Lung Parenchymal Involvement Research Articles

Tocilizumab may not be a good option for vascular involvement due to Behçet's syndrome.

Tocilizumab has been increasingly reported as an alternative therapeutic agent in the management of Behçet's syndrome (BS) and it has been mostly tried in BS patients with neurological and eye involvement. As therapeutic responses to each drug may vary across different types of BS involvement, we aimed to report seven patients with large vessel involvement treated with tocilizumab. We enrolled seven BS patients with vascular involvement who were given tocilizumab at the Behçet's Disease Research Centre in Istanbul University-Cerrahpaşa between 2000 and 2022. Demographic information, BS features, types of vascular involvement, previous and concomitant medications, C-reactive protein (CRP) levels, imaging modality results, and outcomes were documented from the patients' medical records. Within a median of 6 months after the initiation of tocilizumab, 5 patients experienced vascular relapses. These relapses included the emergence of new bilateral pulmonary artery aneurysms, a new pulmonary artery thrombus, parenchymal lung involvement, deep vein thrombosis in the lower extremity, and pseudotumor cerebri in one patient each. CRP levels were normal in 4 of the 5 patients at the time of vascular relapse. One of these 5 patients and another patient with aortitis had an exacerbation of mucocutaneous symptoms. In the last patient, venous ulcers did not respond to tocilizumab and were complicated with infection. Tocilizumab could potentially exacerbate vascular manifestations, similar to what is observed with mucocutaneous lesions in BS patients. Furthermore, CRP levels appear to be ineffective in monitoring these patients.

Assessing disease activity in scleroderma-related interstitial lung disease: a review and practical guide to management.

Systemic sclerosis (SSc) is a heterogeneous disease with a propensity to involve multiple organ systems. There is a significant proportion of these patients with interstitial lung disease (ILD) who are at risk of mortality and morbidity. There are limited available tools to assess the severity of parenchymal lung involvement and are subject to confounding factors, including the presence of pulmonary hypertension and concomitant smoking history. The diagnostic tools include careful clinical history, examination, thoracic imaging, and pulmonary function tests. One of the limitations of assessing disease severity in SSc-ILD is the lack of standardized definitions for disease activity and serum biomarkers to predict future progression. Although there has been significant progress in managing SSc-related ILD over the last couple of decades with a few randomized double-blind clinical trials assessing the role of immunosuppression (mainly Cyclophosphamide and Mycophenolate Mofetil), the efficacy of these therapies is at best modest and is associated with significant toxicities. Furthermore, Nintedanib has shown promise in reducing forced vital capacity decline in SSc-ILD and in progressive fibrotic-ILD of a range of etiologies. Data are emerging for therapies like Rituximab and Tocilizumab, and we are likely to see further evidence of similar drugs being efficacious in this disease cohort. A relatively simplified algorithm is proposed in this review to guide clinicians dealing with ILD and SSc. It is imperative that clinicians take a multi-disciplinary approach to managing this complex disease in a changing therapeutic landscape.

Lung function in patients with asthma in the post-COVID period

Aim. To assess the lung function in patients with bronchial asthma (BA) after new-onset coronavirus infection.Materials and methods. Fifty-five patients who underwent COVID-19 participated in the study under conditions of voluntary informed consent. The main group consisted of 30 patients with mild BA, the comparison group – 25 patients without chronic respiratory diseases (CRD). According to chest computed tomography (CT) findings, the degree of lung parenchyma involvement was classified as follows: mild COVID-19 (CT 0 stage) in 14 patients; moderate COVID-19 (CT 1-2 stages) in 27 patients; and severe COVID-19 (CT 3-4 stages) in 14 patients. Lung function tests were conducted once, adhering to both Russian and international standards.Results. In patients with BA, obstructive pulmonary function impairment was predominant at CT 1-2 stages (79%), CT 0 stage (67%), and CT 3-4 stages (43%). Lung diffusion capacity (LDC) was impaired predominantly in CT 3-4 stages in both BA patients and those without CRD, occurring in 57% of cases. Analysis of lung function showed that LDC reduction was detected in 17% of BA cases and 24% of non-CRD cases. There were no statistically significant changes in pulmonary ventilation among BA patients with impaired LDC compared to patients without CRD.Conclusion. All patients with respiratory symptoms after COVID-19 should undergo comprehensive lung function assessment to identify bronchial obstruction, impaired lung diffusion capacity, and ensure timely intervention.

Neurofibromatosis 1-associated diffuse lung disease in an elderly man—a case report

BackgroundNeurofibromatosis 1 is a form of phacomatosis or neurocutaneous disease inherited as an autosomal dominant disease. Thoracic involvement is rare and involves the lung parenchyma, mediastinum, and thoracic cage, including ribs and the spine. Lung parenchymal involvement includes airspace abnormalities like cysts, bullae, and emphysema with an upper lobe predominance and interstitial abnormality in the form of reticulations and fibrosis in the lower lobes. The structural abnormality of the lung resembles numerous other diseases. Hence, properly identifying and recognizing neurofibromatosis 1-associated diffuse lung disease (NF-1 DLD) is crucial in avoiding misdiagnosis. NF1-DLD is associated with many complications like pulmonary hypertension, lung malignancy, aspergilloma, secondary bacterial infections, and pneumothorax.Case presentationAn elderly male with neurofibromatosis type-1 presented with breathlessness, cough, and mucopurulent expectoration and was found to have diffuse involvement of the lung parenchyma involving cysts, bullae, emphysema, fibrosis, and traction bronchiectasis. He was managed conservatively, controlling infection and optimizing respiratory symptoms.ConclusionNeurofibromatosis-associated diffuse lung disease is a rare disorder. There is no definitive treatment that can reverse the pulmonary lesions. However, early diagnosis will help plan effective preventive measures and avoid complications. We present this case to increase awareness regarding the various pulmonary manifestations of neurofibromatosis.

Impact of COVID-19 on Ventilation-Perfusion (V/Q) Scans: A Comparative Analysis of Pre-COVID-19 Era V/Q Scans and Post-COVID-19 Era Perfusion Scans.

Introduction The COVID-19 pandemic has profoundly impacted medical practices, including nuclear medicine. To minimize aerosol transmission risks, lung perfusion scintigraphy was preferred over traditional ventilation-perfusion (V/Q) scintigraphy during the pandemic. This study compares lung perfusion scans performed during COVID-19 with V/Q scans from the pre-COVID era. After reviewing this study, the reader will learn about V/Q scintigraphy and lung perfusion. Methods This retrospective observational study, conducted from December 2018 to July 2021, involved 868 patients - 511 in the pre-COVID era and 357 in the post-COVID era - at a single tertiary care center. The pretest probability of pulmonary embolism (PE) was determined using Wells' criteria, and data including demographics, clinical findings, and diagnostic test results (V/Q or lung perfusionscintigraphy) were collected. Results A 30% decline in lung scans was observed during the pandemic. In the pre-COVID era, 68.3% of scans had low, 27.8% had intermediate, and 3.9% had high probability for PE. During the pandemic, perfusion-only scans showed 57.3% low, 32.9% indeterminate, and 9.8% high probability for PE. Among COVID-19-positive patients, 48.9% had intermediate, and 11.1% had high probability scans. The rise in indeterminate and high-probability scans during the pandemic is attributed to COVID-19-related lung changes and hypercoagulability. Conclusion The perfusion component of lung scans is typically sufficient for evaluating acute PE. Omitting the ventilation part of the V/Q scan had minimal impact, with only a 5.1% increase in indeterminate/non-diagnostic scans using perfusion-only modified Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) criteria during the post-COVID-19 era, likely due to underlying lung parenchymal involvement in COVID-19 patients. Additionally, there was a 5.9% rise in high-probability scans, attributed to the hypercoagulability and vascular complications associated with COVID-19.

Ventilatory efficiency in long-term dyspnoeic patients following COVID-19 pneumonia

BackgroundLong COVID is defined as persistency of symptoms, such as exertional dyspnea, twelve weeks after recovery from SARS-CoV-2 infection. ObjectivesTo investigate ventilatory efficiency by the use of cardiopulmonary exercise testing (CPET) in patients with exertional dyspnea despite normal basal spirometry after 18 (T18) and 36 months (T36) from COVID-19 pneumonia. MethodsOne hundred patients with moderate-critical COVID-19 were prospectively enrolled in our Long COVID program. Medical history, physical examination and lung high-resolution computed tomography (HRCT) were obtained at hospitalization (T0), 3 (T3) and 15 months (T15). All HRCTs were revised using a semi-quantitative CT severity score (CSS). Pulmonary function tests were obtained at T3 and T15. CPET was performed in a subset of patients with residual dyspnea (mMRC ≥ 1), at T18 and at T36. ResultsRemarkably, at CPET, ventilatory efficiency was reduced both at T18 (V’E/V’CO2 slope = 31.4±3.9 SD) and T36 (V’E/V’CO2 slope = 31.28±3.70 SD). Furthermore, we identified positive correlations between V’E/V’CO2 slope at T18 and T36 and both percentage of involvement and CSS at HRCT at T0, T3 and T15. Also, negative linear correlations were found between V’E/V’CO2 slope at T18 and T36 and DLCO at T3 and T15. ConclusionsAt eighteen months from COVID-19 pneumonia, 20 % of subjects still complains of exertional dyspnea. At CPET this may be explained by persistently reduced ventilatory efficiency, possibly related to the degree of lung parenchymal involvement in the acute phase of infection, likely reflecting a damage in the pulmonary circulation.

Pneumomediastinum in COVID-19: Risk factors and outcomes from a multicentre case-control study

BackgroundAn increased incidence of pneumomediastinum has been observed among patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia. The study aimed to identify risk factors for COVID-19-associated pneumomediastinum and investigate the impact of pneumomediastinum on clinical outcomes. MethodsIn this multicentre retrospective case-control study, we included consecutive patients with COVID-19 pneumonia and pneumomediastinum hospitalized from March 2020 to July 2020 at ten centres; then, we identified a similarly sized control group of consecutive patients hospitalized with COVID-19 pneumonia and respiratory failure who did not develop pneumomediastinum during the same period. Clinical, laboratory, and radiological characteristics, as well as respiratory support and outcomes, were collected and compared between the two groups. Risk factors of pneumomediastinum were assessed by multivariable logistic analysis. ResultsOverall 139 patients with pneumomediastinum and 153 without pneumomediastinum were analysed. Lung involvement ≥75 %, consolidations, body mass index (BMI) < 22 kg/m2, C-reactive protein (CRP) > 150 mg/L, D-dimer >3000 ng/mL FEUs, and smoking exposure >20 pack-year were all independently correlated with the occurrence of pneumomediastinum. Patients with pneumomediastinum had a longer hospital stay (mean ± SD 31.2 ± 20.2 days vs 19.6 ± 14.2, p < 0.001), higher intubation rate (73/139, 52.5 % vs 27/153, 17.6 %, p < 0.001), and in-hospital mortality (68/139, 48.9 % vs 36/153, 23.5 %, p < 0.001) compared to controls. ConclusionsExtensive lung parenchyma involvement, consolidations, low BMI, high inflammatory markers, and tobacco exposure are associated with a greater risk of pneumomediastinum in COVID-19 pneumonia. This complication significantly worsens the outcomes.

Validation of the Behçet's Syndrome Overall Damage Index (BODI) for Retrospective Studies and a Proposal for Modification.

Assessment of damage accrual over time is important for evaluating and comparing long-term results of treatment modalities and strategies. Retrospective studies may be useful for assessing long-term damage, especially in rare diseases. We aimed to validate Behçet's Syndrome Overall Damage Index (BODI) for use in retrospective studies by evaluating its construct validity, reliability, and feasibility in retrospectively collected data. Additionally, we aimed to determine missing items by evaluating Behçet's syndrome patients with different types of organ involvement and long-term follow-up. We included 300 patients who had at least 2 clinic visits at 1-year intervals. The construct validity for use in retrospective trials was assessed by comparing BODI scores calculated from patient charts and during face-to-face visits. BODI was additionally scored using retrospective chart data by 2 different observers and by the same observer six months apart, in a blinded manner. The time for filling BODI was evaluated to assess feasibility. Additionally, damaged items that were missing from BODI were identified. There was a good correlation between the retrospective and face-to-face evaluation of BODI (ICC 0.99; %95 CI 0.99-0.99). Inter-observer and intra-observer agreement were good (ICC 0.96 and 1, respectively). The main damage items that BODI did not capture were hypertension, liver failure, lung parenchymal involvement, glaucoma, and lymphedema. BODI seems to be a reliable and feasible instrument for assessing damage in retrospective studies. Modifying BODI using the additional damage items identified in this study may make it an even better scale.

Is Steatotic Liver Disease Related to Poor Outcome in COVID-19-Hospitalized Patients?

Background: Steatotic liver disease (SLD) has been linked to more exacerbated inflammatory responses in various scenarios. The relationship between SLD and COVID-19 prognosis remains unclear. Our aim was to investigate the impact of SLD on the outcome of COVID-19. Methods: Patients hospitalized with confirmed COVID-19 and who underwent laboratory tests and chest CT scans were included. SLD was assessed by measuring the attenuation coefficient on CT scans. The relationship between SLD, the severity of COVID-19 clinical presentation and in-hospital mortality were assessed. Results: A total of 610 patients were included (mean age 62 ± 16 years, 64% male). The prevalence of SLD was 30%, and the overall in-hospital mortality rate was 19%. Patients with SLD were younger (58 ± 13 vs. 64 ± 16 years, p < 0.001) and had a higher BMI (32 ± 5 vs. 28 ± 4 kg/m2, p = 0.014). Admission AST values were higher in patients with SLD (82 ± 339 vs. 50 ± 37, p = 0.02), while D-dimer (1112 ± 2147 vs. 1959 ± 8509, p = 0.07), C-reactive protein (12 ± 9 vs. 11 ± 8, p = 0.27), ALT (67 ± 163 vs. 47 ± 90, p = 0.11), ALP (83 ± 52 vs. 102 ± 125, p = 0.27), and GGT (123 ± 125 vs. 104 ± 146, p = 0.61) did not significantly differ compared to patients without SLD. No difference was observed regarding lung parenchyma involvement >50% (20% vs. 17%, p = 0.25), hospital length of stay (14 ± 19 vs. 16 ± 23 days, p = 0.20), hemodialysis support (14% vs. 16%, p = 0.57), use of mechanical ventilation (20% vs. 20%, p = 0.96), and in-hospital mortality (17% vs. 20%, p = 0.40) when comparing patients with and without SLD. Conclusions: SLD showed no significant association with morbidity and mortality in patients with COVID-19.

Association of chest computed tomography severity score at ICU admission and respiratory outcomes in critically ill COVID-19 patients.

To evaluate the association of a validated chest computed tomography (Chest-CT) severity score in COVID-19 patients with their respiratory outcome in the Intensive Care Unit. A single-center, prospective study evaluated patients with positive RT-PCR for COVID-19, who underwent Chest-CT and had a final COVID-19 clinical diagnosis needing invasive mechanical ventilation in the ICU. The admission chest-CT was evaluated according to a validated Chest-CT Severity Score in COVID-19 (Chest-CTSS) divided into low ≤50% (<14 points) and >50% high (≥14 points) lung parenchyma involvement. The association between the initial score and their pulmonary clinical outcomes was evaluated. 121 patients were clustered into the > 50% lung involvement group and 105 patients into the ≤ 50% lung involvement group. Patients ≤ 50% lung involvement (<14 points) group presented lower PEEP levels and FiO2 values, respectively GEE P = 0.09 and P = 0.04. The adjusted COX model found higher hazard to stay longer on invasive mechanical ventilation HR: 1.69, 95% CI, 1.02-2.80, P = 0.042 and the adjusted logistic regression model showed increased risk ventilator-associated pneumonia OR = 1.85 95% CI 1.01-3.39 for COVID-19 patients with > 50% lung involvement (≥14 points) on Chest-CT at ICU admission. COVID-19 patients with >50% lung involvement on Chest-CT admission presented higher chances to stay longer on invasive mechanical ventilation and more chances to developed ventilator-associated pneumonia.

Involvement of the Lung Parenchyma Analyzed by Frequency Components of the Tidal Volume Assessed by Electrical Bioimpedance

Pulmonary function tests are vital for detecting pathologies, especially chronic obstructive pulmonary diseases (COPD), emphasizing the importance of assessing lung parenchyma involvement in maintaining proper gas exchange. Electrical impedance tomography (EIT) offers a non-invasive alternative for respiratory function evaluation while preserving natural breathing. We propose using EIT to detect lung parenchyma conditions by analyzing tidal volume patterns (by averaging the impedance image) in the frequency domain. Twenty COPD patients underwent simultaneous evaluation with a pneumotachometer and an EIT device, performing three 30-second respiratory maneuvers. FFT spectra analysis yielded parameters, including the area under the curve and quartiles (25 %, 50 %, 75 %) of power values in six frequency regions. Correlations between these parameters and clinical test results (pulmonary diffusing capacity and arterial blood gas analysis) revealed significant associations, particularly with PCO2. Multiple linear regression analysis predicted PCO2 with an R2adj = 0.827, suggesting the potential for non-invasively detecting lung parenchyma affectation by correlating FFT bioimpedance ventilatory patterns with gas exchange performance in COPD patients.

Clinical and laboratory features of COVID-19 in newborns. Analysis of a severe clinical case

Background. Since the onset of the coronavirus disease 2019 (COVID-19) epidemic until January 1, 2024, more than 5.5 million confirmed cases of COVID-19 have been detected in Ukraine according to official data, approximately 6 % of them among children under 18 years old. Aim: to improve the management of newborns based on studies of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with different course. Materials and methods. Eleven newborns (7 boys and 4 girls) diagnosed with SARS-CoV-2 confirmed by polymerase chain reaction were observed. Disease progression, results of laboratory and instrumental studies were analyzed. Results. An analysis of clinical data and the results of laboratory and instrumental investigations are presented, as well as treatment outcomes in newborns with confirmed COVID-19. It was found that in all cases, children were infected from mothers with SARS-CoV-2. The frequency of clinical symptoms is provided, revealing discrepancies between respiratory symptoms and changes identified on lung ultrasound. Most children exhibited anemia, elevated D-dimer levels in the blood, yet experienced a mild course of the disease. The average duration of illness prior to hospitalization was 3.70 ± 1.48 days, with a hospital stay of 4.01 ± 1.22 days. An exception was in case of patient N., characterized by a severe condition necessitating prolonged oxygen therapy, mechanical ventilation, and administration of remdesivir. This particular case is detailed in the article. Conclusions. In most infants under one month of age observed in this study, the course of ­COVID-19 caused by SARS-CoV-2 was characterized by symptoms such as lethargy, hyperthermia, nasal congestion, diarrhea, and changes detected only through laboratory and instrumental stu­dies: anemia, abnormalities in the coagulation system, and increased lung parenchymal density. Ho­wever, the disease course in infants of this age can also be very severe, with lung parenchymal involvement, pneumonia, COVID-19-associated coagulopathy, complicated by generalized bacterial infection, as presented in the clinical case.

Prognostic value of chest computed tomography in adult inpatients with coronavirus disease 2019 pneumonia in Goma, in the Democratic Republic of the Congo

Objectives: Chest computed tomography (CT) plays a crucial role in evaluating patients with coronavirus disease 2019 (COVID-19) pneumonia. This study aimed to assess the association between initial chest CT findings and mortality in adult inpatients with COVID-19 in the city of Goma, North Kivu province, the Democratic Republic of the Congo. Materials and Methods: This was a multicenter retrospective study of patients hospitalized in Goma with COVID-19 pneumonia who underwent chest CT from January 1, 2021, to December 31, 2022. For each patient included, two experienced radiologists independently reviewed the initial chest CT. A multivariate logistic regression was performed to identify chest CT findings associated with mortality at the 5% significance level. Results: Of 76 patients included in the study, 26 (34.2%) died. The degree of lung parenchymal involvement &gt;25% (adjusted odds ratio [aOR] = 16.27 [3.30–80.16]) and the presence of consolidations (aOR = 3.33 [1.00–11.47]) were predictive of mortality with an area under the receiver operating characteristic curve of 0.8392. Sensitivity was 73.08%, specificity was 82%, positive predictive value was 67.86%, and negative predictive value was 85.42%. Conclusion: Lung involvement &gt;25% and consolidations on chest CT appear to predict death in adult inpatients with COVID-19 pneumonia.

Pulmonary fibrosis after a new coronavirus infection - versions and controversies: A review

Fibrosis is a dynamic process characterized by a typical cascade of events as a result of overexpressed repair of connective tissue in response to injury, and manifested by excessive accumulation of extracellular matrix. The development of fibrosis is a determining factor in the pathogenesis, clinical course and prognosis of many diseases, among which interstitial lung diseases occupy a special place. According to a large Russian registry (ClinicalTrials.gov: NCT04492384), in a third of patients with COVID-19, the volume of lung parenchyma involvement exceeds 50% (CT 3-4). The rapid growth in the number of patients who have had a coronavirus infection with lung damage has raised the issues of its long-term consequences to the number of the most relevant in internal medicine of the current time. Often, in the outcome of a coronavirus infection, patients retain clinical and functional changes that are similar to interstitial lung diseases of a different origin, the prognosis of which is determined by the development of interstitial fibrosis and the rate of its progression. This article is an attempt to consider topical issues of fibrogenesis in patients who have undergone a new coronavirus infection through the prism of polar data on immunobiology, clinical course and prognosis.

Acute Kidney Injury and Chronic Kidney Disease and Their Impacts on Prognosis among Patients with Severe COVID-19 Pneumonia: An Expert Center Case-Cohort Study.

Background: Acute kidney injury (AKI) is associated with substantial mortality. In this case-control study, we analyzed the impacts of AKI and chronic kidney disease (CKD) on outcomes in a group of 323 patients with severe COVID-19. The correlation of clinical and laboratory data with AKI and CKD was also analyzed. Methods: A retrospective case-control study was conducted among AKI, CKD, and normal kidney function (NKF) groups hospitalized in a COVID-19 center in 2021. Results: AKI patients had higher in-hospital mortality (55.2 vs. 18.8%, p < 0.001), more frequent transfers from the HDU to ICU (57.5 vs. 12.9%, p < 0.001), and prolonged hospital stays (15.4 ± 10.7 vs. 10.7 ± 6.7 days, p < 0.001) compared to the NKF group. AKI was a predictor of death (OR 4.794, 95%CI: 2.906-7.906, p < 0.001). AKI patients also had broader lung parenchymal involvement and higher inflammatory markers compared to the NKF group. Patients with prior CKD had higher in-hospital mortality compared to the NKF group (64.0 vs. 18.8%, p < 0.001, OR 4.044, 95%CI: 1.723-9.490, p = 0.013); however, transfers from the HDU to ICU were not more frequent (16.0 vs. 12.9%, p = 0.753). Conclusions: AKI among COVID-19 patients was correlated with more ICU transfers, higher morbidity, and greater markers of severe disease. Patients with CKD had a higher mortality; however, the rate of ICU transfer was not substantially higher due to their poor prognosis.

Disease Course and Pulmonary Involvement of COVID-19 during the Delta Variant Period in Germany: A Comparative Study of Vaccinated and Unvaccinated Patients at a Tertiary Hospital.

The aim of this study was to determine whether there is a radiological difference in lung parenchymal involvement between infected vaccinated and unvaccinated patients. Additionally, we aimed to investigate whether vaccination has an impact on the course of illness and the need for intensive care. This study includes all patients undergoing chest computed tomography (CT) or x-ray imaging in case of a proven SARS-CoV-2 infection between September and November 2021. Anonymized CT and x-ray images were reviewed retrospectively and in consensus by two radiologists, applying an internal severity score scheme for CT and x-ray as well as CARE and BRIXIA scores for x-ray. Radiological findings were compared to vaccination status, comorbidities, inpatient course of the patient's illness and the subjective onset of symptoms. In total, 38 patients with acute SARS-CoV-2 infection underwent a CT scan, and 168 patients underwent an x-ray examination during the study period. Of these, 32% were vaccinated in the CT group, and 45% in the x-ray group. For the latter, vaccinated patients exhibited significantly more comorbidities (cardiovascular (p=0.002), haemato-oncological diseases (p=0.016), immunosuppression (p=0.004)), and a higher age (p<0.001). Vaccinated groups showed significantly lower extent of lung involvement (severity scores in CT cohort and x-ray cohort both p≤0.020; ARDS 42% in unvaccinated CT cohort vs. 8% in vaccinated CT cohort). Furthermore, vaccinated patients in the CT cohort had significantly less need for intensive care treatment (p=0.040). Our data suggest that vaccination, in the case of breakthrough infection, favours a milder course of illness concerning lung parenchymal involvement and the need for intensive care, despite negative predictors, such as immunosuppression or other pre-existing conditions.</p>.

Covid-19 Pneumonia Presenting as a ‘Typical Radiological Bronchopneumonia’ Pattern in Clinical-Radiological-Pathological Phenotype with Transient Hyperglycemia

Radiological phenotypes are radiological patterns or observable characteristics of COVID19 pneumonia. Various phenotypic classifications have been reported in literature. CT severity radiological phenotypes are widely used and universally accepted radiological phenotypic methods. Radiological CT severity phenotypic differentiation has documented very crucial role in initial assessment and during triaging of these cases in indoor and outdoor setting. Typical COVID-19 lung parenchymal involvement described as predominant ground glass opacities (GGOs) and consolidations in peripheral and subpleural portion of any lobe, predominantly involving lower lobes. Atypical Radiological patterns in COVID-19 has been documented as bronchopneumonia, multifocal consolidations, necrotizing pneumonia, cavitations with GGOs with or without consolidations. In present case report, 43-year male, presented with acute febrile respiratory illness with acute hypoxic respiratory failure documented as oxygen saturation of 80% at room air with tachypnea and respiratory distress. HRCT thorax was showing Pleural based, peripheral, central, multifocal patchy, confluent &amp; ill-defined GGOs and consolidations in bilateral lung fields in upper, middle and lower lobes. These typical radiological features suggestive of bronchopneumonia like radiological pattern which was very unusual for typical COVID-19 radiology. His laboratory parameters have shown abnormally raised inflammatory markers like CRP, Ferritin, LDH, D-Dimer and IL-6. Importantly, his random blood sugars were raised with abnormally raised HbA1c levels to label as diabetes mellitus. He was diagnosed with diabetes mellitus this time with COVID-19 illness without use of steroids. He was treated with standardized COVID-19 management institutional protocol with combination of low molecular weight heparin, methylprednisolone, remdesivir, meropenem and teicoplanin. Patient required BIPAP support with higher oxygen requirement with nasals canula for one week due to advanced radiological disease with more anatomical involvement. We have documented successful treatment outcome with use of rational treatment in timely by predicting disease severity with use of composite analysis of clinical, laboratory and radiological markers of illness. Transient hyperglycemia is known to occur and reported after COVID-19 illness due to virus induced inflammatory response and pancreatopathy with beta cell dysfunction. Transient hyperglycemia can be easily managed with insulin during hospitalization and oral anti-diabetic agents after discharge for few weeks. Dietary and lifestyle modification will help in majority with complete reversal of abnormally high sugar levels with restoration of normal HbA1c levels to non-diabetic range.

ЛЕГЕНЕВИЙ АЛЬВЕОЛЯРНИЙ ПРОТЕЇНОЗ: ВИПАДОК СУБТОТАЛЬНОГО УРАЖЕННЯ ПАРЕНХІМИ ЛЕГЕНЬ)

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease, characterized by the intraalveolar accumulation of surfactant-like lipoprotein substance. There are three forms of the disease: autoimmune (formerly known as idiopathic), secondary and congenital PAP. The disturbances of surfactant metabolism (protein-lipoid complex secreted by type II pneumocytes) play the crucial role in the development of the disease. Surfactant decreases a surface tension of alveoli and prevents its collapse at the end of the expiration and takes part in protection against infections as well. Surfactant is inactivated through the transformation into the surface-inactive aggregates, which are mainly absorbed by type II pneumocytes. The rest of surfactant are catabolized by alveolar macrophages (AM). This process is regulated by cytokines, especially granulocyte-macrophage colony-stimulating factor (GM-CSF) being the most important of them. Disturbances of interrelation between GM-CSF and cellular receptors blocks the signals to effector cells for surfactant deactivation. This is resulted in excessive accumulation of surfactant in alveoli. General lavage of the lung is a standard method of symptomatic management of PAP. Contemporary pathogenesis treatment uses two approaches — increasing the clearance of surfactant by means of exogenous GM-CSF administration and decreasing the level of GM-CSF antibodies using the rituximab and plasmapheresis. Due to the use of broncho-alveolar lavage (BAL) 5-year survival rate of th patients reaches 95 %. The mortality depends on the area of lung lesion and reversely correlated with the timely diagnosis and treatment. We report the case of subtotal lung parenchyma lesion associated with severe respiratory failure in 46 years old patient. Three series of BAL (5 procedures in each with 1-2 months interval) were performed using the limited volume of lavage fluid due to the severity of the patient’s condition. The results was an improvement of clinical condition, resolution of respiratory failure, significant reduction of the size of the lesions, improved lung transparency on CT scan, restoration of lung diffusion and total lung capacity. Conclusion. Therapeutic BAL is an effective method of PAP management. The outcome of clinical case presented and our many years experience confirm not only the effectiveness of conventional BAL with reduced lavage volume application but also a safety of fiberoptic bronchoscopy, especially in patients with subtotal involvement of lung parenchyma. Key words: pulmonary alveolar proteinosis, subtotal pulmonary parenchyma involvement, pulmonary bronchoalveolar lavage, efficiency.

LM-DNN: pre-trained DNN with LSTM and cross Fold validation for detecting viral pneumonia from chest CT

ABSTRACT Some of the viruses may cause lung parenchyma and airway involvement. Usually, viral pneumonia causes ground-glass opacities, bilateral peripheral distribution, consolidation, vascular thickening, and reticular opacity. These features are common in COVID-19 rather than Non-Covid-19 viral pneumonia. However, in advanced cases, COVID-19 viral pneumonia may cause organising pneumonia and fibrosis of the lung. Atypical findings of Non-Covid-19 pneumonia have included central peripheral distribution, pleural effusion, lymphadenopathy, nodules, tree-in-bud opacities, and pneumothorax. Therefore, differentiating Non-Covid-19 pneumonia from COVID-19 pneumonia at chest computed tomography (CT) is necessary. In that case, CT scans of the thorax are one of the essential tools for early identification and future prognosis of viral pneumonia. We have proposed a Computer-Aided Diagnostic (CAD) system that can detect features of chest CT using a Deep Neural Network (DNN) with Long Short-Term Memory (LSTM). Transfer learning using pre-trained DNN models (ResNet50, VGG19, InceptionV3, Xception, DenseNet121, and VGG16) is applied to retain both high-level and low-level features effectively. The deep features are passed to the LSTM layer. The LSTM is utilised as a classifier and detects long short-term dependencies. The proposed method employs a hybrid DNN-LSTM network for automatic detection to take advantage of the uniqueness of the two models. The proposed models are trained with common and different features present in the chest CT of COVID-19 and Non-Covid-19 viral pneumonia. The 5-fold cross-validation (CV) method validated and tested the proposed model. The proposed DNN model’s performance is quite improved with LSTM and CV. As a result, the proposed LM-DNN (VGG16+LSTM+CV) model has achieved the classification test accuracy of 91.58% and specificity of 93.86%, which offers superior performance with state-of-the-art. Also, the DenseNet121+LSTM+CV model has reached the classification test accuracy of 90.1% and sensitivity of 92%.

Osteoporosis and major fragility fractures (MOF) in sarcoidosis patients: association with disease severity

BackgroundThe reports on bone mineral loss or major osteoporosis fracture (MOF) in sarcoidosis are scarce and have conflicting outcomes. This study aimed to evaluate the prevalence and risk factors of MOF in sarcoidosis patients.MethodsIn a single-center cohort of 382 patients with sarcoidosis (55.8 ± 11.6 years) we evaluated bone mineral density at lumbar spine, at femoral neck and at total hip and the presence of MOF. Lung function measurements including diffusion capacity for carbon monoxide (DLCO) were assessed. Chest X-rays were performed and radiological staging was done by Scadding score.ResultsNinety patients (23.6%) with sarcoidosis have history of a MOF. BMD T-scores were lower in sarcoidosis with MOF with respect to those without MOF, but the difference was statistically significant only for BMD at femoral neck (p < 0.05). Moreover, BMD values at total hip was positively correlated with DLCO (%) (p < 0.001). Prevalence of MOF was higher in patients with sarcoidosis with lung parenchymal involvement (radiological stages 2–4) than in patients with sarcoidosis in chest X-ray stages 0 and 1 (28.3 vs 19.2% respectively, p < 0.05). Moreover, multiple regression analyses showed that X-ray Scadding score was positively associated with MOF.ConclusionsThis study shows that MOF represent a common and important complication in patients with moderate/severe sarcoidosis. The chest X-ray evaluation and the pulmonary function test could allow to define the risk of MOF in sarcoidosis patients.