Lung Ultrasound as a First-Line Test in the Evaluation of Post-COVID-19 Pulmonary Sequelae

Background: Interstitial lung sequelae are increasingly being reported in survivors of COVID-19 pneumonia. An early detection of these lesions may help prevent the development of irreversible lung fibrosis. Lung ultrasound (LUS) has shown high diagnostic accuracy in interstitial lung disease (ILD) and could likely be used as a first-line test for post-COVID-19 lung sequelae.Methods: Single-center observational prospective study. Follow-up assessments of consecutive patients hospitalized for COVID-19 pneumonia were conducted 2–5 months after the hospitalization. All patients underwent pulmonary function tests (PFTs), high-resolution computed tomography (HRCT), and LUS. Radiological alterations in HRCT were quantified using the Warrick score. The LUS score was obtained by evaluating the presence of pathological B-lines in 12 thoracic areas (range, 0–12). The correlation between the LUS and Warrick scores was analyzed.Results: Three hundred and fifty-two patients who recovered from COVID-19 pneumonia were recruited between July and September 2020. At follow-up, dyspnea was the most frequent symptom (69.3%). FVC and DLCO alterations were present in 79 (22.4%) and 234 (66.5%) patients, respectively. HRCT showed relevant interstitial lung sequelae (RILS) in 154 (43.8%) patients (Warrick score ≥ 7). The LUS score was strongly correlated with the HRCT Warrick score (r = 0.77) and showed a moderate inverse correlation with DLCO (r = −0.55). The ROC curve analysis revealed that a LUS score ≥ 3 indicated an excellent ability to discriminate patients with RILS (sensitivity, 94.2%; specificity, 81.8%; negative predictive value, 94.7%).Conclusions: LUS could be implemented as a first-line procedure in the evaluation of Post-COVID-19 interstitial lung sequelae. A normal LUS examination rules out the presence of these sequelae in COVID-19 survivors, avoiding the need for additional diagnostic tests such as HRCT.

Interstitial lung disease is not rare in immune-mediated necrotizing myopathy with anti-signal recognition particle antibodies

Objectives The purpose was to clarify the characteristics of interstitial lung disease (ILD) in immune-mediated necrotizing myopathy (IMNM) patients with anti-signal recognition particle (SRP) antibodies. Methods Medical records of IMNM patients with anti-SRP antibodies were reviewed retrospectively. Results A total of 60 patients were identified. Twenty-seven (45.0%) patients were diagnosed with ILD based on lung imaging: nonspecific interstitial pneumonia (NSIP) in 17 patients (63.0%) and organizing pneumonia in 9 patients (33.3%). Reticulation pattern was identified in 17 patients (63.0%) whereas 10 cases (37.0%) showed ground glass opacity and patchy shadows by high-resolution computed tomography (HRCT). Pulmonary function tests (PFTs) were available in 18 patients, 6 (33.3%) and 10 (55.6%) patients were included in the mild and moderate group, respectively. The average age at the time of ILD onset was significantly older than those without ILD (48.6 ± 14.4 years vs. 41.2 ± 15.4 years, p < 0.05), and the frequency of dysphagia in the ILD group was higher than the group without ILD (p < 0.05). Long-term follow-up was available on 9 patients. PFTs were stable in 8 (88.9%), and the HRCT remained stable in 6 (66.7%) patients. Conclusions ILD is not rare in IMNM patients with anti-SRP antibodies, most being characterized as mild to moderate in severity. NSIP is the principal radiologic pattern, and ILD typically remains stable following treatment.

Use of Artificial Intelligence to Triage Patients with Flu-Like Symptoms Using Imaging in Non-COVID-19 Hospitals during COVID-19 Pandemic: An Ongoing 8-Month Experience

Background Evaluation of suspected coronavirus disease-2019 (COVID-19) patient is a diagnostic dilemma as it commonly presents like influenza in early stages. Studies and guidelines have emerged both for and against the use of imaging as a frontline tool to investigate such patients. Reverse transcriptase-polymerase chain reaction (RT-PCR) is suggested as the backbone of diagnosis. We designed and tested a diagnostic algorithm using artificial intelligence (AI) to determine the role of imaging in the evaluation of patients with acute flu-like presentation. Materials and Methods Overall, 3,235 consecutive patients with flu-like presentation were evaluated over a period of 240 days. All patients underwent plain radiographs of chest with computer-aided detection for COVID-19 (CAD4COVID) AI analysis. Based on the threshold scores, they were divided into two groups: group A (score < 50) and group B (score > 50). Group A patients were discharged and put on routine symptomatic treatment and follow-up with RT-PCR, while group B patients underwent high-resolution computed tomography (HRCT) followed by COVID-19 AI analysis and RT-PCR test. These were then triaged into COVID-19 and non-COVID-19 subgroups based on COVID-19 similarity scores by AI, and lung severity scores were also determined. Results Group A had 2,209 (68.3%) patients with CAD4COVID score of <50 while 1,026 (31.7%) patients comprised group B. Also, 825 (25.5%) patients were COVID-19 positive with COVID-19 similarity threshold of >0.85 on AI. RT-PCR was positive in 415 and false-negative in 115 patients while 12 patients died before the test could be done. The sensitivity and specificity of CAD4COVID AI analysis on plain radiographs for detection of any lung abnormality combined with HRCT AI analysis was 97.9% and 99% using the above algorithm. Conclusion Combined use of chest radiographs and plain HRCT with AI-based analysis is useful and an accurate frontline tool to triage patients with acute flu-like symptoms in non-COVID-19 health care facilities.

Associations between cardiac and pulmonary involvement in patients with juvenile dermatomyositis—a cross-sectional study

This study aimed at exploring the association between detectable cardiac and pulmonary involvement in long-term juvenile dermatomyositis (JDM) and to assess if patients with cardiac and pulmonary involvement differ with regard to clinical characteristics. 57 JDM patients were examined mean 17.3 (10.5) years after disease onset; this included clinical examination, myositis specific/associated autoantibodies (immunoblot), echocardiography, pulmonary function tests and high-resolution computed tomography. Cardiac involvement was defined as diastolic and/or systolic left ventricular dysfunction and pulmonary involvement as low diffusing capacity for carbon monoxide, low total lung capacity and/or high-resolution computed tomography abnormalities. Patients were stratified into the following four groups: (i) no organ involvement, (ii) pulmonary only, (iii) cardiac only, and (iv) co-existing pulmonary and cardiac involvement. Mean age was 25.7 (12.4) years and 37% were males. One patient had coronary artery disease, seven had a history of pericarditis, seven had hypertension and three had known interstitial lung disease prior to follow-up. There was no association between cardiac (10/57;18%) and pulmonary (41/57;72%) involvement (p = 0.83). After stratifying by organ involvement, 21% of patients had no organ involvement; 61% had pulmonary involvement only; 7% had cardiac involvement only and 11% had co-existing pulmonary or cardiac involvement. Patients with co-existing pulmonary or cardiac involvement had higher disease burden than the remaining patients. Patients with either cardiac or pulmonary involvement only, differed in clinical and autoantibody characteristics. We found no increased risk of developing concomitant cardiac/pulmonary involvement in JDM. Our results shed light upon possible different underlying mechanisms behind pulmonary and cardiac involvement in JDM.

Diagnosis and monitoring of systemic sclerosis-associated interstitial lung disease using high-resolution computed tomography

Patients with systemic sclerosis are at high risk of developing systemic sclerosis–associated interstitial lung disease. Symptoms and outcomes of systemic sclerosis–associated interstitial lung disease range from subclinical lung involvement to respiratory failure and death. Early and accurate diagnosis of systemic sclerosis–associated interstitial lung disease is therefore important to enable appropriate intervention. The most sensitive and specific way to diagnose systemic sclerosis–associated interstitial lung disease is by high-resolution computed tomography, and experts recommend that high-resolution computed tomography should be performed in all patients with systemic sclerosis at the time of initial diagnosis. In addition to being an important screening and diagnostic tool, high-resolution computed tomography can be used to evaluate disease extent in systemic sclerosis–associated interstitial lung disease and may be helpful in assessing prognosis in some patients. Currently, there is no consensus with regards to frequency and scanning intervals in patients at risk of interstitial lung disease development and/or progression. However, expert guidance does suggest that frequency of screening using high-resolution computed tomography should be guided by risk of developing interstitial lung disease. Most experienced clinicians would not repeat high-resolution computed tomography more than once a year or every other year for the first few years unless symptoms arose. Several computed tomography techniques have been developed in recent years that are suitable for regular monitoring, including low-radiation protocols, which, together with other technologies, such as lung ultrasound and magnetic resonance imaging, may further assist in the evaluation and monitoring of patients with systemic sclerosis–associated interstitial lung disease. A video abstract to accompany this article is available at: https://www.globalmedcomms.com/respiratory/Khanna/HRCTinSScILD

Clinical, radiologic, and morphological diagnosis of hypersensitivity pneumonitis

Aim. To study the relationship between clinical, radiologic, and morphological features in nonfibrotic and fibrotic hypersensitivity pneumonitis.Materials and methods. Clinical symptoms, data of high-resolution computed tomography, parameters of external respiration, and histological changes in the lung tissue obtained via open and transbronchial biopsies were studied retrospectively in 175 patients with hypersensitivity pneumonitis (HP). Statistical analysis was performed using the Statistica software.Results. We found that the clinical error rate in the diagnosis of HP was 84.5%, among pathologists – 92%. Among all the variants of HP, the most common was fibrotic HP. It was shown that non-necrotizing granulomas and giant cells in the cavities of the alveoli, microcells, and interalveolar septa were more typical of nonfibrotic HP. In fibrotic HP, peribronchial fibrosis, smooth muscle metaplasia in fibrotic areas, and the presence of fibroblastic foci in the walls of terminal bronchioles are signs of differential diagnosis with usual interstitial pneumonia. The classical triad of histological signs was observed in 19.2% of patients with nonfibrotic HP and in 5.6% of patients with fibrotic HP.Conclusion. Diagnosis of HP is complex and should be based on a multidisciplinary approach involving clinicians (pulmonologists), radiologists, functional diagnostics specialists, and pathologists. In this case, it is imperative to take into account and identify factors causing development of the disease, as well as the age of patients.

Evaluation of Clinical Features and Outcomes of Patients with Coronavirus (COVID-19) Admitted to ICU in Southeastern Iran in 2020

Background: Coronavirus, coronavirus disease 2019 (COVID-19), in humans, mainly causes respiratory and gastrointestinal manifestations that can range from a simple cold to severe clinical symptoms or death. On the other hand, COVID-19 patients’ hospitalization in the intensive care unit (ICU) have serious problems, which can affect their mortality; therefore, the awareness of these problems has a main role in decision-making in the early stages. Objectives: This study aimed to evaluate the clinical features and outcomes of patients with COVID-19 admitted to the ICU. Methods: This cross-sectional (descriptive-analytical) study was conducted on patients with COVID-19 pneumonia admitted to the ICU of Valiasr Hospital, Birjand, Iran, in 2020. A total of 111 patients, including 51 female and 63 male subjects, were enrolled in this study using convenience sampling. Demographic data, comorbidities, signs and symptoms, radiological findings, supportive methods of oxygen therapy, and clinical outcomes were collected using a checklist and compared between two groups (i.e., survivors and nonsurvivors). Results: Among 111 patients (including 59 nonsurvivors and 52 survivors), the numbers of mortalities within the age ranges of ≥ 75 and ≤ 44 years were the highest and lowest, respectively. In the survived patients, hypertension (50.8%), diabetes mellitus (47.5%), heart disease (44.1%), and chronic obstructive lung disease (23.7%) were the most common comorbidities. Moreover, dyspnea (81.1%), fever and chills (73%), cough (64.9%), muscle pain (45%), and weakness, and lethargy (42.3%) were the most common symptoms of the patients. Based on the comparison of survived and nonsurvived groups, diarrhea (P < 0.001), sore throat (P < 0.001), nausea (P < 0.001), and vomiting (P < 0.0001) were significantly higher in the group of survived patients. Among the radiological findings (i.e., chest X-ray and high-resolution computed tomography), bronchoalveolar markings (P = 0.05) and pleural effusion (P = 0.02) were higher in the nonsurvived patients. The average Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥ 16 was reported with a higher mortality rate. Conclusions: Risk factors, including dyspnea, older age, comorbidities, and high APACHE II score, could increase the risk of poor clinical outcomes and help identify ill patients with a poor prognosis at the beginning of ICU admission.

Pulmonary manifestations in a cohort of patients with inborn errors of immunity: an 8-year follow-up study

Background: Inborn errors of immunity (IEIs) are a group of congenital diseases caused by genetic defects in the development and function of the immune system. The involvement of the respiratory tract is one of the most common presentations in IEIs.Methods: Overall, 117 patients with diagnosed IEIs were followed-up within 8 years at the National Research Institute of Tuberculosis and Lung Diseases (NRITLD). Demographic, clinical, and laboratory data were collected in a questionnaire. Pulmonary function test (PFT), chest X-ray (CXR), and high-resolution computed tomography (HRCT) scans were obtained where applicable.Results: Our study population consisted of 48 (41%) patients with predominantly antibody deficiencies (PADs), 39 (32%) patients with congenital defects of phagocytes, 14 (11.9%) patients with combined immunodeficiency (CID), and 16 (14%) patients with Mendelian susceptibility to mycobacterial diseases (MSMD). . Recurrent pneumonia was the most common manifestation, while productive cough appeared to be the most common symptom in almost all diseases. PFT showed an obstructive pattern in patients with PAD, a restrictive pattern in patients with CID, and a mixed pattern in patients with CGD. HRCT findings were consistent with bronchiectasis in most PAD patients, whereas consolidation and mediastinal lesions were more common in the other groups.Conclusions: Pulmonary manifestations vary among different groups of IEIs. The screening for lung complications should be performed regularly to reveal respiratory pathologies in early stages and follow-up on already existing abnormalities.