels were 229 units/L (normal range 135–225 U/L), D-dimer 3,422.26 (0–500 ng/ml), IL-6 levels 23 (normal range 0–7 pg/ml). Troponin-T levels determined by Card test, serum ferritin levels and liver function tests were normal. Total leucocyte count was 7,100 cells/mm3 (4000–11000 cells/mm3 normal range). However differential eucocyte count showed neutrophilia (90%) and relative lymphopenia (2.2%), whereas the normal range is 20%–40%. The patient was treated according to institutional COVID19 protocol and was given piperacillin tazobactam 4.5 mg thrice a day injection, remdesivir 200 mg slow iv infusion and dexamethasone injection 4 mg once daily , low molecular weight heparin 6 mg twice a day subcutaneously for 5 days. For VZV lesions, oral acyclovir was given at a dose of 800mg five times a day for 10 days after which he recovered with mild post herpetic neuralgia. Herpes Zoster Duplex Unilateralis represents a viraemic spread of VZV, probably due to decreased immune protection. In our patient lymphocyte percentage was 2.2% representing a severe lymphopenia. We tried to look into the possible explanations: In COVID 19 patients, the inflammatory cytokine storm is likely a key factor behind the observed lymphopenia. The serum level of pro-inflammatory cytokines, such as TNF-α and IL-6, have been closely correlated with lymphopenia, while recovered patients show close to normal levels of such cytokines (Mazzoni et al., 2020). Autopsy studies on lymphoid organs collected from several patients who succumbed to the disease revealed massive lymphocyte death, which was attributed to high levels of IL-6 as well as Fas–FasL interactions. Our patient also had high IL 6 levels and clinical features suggestive of cytokine storm. COVID-19 infection can result in exhaustion of T cells. A recent study has found both CD4+ and CD8+ T cells from COVID-19 patients had increased cell surface expression of programmed cell death protein 1 (PD-1) and T cell immunoglobulin and mucin domain 3 (Tim-3), the two markers of T cell exhaustion (Diao et al., 2020). The SARS-CoV-2 can directly infect T cells. This infection can interfere with T cell expansion. A report suggests that some genes involved in T cell activation and function, such as MAP2K7 and SOS1 are downregulated in the T cells of severe COVID-19 patients (Ouyang et al., 2020). All these mechanisms may be an explanation to the relative lymphopenia in our patient with an unusual presentation of Herpes Zoster. Nil. None declared.

Clinical Features and Outcomes of Acute Kidney Injury in Patients Infected with COVID-19 in Xiangyang, China

Background: In December 2019, pneumonia associated with COVID-19 has spread from Wuhan to other areas in China. In the present study, we aimed to further clarify the clinical features and outcomes of acute kidney injury (AKI) in patients infected with COVID-19 in Xiangyang, Hubei, China. Methods: All confirmed cases of COVID-19 with AKI in Xiangyang Central Hospital from January 22 to May 31, 2020, were included in this retrospective study. Data of epidemiological, clinical, laboratory, radiological tests, treatment, complication, and outcomes were collected and analyzed. Patients were divided into intensive care unit (ICU) group and isolation ward (non-ICU) group. Results: Of the total patients, 33.3% in the non-ICU group and 85.7% in the ICU group had chronic diseases. In addition, 85.7% of patients in the ICU group died. The most common symptoms were fever, cough, and fatigue. The lymphocyte count in the ICU group was significantly reduced compared with the non-ICU group. The chest computed tomography (CT) images appeared showed multiple mottles and ground-glass opacity. Strip shadow could be found in chest CT images of some recovered patients. All patients received antiviral treatment. Most patients in the ICU group were given methylprednisolone, immunoglobulin, antibiotics, and mechanical ventilation and 35.7% of patients in the ICU group received continuous renal replacement therapy. Conclusions: Elderly with chronic comorbidities were more susceptible to COVID-19, showing a higher mortality rate due to multiple organ damage, and 35.7% of patients with AKI in ICU received renal replacement therapy. Moreover, part of the cured patients might need additional time to recover for poor lung function.

Evolution of computed tomography manifestations of eleven patients with severe coronavirus disease 2019 (COVID-19) pneumonia.

PurposeSevere coronavirus disease 2019 (COVID‐19) pneumonia is associated with high mortality. However, the evolution of computed tomography (CT) manifestations of severe COVID‐19 pneumonia remains unclear, more evidence regarding its evolution process is urgently needed.MethodThe clinical, laboratory and imaging data of eleven patients with severe COVID‐19 pneumonia were collected to investigate the evolution process of severe COVID‐19 cases.ResultsThe main initial CT manifestations of severe COVID‐19 pneumonia were multiple ground‐glass opacities and/or consolidation. The evolution of CT manifestations showed that acute exudative lesions of severe COVID‐19 pneumonia could be gradually resolved after the active intervention.ConclusionsMost of patients with severe COVID‐19 pneumonia showed marked improvement of acute exudative lesions on chest imagings and satisfactory prognosis of severe COVID‐19 pneumonia could be achieved after active treatment.

Middle-aged and elderly patients with COVID-19 pneumonia arising from asymptomatic carriers: A report of six cases.

Middle-aged and elderly patients with COVID-19 pneumonia arising from asymptomatic carriers: A report of six cases.

Characteristics of Pulmonary Auscultation in Patients with 2019 Novel Coronavirus in China

Background: Effective auscultations are often hard to implement in isolation wards. To date, little is known about the characteristics of pulmonary auscultation in novel coronavirus (COVID-19) pneumonia. Objectives: The aim of this study was to explore the features and clinical significance of pulmonary auscultation in COVID-19 pneumonia using an electronic stethoscope in isolation wards. Methods: This cross-sectional, observational study was conducted among patients with laboratory-confirmed COVID-19 at Wuhan Red-Cross Hospital during the period from January 27, 2020, to February 12, 2020. Standard auscultation with an electronic stethoscope was performed and electronic recordings of breath sounds were analyzed. Results: Fifty-seven patients with average age of 60.6 years were enrolled. The most common symptoms were cough (73.7%) during auscultation. Most cases had bilateral lesions (96.4%) such as multiple ground-glass opacities (69.1%) and fibrous stripes (21.8%). High-quality auscultation recordings (98.8%) were obtained, and coarse breath sounds, wheezes, coarse crackles, fine crackles, and Velcro crackles were identified. Most cases had normal breath sounds in upper lungs, but the proportions of abnormal breath sounds increased in the basal fields where Velcro crackles were more commonly identified at the posterior chest. The presence of fine and coarse crackles detected 33/39 patients with ground-glass opacities (sensitivity 84.6% and specificity 12.5%) and 8/9 patients with consolidation (sensitivity 88.9% and specificity 15.2%), while the presence of Velcro crackles identified 16/39 patients with ground-glass opacities (sensitivity 41% and specificity 81.3%). Conclusions: The abnormal breath sounds in COVID-19 pneumonia had some consistent distributive characteristics and to some extent correlated with the radiologic features. Such evidence suggests that electronic auscultation is useful to aid diagnosis and timely management of the disease. Further studies are indicated to validate the accuracy and potential clinical benefit of auscultation in detecting pulmonary abnormalities in COVID-19 infection.