Normal Chest X-Ray in Patients with Pulmonary Embolism May Involve Increased Risk of Massive Pulmonary Embolism

Purpose: Chest radiography is normal in approximately 20-40% of acute pulmonary embolism (PE) patients without cardiopulmonary disease. The aim of this study was to determine whether there is any difference between the patients with normal chest X-ray and those with pathological findings in terms of clinical severity and prognosis. Methods: 178 of PE patients were included in the study. 110 patients had no parenchymal pathology, whereas group 1 (n = 110); group 2 (n = 68) had various pathological parenchymal findings in 68 patients. Clinical and radiological parameters were compared between these groups. Following the diagnosis of PE, the cases were recorded in the fifth year. Results: In 178 participants; those with normal chest X-ray (group 1), with parenchymal pathological findings on the chest X-ray (group 2); echocardiographic systolic pulmonary artery pressure (sPAP) (p = 0.68), gender (p = 0.9) and thrombus type (p = 0.41) were similar. The patients in group 1 were not different in terms of central thrombus detected in computed tomography pulmonary angiogram compared to the patients in group 2; however, the chest radiograph of the patients in group 1 had no parenchymal pathology. Central thrombus group 1, group 2, respectively; 97 (89.0%), 53 (77.9%), p = 0.07. There was no significant difference between the two groups in terms of mortality which was followed up in fifth year (p > 0.05). Conclusions: Normal chest X-ray in PE can determine mortality and may involve increased risk of massive PE.

Pancreatic cyst-solid mass: tuberculosis

Question: A 29-year-old Chinese male was admitted to our department with a history of right upper quadrant pain for two months, anorexia, weight loss about 5 kg and without fever. The pain radiated to the back and it got worst lately. He didn’t have a history of tuberculosis. The sclera was mild icteric. Laboratory test results showed total bilirubin level increased to 58 umol/L (normal level <28 umol/L) and tumor markers were normal. Chest X-ray was normal. Abdominal contrastenhanced CT showed a 25 x 30 mm cyst-solid mass in the head of pancreas (Figure1. A) and the lesion was mild enhancement in arterial phase. Pancreatic tumor was considered. Endoscopic ultrasonography confirmed the mass with uneven echo in the pancreatic head and the boundary of the mass was not clear (Figure1. B). The lesion may invade the portal vein. As the patient was young and the operation was very traumatic, the patient refused surgery unless the lesion was proved to be a tumor.

COVID-19 and Pneumonia Diagnosis in X-Ray Images Using Convolutional Neural Networks

This paper proposes a Convolutional Neural Networks (CNN) based model for the diagnosis of COVID-19 and non-COVID-19 viral pneumonia diseases. These diseases affect and damage the human lungs. Early diagnosis of patients infected by the virus can help save the patient’s life and prevent the further spread of the virus. The CNN model is used to help in the early diagnosis of the virus using chest X-ray images, as it is one of the fastest and most cost-effective ways of diagnosing the disease. We proposed two convolutional neural networks (CNN) models, which were trained using two different datasets. The first model was trained for binary classification with one of the datasets that only included pneumonia cases and normal chest X-ray images. The second model made use of the knowledge learned by the first model using transfer learning and trained for 3 class classifications on COVID-19, pneumonia, and normal cases based on the second dataset that included chest X-ray (CXR) images. The effect of transfer learning on model constriction has been demonstrated. The model gave promising results in terms of accuracy, recall, precision, and F1_score with values of 98.3%, 97.9%, 98.3%, and 98.0%, respectively, on the test data. The proposed model can diagnose the presence of COVID-19 in CXR images; hence, it will help radiologists make diagnoses easily and more accurately.

Abstract 16925: Covid-19 Vaccine Associated Acute Myocarditis

Case Presentation: A 19 year old male presented with sudden onset chest pain radiating to back. He was a smoker and denied using cocaine since his last hospitalization for cocaine-induced myocardial infarction 2 years ago. UDS was negative. EKG showed normal sinus rhythm with no ST-T wave changes. Initial troponin was 0.850. Potassium levels were low at 2.9 mmol/L but other labs were normal. Chest CT angiography ruled out aortic dissection. He was started on heparin drip. Stat Echocardiogram showed LVEF of 55-60% with no wall motion abnormalities. Repeat potassium levels normalized after replacement, however, his troponins were trending up from 3.9 and 11.5. He continued to complain of severe chest pain, so underwent cardiac catheterization which showed normal coronary arteries and LVEF 55-60%. Heparin drip was discontinued and NSAIDs and colchicine were started. Cardiac MRI (see Figure) was done that showed patchy mid-wall and epicardial delayed gadolinium enhancement involving the basal inferolateral wall, with mild hyperintense signal on the triple IR sequence, suggestive of myocarditis. On further probing, he reported receiving a second dose of Moderna COVID vaccine 3 days prior to presentation. Discussion: In December 2019, a novel RNA virus causing COVID-19 infection was reported, which quickly reached a pandemic level. COVID-19 vaccines were granted emergency use authorization by FDA. With millions of people receiving COVID-19 vaccinations worldwide, rare adverse effects are now being reported. The benefits of vaccination undoubtedly outweigh any minor side effects. However major adverse effects like this are potentially fatal. This case report warrants further investigation into the association of myocarditis with COVID-19 vaccinations and further recommendations regarding vaccination in younger adults.

Socio-demographic and Clinical Profile of Covid-19 in Children

Introduction: The corona virus disease 2019 (COVID-19) is a pandemic disease. Infection by COVID-19 in children is not so common but gradually the numbers of children affected with COVID-19 are increasing day by day. The epidemiological importance and clinical pattern in children with COVID-19 is now a challenge to be described by the clinicians. Objectives: To describe socio-demographic and clinical characteristics of COVID-19 infected children. Material and Methods: This cross sectional observational study was conducted among 58 COVID-19 children who were admitted in COVID-19 dedicated Kurmitola General Hospital (KGH), Dhaka from March 2020 to July 2020. Their signs, symptoms, sex, age distribution, laboratory results and familial contact were analyzed. Results: Among 58 most of the children (63.8%) were in school going age (5-15years). The number of female (39) was more than male (19) and female-male ratio was 1:0.48. Most of the children (75.9%) came from urban lower middle socioeconomic group. About 84.4% children were affected from family member. Among all, (8.6%) patients had no symptoms. Main symptoms of the children were cough (36.2%), only fever (22.4%), fever with cough (8.62%) and diarrhoea (5.2%). About 12.06% of the children had additional symptoms including sore throat, nasal congestion, fatigue, headache, body ache, vomiting, abdominal pain, convulsion and rash, 6.9% had respiratory distress and one child came with convulsion. About 12.1% patients showed lymphopenia, 18.9% showed leucopenia, 13.8% patient had neutrophillia. C-Reactive Protein (CRP) and serum ferritin were high in only 12.1% and 8.6% cases respectively. There were 29.3% patients who had normal Chest X-Ray and 58.6% had mild lesion, 8.6% had bilateral consolidation and 3.4% had patchy opacities. Conclusions: COVID-19 is not so common in children and usually presents with mild form or no sign symptoms clinically and by laboratory analysis. But it is noteworthy that they may play role in transmission of disease. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 72-75

Systemic corticosteroids for management of ‘long-COVID’: an evaluation after 3 months of treatment

Some patients even 4 weeks after Corona Virus Disease 2019 (COVID-19) remain to be symptomatic and are known as “long-COVID”. In the present study we performed the follow up evaluation at 3 months of long-COVID patients, after treatment with systemic steroids. During the study duration, out of the 4,542 patients managed in the outpatient department of the particular unit, there were 49 patients of Long-COVID. The patients having abnormal computed tomography (CT) alongwith resting hypoxia or exertional desaturation were treated with systemic steroid (deflazacort) in tapering doses for 8-10 weeks. We retrospectively analysed the clinical and radiological findings of these patients at first presentation and at about 3 months of follow up visit. On follow up, all the 49 long-COVID patients showed improvement. The occurrence of breathlessness decreased from 91.83% to 44.89% (p<0.001) and cough from 77.55% to 8.16% (p<0.001). Twenty-four patients were prescribed systemic steroids. Out of these, nearly 58% patients had MMRC grade 4 breathlessness, which decreased to < 2 MMRC in about 86% of these patients. MMRC grade (median) decreased from 3 to 1 (p<0.001). Majority of patients who were tachypnoeic and hypoxic at rest (n=7) showed improvement (71%), post-treatment with corticosteroids. Occurrence of normal chest X-ray increased from 12% to 71% (p<0.001). All these patients had abnormal CT thorax initially, and post-treatment 25% had normal CT thorax. Hence, we conclude that systemic steroids are helpful in hastening recovery of select subset of long-COVID patients. Simultaneously, we should be cautious of immunosuppressive effects of steroids like tuberculosis reactivation, especially in tuberculosis endemic countries. These findings have therapeutic implications and may serve as guidance for future approach to the management of ‘long-COVID’ with pulmonary sequalae.

Blood eosinophils as a predictor of treatment response in adults with difficult-to-treat chronic cough

There is lack of evidence on the role of blood eosinophil count (BEC) as a predictor of treatment response in patients with chronic cough (CC). The study aimed to evaluate BEC as a predictor of treatment response in all non-smoking adults with CC and normal chest X-ray referred to cough clinic and in subgroup of patients with CC due to asthma or NAEB (non-asthmatic eosinophilic bronchitis).This prospective cohort study included 142 consecutive, non-smoking patients referred to our cough centre due to CC. The management of CC was performed according to the current recommendations. At least a 30 mm decrease of 100-mm visual analogue scale in cough severity and a 1.3 points improvement in Leicester Cough Questionnaire were classified as a good therapeutic response.There was a predominance of females (72.5%), median age 57.5 years with long-lasting, severe cough (median cough duration 60 months, severity 55/100 mm). Asthma, NAEB were diagnosed in 47.2% and 4.9% of patients, respectively. After 12–16 weeks of therapy, a good response to CC treatment was found in 31.0% of all patients. A weak positive correlation was demonstrated between reduction in cough severity and BEC (r=0.28, p<0.001). AUC for all patients with CC was 0.62 with the optimal BEC cut-off for prediction of treatment response set at 237 cells·µL−1 and for patients with CC due to asthma/NAEB was 0.68 (95% CI 0.55–0.81) with the cut-off at 150 cells·µL−1.BEC is a poor predictor of treatment response in adults with CC treated in the cough centre.

SARS-CoV-2 immunity and functional recovery of COVID-19 patients 1-year after infection

The long-term immunity and functional recovery after SARS-CoV-2 infection have implications in preventive measures and patient quality of life. Here we analyzed a prospective cohort of 121 recovered COVID-19 patients from Xiangyang, China at 1-year after diagnosis. Among them, chemiluminescence immunoassay-based screening showed 99% (95% CI, 98–100%) seroprevalence 10–12 months after infection, comparing to 0.8% (95% CI, 0.7–0.9%) in the general population. Total anti-receptor-binding domain (RBD) antibodies remained stable since discharge, while anti-RBD IgG and neutralization levels decreased over time. A predictive model estimates 17% (95% CI, 11–24%) and 87% (95% CI, 80–92%) participants were still 50% protected against detectable and severe re-infection of WT SARS-CoV-2, respectively, while neutralization levels against B.1.1.7 and B.1.351 variants were significantly reduced. All non-severe patients showed normal chest CT and 21% reported COVID-19-related symptoms. In contrast, 53% severe patients had abnormal chest CT, decreased pulmonary function or cardiac involvement and 79% were still symptomatic. Our findings suggest long-lasting immune protection after SARS-CoV-2 infection, while also highlight the risk of immune evasive variants and long-term consequences for COVID-19 survivors.

The Hilar Height Ratio in Normal Chest Radiographs of Adults Seen at Selected Tertiary Hospitals in Kampala, Uganda; A Forgotten Parameter in Pulmonary Medicine

Background: The hilar height ratio (HHR) is a numerical expression of the hila position. Displacement of the pulmonary hilum is the most reliable indirect sign, in conditions that result in pulmonary volume changes. Despite the high utility of the chest radiograph, it has a relatively low diagnostic accuracy, high interobserver disagreement and numerous errors following interpretation. Routine use of the HHR with knowledge of the normal ranges would, therefore, help improve the overall chest radiograph sensitivity, reduce on errors and the interobserver disagreement in the interpretation of pulmonary volume changes. This study aims to determine the HHR in our study population, compare it with previous studies, and to relate it with sex, stratified age groups, height and body mass index (BMI).Methods: A consecutive cross-sectional study with purposive sampling were used to filter out a total of 384 normal chest radiographs of adults seen from three tertiary hospitals in Kampala, Uganda. The right and left HHRs were evaluated for each chest radiograph, along with the age, sex weight, height and BMI.Results: The median right HHR for the participants was 1.42 (IQR = 1.31- 1.57), and the median left HHR was 0.92 (IQR = 0.86- 0.98). There was a significant mean difference in the right HHR between the sex groups (p = 0.017) and age groups (p = 0.001). The mean difference in the left HHR was not affected by sex (p = 0.178) or age (p = 0.198). The right and left HHRs showed a very weak correlation to height (r = - 0.10 and r = 0.08, respectively). The right and left HHRs were not significantly different among the BMI groups (p = 0.254 and 0.20 respectively).Conclusion: The median left HHR was not affected by sex, age, weight and height while the right HHR varied with sex and age in our study population. Weight and height do not affect HHRs. The females in our study population had a higher positioned right hilum, whereas the position of the right hilum progressively lowered with increasing age.

The Relationship of Chest X-Ray in COVID-19 Patients and Disease Severity in Arifin Achmad General Hospital Riau

Introduction: Coronavirus Disease 2019 (COVID-19) pandemic is caused by SARS-CoV-2 which spreads rapidly throughout the world and causes clinical manifestations in various organs, especially in the lungs. Clinical symptoms arise from asymptomatic, mild, moderate, severe, and critical symptoms in patients with or without comorbid disease. Chest X-ray examination is one of the modalities in the management of COVID-19 which is cheap and easy to do.Methods: This study was performed by analyzing medical record data of confirmed COVID-19 patients from March to December 2020. This study aimed to examine the relationship between chest X-ray and the degree of disease severity.Results: The results showed that from the examined 542 total samples, the highest number was found in the age group of 40-49 years old (23.6%), women (53%), mild degree of COVID-19 (67.9%), normal chest X-ray (54.6%), predominance on the lower zone of the lung, peripheral and bilateral on abnormal chest X-ray, no comorbid (56.3%), hypertensive in comorbid disease (26.6%). There was a significant relationship between chest X-ray and comorbidity towards COVID-19 severity (p = 0.000).Conclusion:Chest X-ray can determine disease severity, therefore it can be used as the first modality for triage and treatment evaluation in COVID-19 patients.