Patchy Consolidation Research Articles

Clinico-radiological Profile and Outcome of Children with Viral Pneumonia admitted to Paediatric Intensive Care Unit in the pre COVID 19 period

Introduction: Viruses are common etiological agents of severe acute respiratory illness in under five children. Very few studies are available considering the profile of children with viral pneumonia admitted to paediatric intensive care unit (PICU) in our setting. Hence this study was done to describe the clinico- radiological profile and outcome of children diagnosed with viral pneumonia admitted to PICU. Methods: This was a retrospective descriptive study done in the PICU of a tertiary care hospital in South India. The presenting clinical features, blood parameters, chest radiography findings, course during the hospital stay and outcome of children with viral pneumonia (RT- PCR Positive) admitted to PICU were studied. Results: The aetiological profile of 28 children included - Influenza virus - 14 cases, Respiratory Syncytial Virus - 6 cases, Adeno virus - 4 cases, Human Boca virus - 2 cases, Human Rhino Virus - 1 case and Human metapneumo Virus - 1 case. Majority of children (50%) presented with severe respiratory distress. Predominant radiological picture included bilateral interstitial infiltrates followed by patchy alveolar consolidation. Eight children required mechanical ventilation. Complications included septic shock and MODS (n = 5), pneumothorax (n = 2), myocarditis (n = 2), pleural effusion (n = 1), ventilator associated pneumonia (n = 2) and pulmonary artery hypertension (n = 2). Mortality was observed in seven (25%) children. SpO2 / FiO2 ratio < 300, shock at admission, neutrophil leucocyte ratio > 2 and hypoalbuminemia were found to be significant predictors of mortality. Conclusions: Malnutrition and iron deficiency analmia were the common risk factors. Patchy alveolar consolidation is also a common radiological finding along with interstitial infiltrates. Hypoalbuminemia was a common finding among non-survivors.

Barotrauma in a Previously Healthy and Young COVID-19 Patient: an Autopsy Case Report

Abstract Introduction/Objective Since the emergence of a novel SARS-CoV-2 virus caused coronavirus disease 2019 (COVID-19), a great number of autopsy studies have been published. However, histopathologic studies focused on pulmonary barotrauma are very rare. Here we report an autopsy confined to the lungs on a young COVID-19 patient. Methods/Case Report The patient was a 37-year-old male, non-smoker, with no significant past medical history, and a body mass index of 24.1, who presented with shortness of breath and cough. A computerized tomography (CT) showed features of atypical pneumonia. The main abnormal laboratory data included elevated partial thromboplastin time, fibrinogen, and D-Dimer. The patient had been on mechanical ventilation for 35 days, and was complicated by recurrent pneumothoraces, hypotension, and worsening hypoxia. An autopsy limited to the lungs was performed after the patient expired. Grossly, the lungs showed increased weight, adhesions on visceral pleural surface, patchy consolidation and dilated subpleural cysts. Histological examination revealed cystically dilated/remodeled airspaces with extensive coagulative necrosis, focal alveolar hemorrhage and edema, focal confluent fibrosis, and subpleural blebs. Fresh fibrinous thrombi were seen in small- and medium-sized vessels. Viral cytopathic changes or significant inflammation were not observed. The findings in the lungs were consistent with barotrauma in COVID-19. Results (if a Case Study enter NA) NA. Conclusion This case demonstrates various histopathologic changes of the lungs in a previously healthy and young COVID-19 patient with prolonged hospital course of mechanical ventilation. The features of diffuse alveolar damage with inflammation usually seen in the early stage of barotrauma are not identified. Our findings in the lungs may represent the histopathologic characteristics of the later stage of barotrauma in COVID-19.

An Observational Study on Unique High Resolution Computed Tomography Pattern of Post-COVID Pulmonary Fibrosis

Background: As the severe acute respiratory syndrome coronavirus 2 era commenced, a new entity was added to the already hefty bulk of parenchymal lung diseases in post-COVID-19 pulmonary fibrosis. A wide range of findings from mild ground glass opacities to exuberant fibrosis are seen on high resolution CT of the thorax. However, the authors came across a pattern that was frequently repeated, and therefore conducted an observational study on the radiological findings. Method: The study was conducted for a period of 6 months in the departments of Respiratory Medicine and Radiodiagnosis at King George’s Medical University, Lucknow, India. The radiological findings on high resolution CT thorax of consecutive patients who reported to the Department of Respiratory Medicine after recovering from COVID-19, and were previously reverse transcriptase-PCR-positive or serologically confirmed, were studied. Result: There were a total of 56 subjects (32 males; mean age: 56 years). The most common finding was ground glass opacities (89%). Reticulations were seen in 86% of patients, with a unique dome-shaped fibrosis parallel to pleural surface in 54%, patchy consolidation in 49%, and scattered cysts in 43%. The distribution was mostly bilateral with slight predominance of lower lobes (57%). Conclusion: Ground glass opacities, reticulations, and consolidation are fairly common in patients with pulmonary sequelae of COVID-19. It has a peculiar predilection for involvement of subpleural space with cupola or band-shaped fibrosis.

Sensitivity, Specificity and Predictive Values of Chest Indrawing in the Diagnosis of Severe Pneumonia

Background: Pneumonia is a recognized leading killer disease in under 5 children not only in Bangladesh but also in all developing countries. The presence of lower chest indrawing means that the child has severe pneumonia. This study aimed to determine the sensitivity, specificity and predictive values of chest indrawing in the diagnosis of severe pneumonia. Methods: This analytical study was conducted in the department of pediatrics, Sher-e-Bangla Medical College Hospital, Barisal, from January 2015 to December 2015. A total of 100 cases of severe pneumonia aged from 2 months to 5 years and similar numbers of suitably matched controls who fulfilled inclusion criteria were enrolled in this study. A detailed history was taken, a thorough physical examination was done, data were recorded in a preformed questionnaire and were analyzed using a scientific calculator. Results: Out of 100 cases, 80 (80%) and 100 controls, 72 (72%) were in the age group of 2 months to 1 year. Fast breathing was present in 98 (98%) cases and 88 (88%) controls. Chest indrawing was present in 56 (56%) cases and 42 (42%) controls. Roentgenographically, 44 (44%) cases revealed labor/segmental consolidation, and bilateral patchy consolidation was present in 56 (56%) cases. Among the control group, 28 (28%) patients had hyperlucency of peripheral lung fields in their chest X-rays. In this study, it was found that sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of chest indrawing in the diagnosis of severe pneumonia was 56%, 58%, 57.1% and 56.8% respectively. Conclusion: Chest indrawing alone is not a highly sensitive tool to predict severe pneumonia but in rural areas where X-ray facilities are not available, chest indrawing may play an important role in identifying children with possible severe pneumonia. Mediscope 2022;9(2): 54-59

Clinical characteristics of rheumatoid arthritis patients complicated with pulmonary nontuberculous mycobacterial disease: A cross-sectional case series study.

Pulmonary nontuberculous mycobacterial disease (pNTM) is a common pulmonary complication of rheumatoid arthritis (RA), but their association has rarely been researched. We aimed to reveal the clinical characteristics of RA with pNTM. Among all the RA patients who visited Tenri hospital from April 2017 to March 2018, we enrolled those fulfilling the 2007 ATS/IDSA diagnostic criteria of pNTM, and sex- and age- matched control group at a ratio of 1:5. Demographic characteristics were compared between the two groups. Among 865 RA patients, 35 (4.0%) patients were complicated with pNTM. RA patients with pNTM had significantly lower BMI and higher rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) positivity. Bronchiectasis was the most frequent lesion, followed by clusters of small nodules, patchy consolidation and cavity. Multivariable logistic regression analysis revealed bronchiectasis as a strong independent associated factor of pNTM. Treatment for pNTM was needed in 14 of the 35 (40%) RA patients with pNTM and sputum negative conversion was accomplished in 11 of the 14 cases (78.6%). RA patients with lower BMI, RF/ACPA positivity, and bronchiectasis were associated with pNTM. Treatment for pNTM may attain sputum negative conversion and radiological improvement in patients with RA.

Cryptococcal Pneumonia in an Immunocompetent Patient: A Rare Occurrence

Cryptococcosis isan invasive yeast infection commonly found among immunosuppressed patients.Pulmonary cryptococcal infection can have variable presentations ranging from pulmonary nodulesand masses to consolidation. A patient can present with shortness of breath, cough, sputum production, chest pain, fatigue, and weight loss. Diagnosis can be made using fungal culture, histology, radiographic findings, and cryptococcal antigen in serum as well as in the cerebrospinal fluid. Treatment is usually with a combination or a single antifungal agent. Few cases have been reported in immunocompetent individuals. Here we present a case of 69-year-old immunocompetent individual, who was initially seen in the outpatient clinic for dyspnea, cough, and fatigue and was treated for pneumonia. The patientremained symptomatic despite multiple courses of oral antibiotics. He was then sent for inpatient admission. CT scan was obtained that showed patchy infiltrates and consolidations, followed by bronchoscopy. The cytology confirmed adenocarcinoma. The fungal smear and culture grew Cryptococcus neoformans. The patient was treated with fluconazole with improvement of his symptoms before starting chemotherapy. We are reporting this case as clinicians usually focus on bacterial etiologies in outpatient setting. Our patient, who wasimmunocompetent, had a new diagnosis of cryptococcal pneumonia and was also found to have lung adenocarcinoma. This case highlights the rare occurrence of this type of pneumonia in immunocompetent patientsand the importance of considering fungal causes of pneumonia in patients.

ATYPICAL PRESENTATION OF FAT EMBOLISM SYNDROME IN AN IMMUNOCOMPROMISED PATIENT

ATYPICAL PRESENTATION OF FAT EMBOLISM SYNDROME IN AN IMMUNOCOMPROMISED PATIENT

Coexistence of carbon monoxide intoxication and COVID-19

Introduction
 This case report aimed to report two patients admitted to the emergency department with a preliminary diagnosis of carbon monoxide intoxication and was diagnosed with COVID-19 during their follow-up.
 Case 1
 A 73-year-old female patient presented with weakness and shortness of breath complaints to the emergency department. Carboxyhemoglobin (COhgb) reached 36.2 %. Atypical pneumonic infiltration with peripheral and central patchy consolidations in the zones in hemothorax images from computerized tomography. The patient was tested positive for COVID-19 after a PCR test. The COhgb values of the patient reached 16 % after 3 h. Then, it dropped to 3.0 % after 8 h.
 Case 2
 A 77-year-old male patient presented with shortness of breath and nausea complaints to the emergency department. COhgb (carboxyhemoglobin) reached 30%. Emphysematous changes in the lung parenchyma and increased peribronchial densities in the lobes were shown in computed tomography. The patient was tested positive for COVID-19 after a PCR test. The COhgb values of the patient reached 13 after 3 h. It dropped to 2.4 after 8 h. 
 Conclusion
 Carbon monoxide intoxication is a significant public health problem with a high probability of death. Detailed studies and meta-analyses are needed to affect the prognosis of COVID-19 disease.

Neumonía organizada

Organizing pneumonia is a non-specific pathologic pattern of response to lung damage. It can be idiopathic, or it can occur secondary to various medical processes, most commonly infections, connective tissue disease, and pharmacological toxicity.Although there is no strict definition of the radiological pattern of organizing pneumonia as in other idiopathic interstitial pneumonias, the characteristic pattern of this disease could be considered to include patchy consolidations and ground-glass opacities in the peribronchial and subpleural areas of both lungs. Moreover, follow-up examinations show that these lesions respond to treatment with corticoids, migrate with or without treatment, and tend to recur when treatment is decreased or withdrawn.Other manifestations of organizing pneumonia include nodules of different sizes and shapes, solitary masses, nodules with the reversed halo sign, a perilobular pattern, and parenchymal bands.

Use of convalescent plasma in pregnant women with early stage COVID-19 infection in a tertiary care hospital in Dubai, February to March 2021: a case series study

BackgroundThe use of COVID-19 convalescent plasma (CCP) for the treatment of SARS-CoV-2 infection in pregnancy is intriguing in view of its safety profile in pregnancy and historical precedence of the use of plasma for other viral illnesses. This study aimed to evaluate the use of CCP in pregnant women with early COVID-19 infection.MethodsThis is a retrospective case series study. We have included seven pregnant women admitted with early COVID-19 infection to a tertiary care hospital, Latifa Maternity Hospital in Dubai, United Arab Emirates between 12 February and 04 March 2021 and who consented to receive COVID-19 convalescent plasma as part of their treatment plan. Main outcomes measured were clinical and radiological features, laboratory tests, WHO clinical progression scale pre and post treatment, and maternal, fetal outcomes. COVID-19 clinical severity was classified according to the NIH guidelines for criteria of SARS-CoV-2. For the radiological features, a modified chest X-ray scoring system was used where each lung was divided into 6 zones (3 on each side upper, middle, and lower). Opacities were classified into reticular, ground glass, patchy and dense consolidations patterns.ResultsSeven pregnant women with early COVID-19 were enrolled in this study, their mean age was 28 years (SD 3.6). Four had comorbidities: 2 with diabetes, 1 with asthma, and 1 was obese. Five patients were admitted with a WHO clinical progression score of 4 (hospitalized; with no oxygen therapy) and 2 with a score of 5 (hospitalized; oxygen by mask/nasal prongs). Upon follow up on day 10, 6 patients had a WHO score of 1 or 2 (asymptomatic/mild symptoms) indicating clinical recovery. Adverse reactions were reported in 2 patients, one reported a mild skin rash, and another developed transfusion related circulatory overload. All patients were discharged alive.ConclusionCCP seems to be a promising modality of treating COVID-19 infected pregnant women. However, further studies are needed to ascertain the efficacy of CCP in preventing progressive disease in the management of COVID-19 infection in pregnant women.

P144 The uncommon meets the common: Invasive Aspergillosis and tuberculosis co-infection in non-neutropenic patients— arare association

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMBackground and ObjectiveInvasive aspergillosis (IA) is known to occur in immunocompromised patients including neutropenic patients. But, recently increasing cases have been reported in patients with non-classical risk factors and non-neutropenic patients like diabetes mellitus, chronic lung disease, HIV infection, critically ill patients, etc. According to ISHAM these non-classical risk factors should be included in EORTC/MSG host criteria for diagnosis of invasive aspergillosis.India has a high tuberculosis (TB) burden, and this is always considered as the first differential for any patient with fever, cough, hemoptysis, and weight loss. Post-tubercular chronic pulmonary aspergillosis common reported condition. However, co-infection of active TB and invasive aspergillosis is less reported. This co-infection could be one of the contributors of high morbidity and mortality in cases with tuberculosis.We hereby present a series of five cases of TB concomitant with invasive aspergillosis in non-neutropenic patients.MethodsThis is a prospective observational study, all patients admitted with molecular diagnosis (GeneXpert) of tuberculosis and with at least one non-classical risk factor for invasive aspergillosis were subjected to further evaluation. Diagnosis of invasive aspergillosis was considered in patients who had at least one clinical and one mycological EORTC criteria. Galactomannan level in different samples was measured via PlateliaTM ELISA. The efficacy of different antifungals and outcomes were analyzed.ResultsTotal 57 patients with TB underwent for evaluation of invasive aspergillosis. Among them, five patients were diagnosed to have concomitant TB and invasive aspergillosis, of which three cases of CNS TB and CNS aspergillosis and two had concomitant pulmonary infections. The average age was 31 ± 12 years with a female preponderance (4/5). Two patients were HIV positive, while among non-HIV patients, one had CD4 cytopenia (CD4-171). One patient had no known predisposing factor. Radiologically, most common pulmonary lesions were patchy consolidation with centrilobular nodules with tree in bud appearance, while CNS lesions showed multiple ring-enhancing lesions. All the patients had CBNAAT positive, two from BAL sample, 1 from CSF, and 1 from the lymph node. Rifampicin was sensitive in all, except one who had rifampicin resistance indeterminate. Of these patients, four were probable invasive aspergillosis satisfying the host, mycological and clinical factors as per the EORTC/MSGERC 2021 guidelines. The treatment of coinfection is challenging due to the interaction of rifampicin with voriconazole, which is the drug of choice for invasive aspergillosis. Here, 3 patients were treated with Inj amphotericin B, while the other 2 patients were started on voriconazole with rifampicin sparing regimen for TB. Of the 5 patients, 4 patients survived with excellent response to the treatment, with one fatality.ConclusionThe possibility of concurrent TB and invasive aspergillosis in non-neutropenic hosts should be considered to avoid devastating outcomes. The lack of clinical suspicion may result in misdiagnosis, and most importantly, the chronicity of the infection makes it indistinguishable from TB. Moreover, the co-administration of antifungal and anti-TB medications presents significant therapeutic challenges necessitating thorough evaluation and monitoring.

Transvenous retrograde thoracic duct embolization for effective treatment of recurrent plastic bronchitis after Fontan palliation

Plastic bronchitis (PB) is a rare but potentially detrimental complication of the Fontan circulation. Retrograde transvenous thoracic duct embolization (TDE) has been proposed as a treatment strategy for lymphatic dysfunction. A 5.5-year-old patient (16 kg/105 cm) was referred to our institution for severe PB refractory to conservative treatment 3 months after completion of Fontan palliation. CT-scan showed multiple bilateral areas of patchy consolidation and ground-glass opacity with obstruction of the right main and right lower bronchi. Bi-inguinal transnodal fluoroscopy-guided lymphangiogram confirmed the diffuse and abnormal lymphatic leak originating from the thoracic duct into the chest, predominantly right-sided, and showed the TD ostium near the left venous angle. There was no opacification of any target central lymphatic vessel for direct transabdominal puncture. Retrograde approach from the femoral vein was adopted to catheterize the thoracic duct and selectively embolize its distal portion using intercalation of microcoils and liquid embolic adhesive. Recurrence of symptoms after 2 months indicated a redo catheterization that revealed the persistence of dilated peribronchial lymphatic network with a minimal residual leak across the previously embolized caudal section of the TD. Complete occlusion of the TD over its entire length was performed using the same technique. The procedure was technically successful and the patient was uneventfully discharged after 2 days. There was no cast recurrence or procedure-related complications and sustained clinical improvement at 18-month of postoperative follow-up. Fluoroscopy-guided lymphangiography was essential to understand the anatomy and flow pattern of the lymphatic system and to plan the lymphatic intervention. End-to-end TDE is an effective minimally invasive treatment in Fontan patients with PB and can be necessary in case of relapse after selectively embolizing the TD distal section.

396 A Rare Encounter of “Forgotten Disease”

Abstract With the advent and prompt use of antibiotics after throat infections, the rare entity of Necrobacillosis has almost disappeared in clinical practice. Here we present a case of a fit and well 27-year-old lady who was brought into A&E with septic shock, DIC and MODS after initial diagnosis of a sore throat 4 days ago which was treated by oral antibiotics. She was found to have bilateral patchy consolidations which later became necrotic cavities, empyema thoracis, peritonitis and abscess cavities in abdomen with evolving splenic abscess, prolonged QT and ectopics and type 2 respiratory failure. She was resuscitated, intubated, and transferred to the ICU. With an isolate of Fusobacterium necrophorum from blood culture Meropenem, clindamycin and metronidazole were started. However, over the next few days of treatment, lack of clinical response prompted antibiotics changing, and surgical drainage of abscesses in chest and abdomen. Eventually after a considerable period of abdominal abscess drainage and about 3 weeks of metronidazole and other antibiotics followed by Piperacillin and tazobactam for another 3 weeks the patient recovered from sepsis and was stepped down to ward. This case though rare is a good example of the benefits of surgical drainage and prolonged antibiotics for septic patients with collections. A rapid weaning only results in re-collection and clinical deterioration, or recurrent collection as happened to this patient. This is a rare case of Lemierre's syndrome which depicts the surgical difficulties faced due to recurrent abscess cavities formed in this condition.

Fourth wave of COVID-19 and CT imaging

The purpose of current study is to evaluate findings of COVID fourth wave through Computed Tomography (CT) Imaging in Malakand division of Pakistan. Thus, to obtain the research findings, the study adopted experimental approach to evaluate how the CT scan facilitates the radiologists to study about fourth wave of COVID-19, and how the experiment can be implemented in Malakand, Pakistan. The patients with COVID-19 positive were involved in the study, where the results of their CT scan were analyzed to evaluate the difference in examination and other factors associated with COVID symptoms. Total 50 patients with COVID positive were involved in the study from Malakand division of Pakistan, and their CT imaging was performed in a well-known hospital of Swat. The findings were then analyzed through CT Images, which showed that approximately, 81% of the participant’s images were found with patchy ground-glass opacities, whereas 69% patients were found with patchy consolidations. Also, 31% patients had nodules found in CT imaging. Also, in 52% patients, the interlobular septal thickness was also observed, which had thickened the vascular, air bronchogram, or fibrous foci. Further conclusions were drawn on the effectiveness of the CT scan images in prediction of COVID impact on the patients in future.

EP-168 A rare encounter of “Forgotten disease”

Abstract With the advent and prompt use of antibiotics after throat infections, the rare entity of Necrobacillosis has almost disappeared in clinical practice. Here we present a case of a fit and well 27 year old lady who was brought into A&E with septic shock, DIC and MODS after initial diagnosis of a sore throat 4 days ago which was treated by oral antibiotics. She was found to have bilateral patchy consolidations which later became necrotic cavities, empyema thoracis, peritonitis and abscess cavities in abdomen with evolving splenic abscess, prolonged QT and ectopics and type 2 respiratory failure. She was resuscitated, intubated and transferred to the ICU. With an isolate of Fusobacterium necrophorum from blood culture Meropenem, clindamycin and metronidazole were started. However, over the next few days of treatment, lack of clinical response prompted antibiotics changing, and surgical drainage of abscesses in chest and abdomen. Eventually after a considerable period of abdominal abscess drainage and about 3 weeks of metronidazole and other antibiotics followed by Piperacillin and tazobactam for another 3 weeks the patient recovered from sepsis and was stepped down to ward. This case though rare is a good example of the benefits of surgical drainage and prolonged antibiotics for septic patients with collections. A rapid weaning only results in re-collection and clinical deterioration or recurrent collection as happened to this patient. This is a rare case of Lemierre's syndrome which depicts the surgical difficulties faced due to recurrent abscess cavities formed in this condition.

Pulmonary Histoplasmosis in a Referral Hospital in Mexico City.

Pulmonary histoplasmosis is caused by inhaling Histoplasma capsulatum. Less than 1% develops the disease. Risk factors in immunocompetent individuals are environmental exposures in endemic areas. The objective of this study is to determine the frequency, clinical, and microbiological characteristics in immunocompetent patients. A retrospective case series study of patients diagnosed with pulmonary histoplasmosis was performed in a respiratory care unit in Mexico City from 2000 to 2020. Each patient had bronchial lavage, and three patients underwent thoracoscopy for the lung tissue sample taken for the culture in Sabouraud Dextrose Agar. Twelve patients were identified, 8 males and 4 females; the predominant symptoms were fever (83%), dyspnea (75%), chest pain (66%), hemoptysis (41%), and weight loss (33%). The computed tomography of the chest showed the following findings: patchy consolidation 12 (100%), hilar adenopathy 6 (50%), pleural effusion 6 (50%), caverns 3 (25%), and solitary pulmonary nodule in one patient (8%). Histoplasma capsulatum was found in the culture of all twelve patients. The signs and symptoms of the disease are mediated by the immune status of the host. The clinical picture is often confused with systemic diseases. It is important to have a high degree of clinical suspicion to make a timely diagnosis.

Acute fibrinous and organizing pneumonia in a patient with Sjögren’s syndrome and Legionella pneumonia: a case report and literature review

BackgroundAcute fibrinous and organizing pneumonia (AFOP) is a rare clinicopathological condition. Studies in the literature have reported that AFOP may be associated with respiratory infections, such as respiratory syncytial virus, influenza virus, Pneumocystis jirovecii, Penicillium citrinum, and Chlamydia infections. However, AFOP associated with Legionella infection has not been reported previously. Here, we report a case of a patient with AFOP secondary to Sjögren’s syndrome and Legionella infection.Case presentationA 47-year-old man was admitted to the hospital because of fever, expectoration, and shortness of breath. Lung imaging showed irregular patchy consolidation. A diagnosis of Legionella pneumonia was initially considered on the basis of the patient’s history of exposure to soil before disease onset, signs of extrapulmonary involvement, and a positive Legionella urine antigen test result. However, the patient’s symptoms and lung imaging did not improve after treatment with levofloxacin, moxifloxacin, and tigecycline for Legionella infection. In addition, Sjögren’s syndrome was diagnosed on the basis of clinical manifestations and immunological indicators. Pathological changes associated with AFOP were confirmed from the results of ultrasound-guided percutaneous lung biopsy. The patient’s clinical symptoms improved rapidly after a short course of low-dose corticosteroid therapy, and lung imaging showed significant improvement.ConclusionsThe possibility of secondary AFOP should be considered when Legionella pneumonia does not improve after standard antibiotic therapy. Lung biopsy and histopathological examination are important for the adjustment of treatment strategy. Our case also highlights the importance of screening for autoimmune diseases in patients with AFOP.

A Frequently Missed Pulmonary Infarction: Clinical and 18F-FDG PET/CT Manifestation of Hilar Tumor-Induced Pulmonary Infarction.

PurposeThis study aimed to summarize the clinical and 18F-FDG PET/CT manifestations of hilar tumor–induced pulmonary infarction.MethodsA retrospective analysis was performed on patients with hilar masses who underwent FDG PET/CT scans between July 2015 and January 2021 and had complete clinical data. Pulmonary infarction was confirmed by concurrent chest CT and imaging follow-up or pathology.ResultsA total of 58 patients (mean age, 56 [SD, 13] years; 44 males) with 122 infarcts were included in the study. Hilar masses were mostly associated with small cell lung cancer (64%). The most common clinical manifestations were cough (64%) and hemoptysis (36%). Most patients (62%) had multiple pulmonary infarcts. The CT findings of pulmonary infarcts included the “Hampton hump” (48%) and patchy consolidation (52%). The density of infarcts included “bubbly consolidation” (61%) and “homogenous consolidation” (39%). The metabolic activity of 95 infarcts (78%) was higher than lung parenchyma, with the SUVmax of 3.3 (SD, 1.1). The metabolic patterns on PET/CT were “rim sign,” “mismatch between PET and CT,” and “no metabolism.” Pulmonary vein involvement was found in 25 patients (43%), pleural effusion in 22 patients (38%), and the pleural curvilinear sign in 8 patients (14%).ConclusionsThe clinical manifestations of hilar tumor–induced pulmonary infarction are not specific, and 18F-FDG PET/CT could be an effective diagnostic tool.

Positron-emission tomography-computed tomography appearance of COVID-19 infection.

An elderly man who had recently recovered from COVID-19 infection presented to the post-COVID clinic of our hospital for checkup. He was diagnosed to have Hodgkin’s lymphoma (nodal only disease) a year back and had received six cycles of chemotherapy. A day prior to review, he had undergone a fluorodeoxyglucose positron-emission tomography–computed tomography (FDG PET CT) to assess the response to chemotherapy. Maximum intensity projection [Figure 1] axial [Figure 2] and coronal [Figure 3] images showed patchy subsegmental consolidation, ground-glass attenuation, and interstitial septal thickening involving all lobes of both lungs with associated heterogeneously increased parenchymal FDG uptake. These findings are consistent with lung involvement due to COVID-19 infection.Figure 1: Maximum intensity projection image of whole-body fluorodeoxyglucose positron-emission tomography–computed tomography scan showing hypermetabolic residual nodal disease involving the right paratracheal node with bilateral hypermetabolic consolidation patches noted in all segments of both lungsFigure 2: Axial high-resolution computed tomography image and corresponding fluorodeoxyglucose positron-emission tomography image showing predominantly peripheral ground-glass opacities with intralobular and interlobular interstitial septal thickening and subsegmental peripheral consolidation involving both lungsFigure 3: Coronal image of the positron-emission tomography–computed tomography images demonstrating heterogeneously fluorodeoxyglucose avid consolidation patches in a vertical curvilinear patternThe most striking features of FDG PET CT in patients with COVID-19 are increased FDG uptake in the ground-glass densities and plaques, which are typical CT findings in early disease. FDG uptake of lung lesions of COVID-19 has an atypical appearance in terms of density-based consideration, and it suggests a high level of inflammatory processes occurring in the lung.[123] The intense FDG uptake happens in the active stage of disease and progression but persists even during recovery stage of COVID.[4] This could be caused by nonviable RNA remnants of SARS-CoV-2, immunotherapeutic response, or angiovascular damage.[5] Metabolic changes precede morphological changes, and hence, functional imaging using PET is a useful early predictor of therapeutic response in inflammatory conditions. Thus, FDG PET CT has the potential to enhance our understanding of the pathogenetic mechanisms of COVID-19. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Clinical features and long-term prognosis of acute fibrinous and organizing pneumonia histologically confirmed by surgical lung biopsy

BackgroundAcute fibrinous and organizing pneumonia (AFOP) is a rare interstitial pneumonia characterized by intra-alveolar fibrin deposition and organizing pneumonia. The clinical manifestations and long-term prognosis of AFOP are unclear. Our objective was to investigate the clinical features and prognosis of AFOP.MethodsWe identified patients diagnosed with AFOP by surgical lung biopsy between January 2011 and May 2018 at Seoul National University Bundang Hospital. We retrospectively reviewed clinical and radiologic findings, treatment, and outcomes of AFOP.ResultsFifteen patients with histologically confirmed lung biopsies were included. The median follow-up duration was 2.4 (range, 0.1–82) months. The median age was 55 (range, 33–75) years, and four patients were immunocompromised. Fever was the most common clinical presentation (86.7%). Patchy ground-glass opacities and/or consolidations were the most predominant findings on chest computed tomography images. Nine patients (60%) received mechanical ventilator care, and eight patients (53.3%) died. The non-survivors tended to have slightly higher body mass index (BMI) and a long interval between symptom onset and diagnosis than the survivors, but these findings were not statistically significant. Among seven survivors, five patients were discharged without dyspnea and oxygen supplement.ConclusionsThe clinical course of AFOP was variable. Although AFOP was fatal, most of the patients who recovered from AFOP maintained normal life without supplemental oxygen therapy and respiratory symptoms.