Predominant Ground-glass Opacities Research Articles

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 & 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.

Segmentectomy for patients with early-stage pure-solid non-small cell lung cancer.

For decades, lobectomy has been the recommended surgical procedure for non-small cell lung cancer (NSCLC), including for small-sized lesions. However, two recent pivotal clinical trials conducted by the Japanese Clinical Oncology Group/West Japan Oncology Group (JCOG0802/WJOG4607L) and the Cancer and Leukemia Group B (CALGB140503), which compared the survival outcomes between lobectomy and sublobar resection (the JCOG0802/WJOG4607L included only segmentectomy, not wedge resection), demonstrated the efficacy of sublobar resection in patients with early-stage peripheral lung cancer measuring ≤ 2 cm. The JCOG0802/WJOG4607L demonstrated the superiority of segmentectomy over lobectomy with respect to overall survival, implying the survival benefit conferred by preservation of the lung parenchyma. Subsequently, the JCOG1211 also demonstrated the efficacy of segmentectomy, even for NSCLC, measuring up to 3 cm with the predominant ground-glass opacity phenotype. Segmentectomy has become the standard of care for early-stage NSCLC and its indications are expected to be further expanded to include solid lung cancers > 2 cm. However, local control is still a major concern for segmentectomy for higher-grade malignant tumors. Thus, the indications of segmentectomy, especially for patients with radiologically pure-solid NSCLC, remain controversial due to the aggressive nature of the malignancy. In this study, we reviewed previous studies and discussed the efficacy of segmentectomy for patients with such tumors.

A STUDY IN TO THE DISEASE SEVERITY AND THE CLINICO-RADIOLOGICAL FINDING IN COVID-19 CASES

Objective: To study the disease severity and the clinical-radiological finding in COVID-19 patients.
 Methods: The study was carried out in the Department of Respiratory Medicine of R. D. Gardi Medical College, a tertiary care centre as well a Dedicated Covid Centre in the Ujjain district of MP.
 Results: A total of 107 patients with COVID-19 disease were assessed; the patients had a median age of 52 y and a mean age of 50.79±16.81 y. The most common clinical presentation were fever which was seen in 80(74.8%) cases, breathlessness (SOB) in 84(78.5%), cough in 71(66.4%), weakness in 29(27.1%), loss of smell in 34(31.8%) and loss of taste in 32(29.9%). The most common co-morbidity present in the study group was diabetes mellitus, which was present in 51(47.7%) cases. The chest radiograph of the patients revealed consolidation in 51(47.7%), GGOs in 29(27.1%), GGO with consolidation in 3(2.8%), reticular pattern in one case and 23(21.5%) cases had the normal pattern. Severity of disease was significantly associated with age of the patient. The typical findings of chest CT in the case of COVID-19 pneumonia include “bilateral, peripheral, and basal predominant ground-glass opacities with or without consolidation and broncho-vascular thickening, In addition, atypical findings are “cavitations, central upper lobe predominance, nodules, masses, tree-in bud sign, and lymphadenopathy A significant statistical correlation was found between CT severity score.
 Conclusion: The radiology played a very important part in the diagnosis and management of covid patients during the pandemic. The typical presentation of chest radiographs and HRCT thorax helped in diagnosing cases even when the RTPCR, RAT were negative or not available and chest CT severity score of patients positively correlated with clinical severity, inflammatory laboratory markers, especially the CRP, LDH, D-dimer and S. Ferritin and hence was very useful as an predictor of disease severity.

Lung Ultrasonography Is an Acceptable Imaging Modality to Diagnose COVID-19 and Effectively Correlates with HRCT Chest-A Prospective Study.

It has been validated beyond doubt that High-Resolution Computed Tomography (HRCT) chest and to some extent chest radiographs have a role in corona virus disease-19 (COVID-19). Much less is known about the role of lung ultrasonography (LUS) in COVID-19. In this paper, our main purpose was to gauge the relationship between LUS and chest HRCT in reverse transcriptase polymerase chain reaction (RT-PCR) documented cases of COVID-19, as well as in those with high suspicion of COVID-19 with negative RT-PCR. It was a prospective study carried out at our tertiary care hospital, namely, SKIMS Soura. The total number of patients in this study were 152 (200 patients were selected out of which only 152 had undergone both LUS and chest HRCT). The patients were subjected to both LUS and chest HRCT. The radiologist who performed LUS was blinded to clinical findings and HRCT was evaluated by a radiologist with about a decade of experience. The LUS findings compatible with the disease were subpleural consolidations, B-lines and irregular pleural lines. Findings that were compatible with COVID-19 on chest HRCT were bibasilar, subpleural predominant ground glass opacities, crazy paving and consolidations. COVID-19-positive patients were taken up for chest HRCT for disease severity stratification and were also subjected to LUS. On HRCT chest, the imaging abnormalities compatible with COVID-19 were evident in 110 individuals (72.37%), and on Lung Ultrasound they were observed in 120 individuals (78.95%). Imaging of COVID-19 patients assessed by both LUS and HRCT chest,, showed a positive correlation (p < 0.0001). The study revealed a sensitivity of 88%, a specificity of 76.62%, a positive predictive value of 78.57% and a negative predictive value of 86.76%. None of the individuals with a diagnosis of COVID-19 on HRCT were missed on LUS. An excellent correlation was derived between the LUS score and CT total severity score (p < 0.0001 with a kappa of 0.431). Similar precision compared with chest HRCT in the detection of chest flaws in COVID-19 patients was obtained on LUS.

Lymph Node Metastases in Surgically Resected Solitary Ground-Glass Opacities: A Two-Center Retrospective Cohort Study and Pooled Literature Analysis.

An increasing body of evidence supports the noninferiority of sublobar resection compared with lobectomy in terms of survival for patients with early-stage lung cancer with ground-glass opacities (GGOs). However, few studies have focused on the incidence of lymph node (LN) metastases in these patients. We aimed to analyze N1 and N2 lymph node involvement in patients with non-small cell lung cancer (NSCLC) with GGO components stratified with different consolidation tumor ratio (CTR). We performed two-center studies by retrospectively reviewing a total of 864 patients with NSCLC with semisolid or pure GGO manifestation (diameter≤3cm). Clinicopathologic features and outcomes were analyzed. We also reviewed 35 studies to characterize the patient with NSCLC population with the GGO manifestation. In both cohorts, there was no LN involvement for pure GGO NSCLC, while solid predominant GGO exhibited a relatively high LN involvement rate. On the basis of a pooled literature analysis, the incidence of pathologic mediastinal LN was 0% and 3.8% for pure and semisolid GGOs, respectively. GGO NSCLCs with CTR≤0.5 also had rare LN involvement (0.1%). From two cohorts and pooled literature analysis, LN involvement was not observed in patients with pure GGO, and very few patients with semisolid GGO NSCLC with CTR ≤0.5 had LN involvement, revealing that it may be unnecessary to perform lymphadenectomy for pure GGOs, while mediastinal lymph node sampling (MLNS) is enough for semisolid GGOs with CTR ≤0.5. For the patients with GGO CTR >0.5, mediastinal lymphadenectomy (MLD) or MLNS should be considered.

Segmentectomy for ground-glass-dominant lung cancer with a tumour diameter of 3 cm or less including ground-glass opacity (JCOG1211): a multicentre, single-arm, confirmatory, phase 3 trial

Although segmentectomy is a widely used surgical procedure, lobectomy is the standard procedure for resectable non-small-cell lung cancer (NSCLC). This study aimed to evaluate the efficacy and safety of segmentectomy for NSCLC up to 3 cm in size, including ground-glass opacity (GGO) and predominant GGO. A multicentre, single-arm, confirmatory phase 3 trial was conducted across 42 institutions (hospitals, university hospitals, and cancer centres) in Japan. Segmentectomy with hilar, interlobar, and intrapulmonary lymph node dissection was performed as protocol surgery for patients with a tumour diameter of up to 3 cm, including GGO and dominant GGO. Eligible patients were those aged 20-79 years with an Eastern Cooperative Oncology Group performance score of 0 or 1 and clinical stage IA tumour confirmed by thin-sliced CT. The primary endpoint was 5-year relapse-free survival (RFS). This study is registered with the University Hospital Medical Information Network Clinical Trials (UMIN000011819), and is ongoing. A total of 396 patients were registered from Sept 20, 2013, to Nov 13, 2015, of whom 357 underwent segmentectomy. At a median follow-up of 5·4 years (IQR 5·0-6·0), the 5-year RFS was 98·0% (95% CI 95·9-99·1). This finding exceeded the 87% of the pre-set threshold 5-year RFS and the primary endpoint was met. Grade 3 or 4 early postoperative complications occurred in seven patients (2%), but no grade 5 treatment-related deaths occurred. Segmentectomy should be considered as part of standard treatment for patients with predominantly GGO NSCLC with a tumour size of 3 cm or less in diameter, including GGO even if it exceeds 2 cm. National Cancer Centre Research and Development Fund and Japan Agency for Medical Research and Development.

Variation of Chest Computed Tomographic Findings in Coronavirus Disease-19 (COVID-19) Positive Patients in a Tertiary Care Hospital, Bangladesh

Background: We aimed to report different patterns of chest computed tomographic (CT) findings in coronavirus disease-19 (COVID-19) infected patients in Bangladesh.&#x0D; Methods: This was a cross-sectional descriptive study of 200 consecutive reverse transcriptase polymerase chain reaction (RT-PCR) positive patients who underwent CT chest. Distribution, type of abnormal lung findings and Prevalence were recorded.&#x0D; Result: Among the total study cohort of 200 patients, 148(74 %) were males and 52 (26 %) were females with mean age of 53.9 ± 16.7 years (range 20–92 years). We observed lung parenchymal abnormalities in 125 (62.0 %) cases whereas 75 (37.5 %) RT-PCR positive cases had a normal chest CT. Common symptom was cough in 108 (54%), Only 18.0% of the patients were dyspneic. Among the patients with abnormal CT findings bilateral involvement was commonest 98/125 (78.4 %), multilobar (54.0 %) lung involvement with a predominant peripheral and posterior distribution was more commonly observed. With regards to the type of opacity, ground glass opacity (GGO) was the predominant abnormality found in 122/125 cases. Pure GGO was observed in 29 (23.2 %), most common pattern was GGO mixed with consolidation was noted in 52(41.6 %). GGO with crazy paving pattern was seen in 33 (26.4 %) and sub pleural linear and curvilinear lines were seen in 23(18.4%). Peri-lesional or intralesional segmental or subsegmental pulmonary vessel enlargement was observed in 36 (70.6 %) cases.&#x0D; Conclusion: In this study population, we found a high proportion of symptomatic laboratory-confirmed SARS-CoV-2 patients had positive chest CT findings. Patients with a positive CT showed typical findings of predominant GGOs in a bilateral and multilobar distribution with peripheral predilection.&#x0D; AKMMC J 2021; 12(1) : 38-44

COVID-19 INFECTION AS A CAUSE FOR PROGRESSION OF PREVIOUSLY ASYMPTOMATIC SARCOIDOSIS TO SYMPTOMATIC SARCOIDOSIS

COVID-19 INFECTION AS A CAUSE FOR PROGRESSION OF PREVIOUSLY ASYMPTOMATIC SARCOIDOSIS TO SYMPTOMATIC SARCOIDOSIS

RAPIDLY PROGRESSING DERMATOMYOSITIS-ASSOCIATED RESPIRATORY FAILURE SUCCESSFULLY STABILIZED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

RAPIDLY PROGRESSING DERMATOMYOSITIS-ASSOCIATED RESPIRATORY FAILURE SUCCESSFULLY STABILIZED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

Pictorial guide for variants of Covid-19: CT imaging and interpretation.

Typical radiologic images of Covid-19 pneumonia consists in a wide spectrum of chest manifestations, which range from peripheral predominant ground-glass opacities to an organizing pneumonia pattern, with additional features including crazy-paving, consolidations, fibrotic streaks and linear opacities. With variants imaging profile of Covid-19 evolves, producing relatively atypical/indeterminate CT pattern of pulmonary involvement, which overlap with imaging features of a variety of other respiratory diseases, including infections, drug reaction and hypersensitivity pneumonia. Our knowledge of these radiological findings is incomplete and there is a need to strengthen the recognition of the many faces of Covid-19 pneumonia.

A study of the chest imaging findings of adult patients with COVID-19 on admission to a tertiary hospital in Johannesburg, South Africa.

BackgroundSouth Africa has experienced multiple waves of the coronavirus disease 2019 (COVID-19) with little research documenting chest imaging features in an human immunodeficiency virus (HIV) and tuberculosis (TB) endemic region.ObjectivesDescribe the chest imaging features, demographics and clinical characteristics of COVID-19 in an urban population.MethodRetrospective, cross-sectional, review of chest radiographs and computed tomographies (CTs) of adults admitted to a tertiary hospital with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, between 01 May 2020 and 30 June 2020. Imaging was reviewed by three radiologists. Clinical parameters and laboratory data were analysed.ResultsA total of 113 adult patients with a mean age of 46 years and 10 months were included. A total of 113 chest radiographs and six CTs were read. Nineteen patients were HIV-positive (16.8%), 40 were hypertensive and diabetic (35.4%), respectively, and one had TB (0.9%). Common symptoms included cough (n = 69; 61.6%), dyspnoea (n = 60; 53.1%) and fever (n = 46; 40.7%). Lower zone predominant ground glass opacities (58.4%) and consolidation (29.2%) were most frequent on chest radiographs. The right lower lobe was most involved (46.9% ground glass opacities and 17.7% consolidation), with relative sparing of the left upper lobe. Bilateral ground glass opacities (66.7%) were most common on CT. Among the HIV-positive, ground glass opacities and consolidation were less common than in HIV-negative or unknown patients (p = 0.037 and p = 0.05, respectively).ConclusionCOVID-19 in South Africa has similar chest imaging findings to those documented globally, with some differences between HIV-positive and HIV-negative or unknown patients. The authors corroborate relative sparing of the left upper lobe; however, further research is required to validate this currently unique local finding.

CT perfusion imaging can detect residual lung tumor early after radiofrequency ablation: a preliminary animal study on both tumoral and peri-tumoral region assessment.

BackgroundRadiofrequency ablation (RFA) is a minimally invasive procedure to treat lung cancer. Timely evaluation on residual lung tumor after RFA is crucial to the prognosis, hence, our objective is to assess CT perfusion (CTP) on detection of residual lung tumor early after RFA.MethodsCTP imaging was performed in 24 lung VX2 tumor models 1 day before and within 1 hour after RFA. CTP maps with dual-input (n=24) and single-input [n=13, with predominant ground glass opacity (GGO) after RFA] models were generated using the maximal slope method. Regions of interest were independently placed on the maximal cross-sectional tumor before and after RFA and on GGO after RFA by two thoracic radiologists. The bronchial flow (BF), pulmonary flow (PF) and perfusion index (PI) were compared between pre-RFA and post-RFA images. The parameters (BF, PF and PI of tumor; PF of GGO) of the complete and incomplete RFA groups were compared based on nicotinamide adenine dinucleotide hydrogen (NADH) and TdT-mediated dUTP nick-end labeling (TUNEL) staining and were correlated with the microvascular density (MVD).ResultsThe BF and PF decreased after RFA (all P values <0.03). The decrease in BF and PF (ΔBF and ΔPF) in the complete RFA group was higher (P=0.01; 0.02). The areas under the curve (AUC) of ΔBF and ΔPF at 14.85 and 17.25 mL/min/100 mL in determination of tumor with complete ablation were 0.80 and 0.78, respectively. ΔBF was positively correlated with MVD (P=0.046, r=0.468). PF of GGO with incomplete RFA was higher (P=0.001). The AUC of PF ≤29.4 mL/min/100 mL in determination of tumor with complete ablation was 0.99.ConclusionsCTP could detect residual lung tumor early after RFA in a rabbit model, which might provide a clinical solution to early treatment assessment after RFA.

Chest imaging findings in COVID-19-positive patients in an Australian tertiary hospital.

IntroductionCoronavirus disease 2019 (COVID‐19) has infected over 215 million individuals worldwide. Chest radiographs (CXR) and computed tomography (CT) have assisted with diagnosis and assessment of COVID‐19. Previous reports have described peripheral and lower zone predominant opacities on chest radiographs. Whilst the most common patterns on CT are bilateral, peripheral basal predominant ground glass opacities (Wong et al., Radiology, 296, 2020, E72; Karimian and Azami, Pol J Radiol, 86, 2021, e31). This study describes the imaging findings in an Australian tertiary hospital population.MethodsCOVID‐PCR‐positive patients who had chest imaging (CXR, CT and ventilation perfusion (V/Q) scans) from January 2020 to August 2020 were included. Distribution, location and pattern of involvement was recorded. Evaluation of the assessors was performed using Fleiss Kappa calculations for review of radiographic findings and qualitative analysis of CT findings.ResultsA total of 681 studies (616 CXRs, 59 CTs, 6 V/Q) from 181 patients were reviewed. The most common chest radiograph finding was bilateral lower lobe predominant diffuse opacification and most common CT pattern being ground glass opacities. Of the CT imaging, 33 were CT Pulmonary Angiograms of which five demonstrated acute pulmonary emboli. There was good inter‐rater agreement between radiologists in assessment of imaging appearances on CXR (kappa 0.29–0.73) and CT studies.ConclusionA review of imaging in an Australian tertiary hospital demonstrates similar patterns of COVID‐19 infection on chest X‐ray and CT imaging when compared to the international population.

METHOTREXATE-INDUCED PNEUMONITIS

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Methotrexate is an analogue of folic acid that inhibits cellular proliferation by inducing an intracellular deficiency of folate coenzymes. Lung toxicity, while rare, often occurs after weeks to months of low dose oral methotrexate therapy. CASE PRESENTATION: A 46 year old male with a history of T cell lymphoma status post chemotherapy on POMP maintenance therapy and pleurX catheter for malignant pleural effusion presented to the ED with fever for 4 days. Associated symptoms were dry cough, chills, and fatigue. He denied drug allergies.BP 153/84, HR 135, SpO2 98% on room air, and temperature 101.5F. WBC was 3.2 and COVID PCR was negative. Broad spectrum antibiotics were initiated. CT thorax showed upper lobe predominant ground-glass opacities suggestive of a multifocal pneumonia or drug reaction. He became hypoxic requiring 3L of oxygen and underwent bronchoscopy. Transbronchial biopsy revealed lung parenchyma with isolated giant cells and loosely formed granulomas consistent with hypersensitivity pneumonia. Left upper lobe broncho-alveolar lavage had lymphocytic predominance and elevated CD4:CD8 ratio (4.7), all supporting the diagnosis of methotrexate pneumonitis. Empiric treatment for PJP and Prednisone were started. Viral, bacterial, fungal studies and PJP stain were negative. Antibiotics were stopped and steroids were continued for 2 weeks. His symptoms improved and fevers subsided. As an outpatient, repeat CT thorax and PFTs were ordered and he continues to improve clinically. DISCUSSION: There is a set of criteria to establish the diagnosis. Major criteria includes: 1. hypersensitivity pneumonitis by histopathology without pathogenic organisms 2. imaging with diffuse ground-glass or consolidative opacities 3. negative blood cultures (if febrile) and initial sputum cultures (if produced). Minor criteria includes: 1. dyspnea for <8 weeks 2. nonproductive cough 3. SpO2< 90% on room air at initial evaluation 4. DLCO < 70% of predicted for age and 5. WBC < 15k. Methotrexate pneumonitis is definite if major criteria 1 or 2 and major criterion 3 are present with three of the five minor criteria and probable if major criteria 2 and 3 plus two of the five minor criteria are present (1). Our patient met all major criteria and four minor criteria. CONCLUSIONS: Although rare with a prevalence of 0.3-11.6% (1,3), methotrexate pneumonitis has a mortality rate of 13-17.6% (2,4). Patients should be advised about the possibility of lung toxicity. Some data suggests patients should be screened for lung disease prior to medication initiation (5) and clinicians should be cautious using the drug in patients with underlying lung disease (6). REFERENCE #1: Salehi, Mashal et al. "Methotrexate-induced Hypersensitivity Pneumonitis appearing after 30 years of use: a case report." Journal of medical case reports vol. 11,1 174. 28 Jun. 2017, doi:10.1186/s13256-017-1333-0 DISCLOSURES: No relevant relationships by Bianca Dominguez, source=Web Response No relevant relationships by Gurjot Garcha, source=Web Response No relevant relationships by Wael Nasser, source=Web Response No relevant relationships by Olatunji Otegbeye, source=Web Response

Efficient COVID-19 Segmentation from CT Slices Exploiting Semantic Segmentation with Integrated Attention Mechanism.

Coronavirus (COVID-19) is a pandemic, which caused suddenly unexplained pneumonia cases and caused a devastating effect on global public health. Computerized tomography (CT) is one of the most effective tools for COVID-19 screening. Since some specific patterns such as bilateral, peripheral, and basal predominant ground-glass opacity, multifocal patchy consolidation, crazy-paving pattern with a peripheral distribution can be observed in CT images and these patterns have been declared as the findings of COVID-19 infection. For patient monitoring, diagnosis and segmentation of COVID-19, which spreads into the lung, expeditiously and accurately from CT, will provide vital information about the stage of the disease. In this work, we proposed a SegNet-based network using the attention gate (AG) mechanism for the automatic segmentation of COVID-19 regions in CT images. AGs can be easily integrated into standard convolutional neural network (CNN) architectures with a minimum computing load as well as increasing model precision and predictive accuracy. Besides, the success of the proposed network has been evaluated based on dice, Tversky, and focal Tversky loss functions to deal with low sensitivity arising from the small lesions. The experiments were carried out using a fivefold cross-validation technique on a COVID-19 CT segmentation database containing 473 CT images. The obtained sensitivity, specificity, and dice scores were reported as 92.73%, 99.51%, and 89.61%, respectively. The superiority of the proposed method has been highlighted by comparing with the results reported in previous studies and it is thought that it will be an auxiliary tool that accurately detects automatic COVID-19 regions from CT images.

COVID-19: What Iodine Maps From Perfusion CT can reveal\u2014A Prospective Cohort Study

BackgroundSubtraction CT angiography (sCTA) is a technique used to evaluate pulmonary perfusion based on iodine distribution maps. The aim of this study is to assess lung perfusion changes with sCTA seen in patients with COVID-19 pneumonia and correlate them with clinical outcomes.Material and methodsA prospective cohort study was carried out with 45 RT-PCR-confirmed COVID-19 patients that required hospitalization at three different hospitals, between April and May 2020. In all cases, a basic clinical and demographic profile was obtained. Lung perfusion was assessed using sCTA. Evaluated imaging features included: Pattern predominance of injured lung parenchyma in both lungs (ground-glass opacities, consolidation and mixed pattern) and anatomical extension; predominant type of perfusion abnormality (increased perfusion or hypoperfusion), perfusion abnormality distribution (focal or diffuse), extension of perfusion abnormalities (mild, moderate and severe involvement); presence of vascular dilatation and vascular tortuosity. All participants were followed-up until hospital discharge searching for the development of any of the study endpoints. These endpoints included intensive-care unit (ICU) admission, initiation of invasive mechanical ventilation (IMV) and death.ResultsForty-one patients (55.2 ± 16.5 years, 22 men) with RT-PCR-confirmed SARS-CoV-2 infection and an interpretable iodine map were included. Patients with perfusion anomalies on sCTA in morphologically normal lung parenchyma showed lower Pa/Fi values (294 ± 111.3 vs. 397 ± 37.7, p = 0.035), and higher D-dimer levels (1156 ± 1018 vs. 378 ± 60.2, p < 0.01). The main common patterns seen in lung CT scans were ground-glass opacities, mixed pattern with predominant ground-glass opacities and mixed pattern with predominant consolidation in 56.1%, 24.4% and 19.5% respectively. Perfusion abnormalities were common (36 patients, 87.8%), mainly hypoperfusion in areas of apparently healthy lung. Patients with severe hypoperfusion in areas of apparently healthy lung parenchyma had an increased probability of being admitted to ICU and to initiate IMV (HR of 11.9 (95% CI 1.55–91.9) and HR 7.8 (95% CI 1.05–61.1), respectively).ConclusionPerfusion abnormalities evidenced in iodine maps obtained by sCTA are associated with increased admission to ICU and initiation of IMV in COVID-19 patients.

Lung MRI to predict response or lack of response to treatment in interstitial lung disease: initial observations on SSFSE/PROPELLER T2 match/mismatch

ABSTRACT Background Ground-glass opacities (GGO) are frequently found in interstitial lung diseases (ILD) and may represent either active inflammation or subresolution interstitial fibrosis. We sought to investigate the ability of lung MRI to predict treatment response in individuals with ILD presenting with predominant GGO. Methods: prospective cohort, 15 participants presenting with ILD manifested as predominant GGO and referred for a new treatment regimen with a systemic glucocorticoid and/or an immunosuppressive agent, underwent 1.5 T lung MRI. SSFSE/PROPELLER T2 mismatch sign, relative signal intensity on T2-weighted images and relative enhancement of lung lesions were compared to functional response, defined as a greater than 10% increase in forced vital capacity in 10 weeks (primary endpoint). Results SSFSE/PROPELLER T2 match/mismatch was able to discriminate responders from nonresponders for the primary endpoint in 12 of 15 participants (80% accuracy, p = 0.026) for readers 1 and 2, and in 13 of 15 participants (87% accuracy, p = 0.011) for reader 3, with interrater agreement of 87% between readers 1 and 2 (Cohen’s kappa coefficient of 0.732) and 93% between readers 1/2 and 3 (Cohen’s kappa coefficient of 0.865). Conclusions SSFSE-PROPELLER T2 match/mismatch was predictive of treatment response status in this group of ILD patients. Abbreviations FVC: forced vital capacityGGO; ground-glass opacities; HRCT: High-Resolution Computed Tomography; ILD: interstitial lung disease; LAVA: Liver Acquisition with Volume Acceleration; mMRC: modified Medical Research Council dyspnea score; MRI: Magnetic Resonance Image; PROPELLER: Periodically Rotated Overlapping Parallel Lines with Enhanced Reconstruction; SI: signal intensity; SSFSE: Single-Shot Fast Spin Echo

O07 Sarcoidosis: it's bone deep

Case report - IntroductionThis is a report of a Caucasian patient with sarcoidosis presenting as groin pain.Case report - Case descriptionA 58-year-old Caucasian female from South Africa self-referred for physiotherapy following sudden onset right groin pain. Pelvic Xray was normal, but MRI pelvis showed lytic lesions in the acetabulum and proximal femur. The presence of night sweats suggested haematological malignancy leading to haematology referral. PET CT showed widespread metabolically active soft tissue lesions, lymph nodes and skeletal foci. Bone marrow trephine biopsy showed well-formed granulomata. An extensive infection screen was negative. A cervical lymph node biopsy and CT guided biopsy of pelvic and femoral lesions confirmed non-necrotising granulomas suggestive of sarcoidosis. Lung function tests were normal. Treatment with 30mg prednisolone for one month was poorly tolerated and steroids were rapidly weaned. She was unable to tolerate even low dose prednisolone. Severe pelvic pain and night sweats continue despite methotrexate, hydroxychloroquine and IV zoledronate (given for osteoporosis).Case report - DiscussionThis patient presented with groin pain, fatigue and night sweats, no demonstrable extra-osseous organ abnormality and normal plain radiography. Our diagnostic strategy was to first exclude malignancy and infection, particularly TB, but the unusual presentation created significant diagnostic uncertainty. Treatment is challenging due to intrusive side effects of steroids and hydroxychloroquine, and neutropenia induced by methotrexate.Osseous involvement is rare and has been reported in 1-15% of sarcoidosis patients. It is usually accompanied by skin lesions. There were no features on history or examination to suggest sarcoidosis and the diagnosis was based on bone biopsies.In a case series of 20 patients with osseous sarcoidosis, bone lesions were found on imaging during the initial presentation in 60% of cases. Ten patients were symptomatic, and all had multiple joint involvement. Axial involvement, primarily pelvis and lumbar spine was seen in 90% of cases. Lesions were detected on plain radiographs in 2 cases and were identified on MRI in 13 cases, PET-CT in 9 cases, CT in 4 cases and technetium-99m bone scintigraphy in 1 case. 55% of the cases required no treatment and 45% were treated most commonly with prednisolone, methotrexate, or hydroxychloroquine. Two cases required treatment with tumour necrosis factor inhibitors for refractory disease.Case report - Key learning pointsOsseous sarcoidosis can mimic many conditions including multiple myeloma and lymphoma, due to presentation with lytic lesions. Even pulmonary presentations can be atypical with predominant ground glass opacity or cavitating consolidation and parenchymal masses. Histopathological diagnosis is of critical importance, particularly in patients with atypical presentations. Assessment of organ involvement and disease extent is important in monitoring of treatment response. Plain radiographs tend to be normal in these cases and advanced imaging, including MRI, PET-CT, and CT, is often required. Symptomatic osseous disease may respond to steroids and conventional immunosuppression; a minority of refractory cases require TNF inhibition.

COMMON VARIABLE IMMUNODEFICIENCY-ASSOCIATED GRANULOMATOUS-LYMPHOCYTIC INTERSTITIAL LUNG DISEASE DIAGNOSED ON TRANSBRONCHIAL LUNG CRYOBIOPSY

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Granulomatous-Lymphocytic Interstitial Lung Disease (GLILD) is a rare entity involving granulomatous and lymphoproliferative inflammation of the small airways and pulmonary interstitium. Imaging reveals lower lung predominant ground glass and/or consolidative opacities and nodules. Histopathology may have features of lymphocytic interstitial pneumonia, follicular bronchiolitis and/or organizing pneumonia. GLILD is often seen as a manifestation of common variable immunodeficiency (CVID). Diagnosis requires lung biopsy as imaging findings are nonspecific. Surgical lung biopsy (SLB) is the gold standard in diagnosing interstitial lung disease. However, the relatively new, less invasive approach of transbronchial lung cryobiopsy (TBLC) has been increasingly considered for diagnostic purposes for diffuse parenchymal lung disease (DPLD). CASE PRESENTATION: A 58 year old male with a history of idiopathic thrombocytopenic purpura status-post splenectomy and rituximab presented with dyspnea on exertion, chest pressure and a chronic cough. CT chest revealed areas of consolidation and ground glass opacities in a lower lung distribution on a background of pulmonary fibrosis. Pulmonary function tests showed mild restriction and low diffusing capacity. He underwent outpatient TBLC with histopathologic findings of organizing pneumonia, patchy chronic inflammation, fibrosis and peribronchial lymphoid hyperplasia. Labs revealed low IgG and IgA, absence of member B cells, and deficiency of T cells. The patient was diagnosed with GLILD in setting of CVID. He was started on prednisone and IVIG with improvement in imaging findings and symptoms. DISCUSSION: GLILD is a granulomatous and lymphoproliferative disorder that occurs in 8-25% of patients with CVID. Patients may have shortness of breath and cough, as well as splenomegaly, cytopenia, and adenopathy. The constellation of signs and imaging findings are suggestive but not specific. Biopsy is needed for diagnosis. SLB is associated with relatively higher morbidity and mortality compared to TBLC, and necessitates hospitalization. TBLC has been proposed as a less invasive alternative to SLB. Advantages include lower mortality and complication rate, and no requirement for hospitalization. In this case, we demonstrate the utility of TBLC done as an outpatient in obtaining a diagnostic tissue sample, with clinical improvement on steroids and IVIG. There is no standard treatment for GLILD, but corticosteroids are recommended as first line therapy. Success has also been shown with azathioprine, ritxumab and IVIG. CONCLUSIONS: Transbronchial lung cryobiopsy is emerging as a less invasive alternative modality for obtaining tissue with less morbidity, less mortality and the advantage of being performed in the outpatient setting. Further studies regarding safety, diagnostic accuracy and yield in SLB versus TBLC are required to establish TBLC as common practice. Reference #1: Granulomatous-lymphocytic interstitial lung disease (GLILD) in common variable immunodeficiency (CIVD). Park JH, Levinson AI. Clin Immunol. 2010; 134(2):97. Reference #2: Transbronchial Lung Cryobiopsy in Idiopathic Pulmonary Fibrosis: A State of the Art Review. Adv Ther (2019) 36:2193-2204. Reference #3: British Lung Foundation/United Kingdom Primary Immunodeficiency Network Consensus Statement on the Definition, Diagnosis, and Management of Granulomatous-Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency Disorders. Hurst JR, Verma N. Lowe D, Daxendale HE, Jolles S, Kelleher P, Longhurst HJ, Patel Sy, Renzoni EA, Sander CR, Avery GR, Babar JL, Buckland MS, Burns S, Egner W, Gompels MM, Gordins P, Haddock JA, Hart SP, Hayman GR, Herriot R, Hoyles RK, Huissoon AP, Jacob J, Nicholson AG, Rassl DM, Sargur RB, Savic S, Seneviratne SL, Sheaff M, Vaailta PM, Walters GI, Whitehouse JL, Wright PA, Condliffe AM. J Allergy Clin Immunol Pract. 2017;5(4):938. Epub 2017 Mar 25. DISCLOSURES: No relevant relationships by Lawrence Benjamin, source=Web Response Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 Added 04/07/2020 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 Added 04/07/2020 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Houda Boucekkine, source=Web Response No relevant relationships by Scott Oh, source=Web Response

Pulmonary fibrosis in critical ill patients recovered from COVID-19 pneumonia: Preliminary experience

ObjectiveTo investigate chest computed tomography (CT) findings associated with severe COVID-19 pneumonia in the early recovery period. MethodsWe retrospectively analyzed the cases of patients diagnosed with severe COVID-19 pneumonia at a single center between January 12, 2020, and March 16, 2020. The twelve ICU patients studied had been diagnosed SARS-CoV-2 (COVID-19) nucleic acid positive. Patient clinical symptoms were relieved or disappeared, and basic clinical information and laboratory test results were collected. The study focused on the most recent CT imaging characteristics. ResultsThe average age of the 12 patients was 58.8 ± 16.2 years. The most prevalent symptoms were fever (100%), dyspnea (100%), and cough (83.3%). All patients experienced acute respiratory distress syndrome (ARDS), of which 9 were moderate to severe. Six patients used noninvasive ventilators, and 4 patients used mechanical ventilation. One patient was treated with extracorporeal membrane oxygenation (ECMO). The lymphocyte count decreased to 0.67 ± 0.3 (× 10 9/L). The average day from illness onset to the last follow-up CT was 56.1 ± 7.7 d. The CT results showed a decrease in ground glass opacities (GGO), whereas fibrosis gradually increased. The common CT features included GGO (10/12, 83.3%), subpleural line (10/12, 83.3%), fibrous stripes (12/12, 100%), and traction bronchiectasis (10/12, 83.3%). Eight patients (66.7%) showed predominant reticulation and interlobular thickening. Four patients (33.3%) showed predominant GGO. Lung segments involved were 174/216 (80.6%). ConclusionsFibrous stripes and GGO are common CT signs in critically ill patients with COVID-19 pneumonia in the early recovery period. Signs of pulmonary fibrosis in survivors should be carefully monitored.