Detailed short-term follow-up high-resolution CT series of differentiation syndrome

A 57-year-old man with acute promyelocytic leukaemia (APML) received induction therapy including all-trans-retinoic acid (ATRA). At day 15, he developed dyspnoea, haemoptysis and hypoxia. Thorax CT demonstrated diffuse ground-glass opacity and consolidation predominantly in dorsal regions, which may reflect increased vascular permeability. He was diagnosed with differentiation syndrome. After dexamethasone was administered and chemotherapy suspended, his symptoms improved and abnormal lesions mostly disappeared on follow-up CT examinations. We report a short-term high-resolution CT series of differentiation syndrome.

Clinical Use of Tailored Computed Tomography to Prevent Poststernotomy Dehiscence

Background Morphological and tissue density analysis of the sternum can be performed in the preoperative computed tomography (CT). The purpose of this study was to analyze morphology and tissue density of sternum in CT and effect for comparison sternal instability. Methods Patients with sternal instability (n = 61) and sternal stability (n = 66) were enrolled in this study. All of the patients were studied using same thorax CT procedure. All the measurements were performed by one specific cardiovascular radiologist. The Hounsfield units (HUs) were measured in axial sections of the sternum trabecular bone. Results Sternal instability group mean HU was 75.36 ± 13.19 and sternal stability group HU was 90.24 ± 12.16 (p < 0.000). HU is the statically significant predictor of sternal instability. Conclusion Our study showed a significant correlation between the mean HU value of sternum and sternal instability. We think that it is important to evaluate the existing thorax CT while performing preoperative risk analysis for sternal dehiscence.

Evaluation of 86 Patients Whom Death While Being Followed up with Pre-Diagnosis of Covid-19

The Coronavirus-19 pandemic continues at full speed, and the number of patients who die from Covıd-19 is increasing. It was aimed to evaluate the demographic information and laboratory findings of 86 patients who died while being followed up in our hospital with a pre-diagnosis of Covıd-19. Identifying these characteristics of deceased patients will be essential to guide clinicians in identifying critically ill patients. Data on demographic information, comorbidities, time from hospitalization to death, molecular test results, thorax CT findings, biochemical findings, culture, antibiotic susceptibility, and the given treatments of the cases were collected from the electronic system Kastamonu Training and Research Hospital. While the RT-PCR test of 21 of the cases was positive, in 9 of the cases, control PCR tests were negative after a while. The CT results of 18 of the 21 initially RT-PCR positive cases were compatible with Covid-19, and the CT result of 3 could not be reached. When the blood test results of the cases were examined, neutrophil increase, white blood cell increase, lymphocyte reduction, and inflammatory markers increase were determined. A total of 43 bacterial growths were found in 21 cases. It has been observed that deaths in patients who were followed up with the pre-diagnosis of Covıd-19 generally occur in older people, males, and those with underlying diseases. It was thought that the cause of death could be underlying diseases, pathologies caused by inflammation, and secondary bacterial infections in addition to viral infection. Clinicians should be more careful about elderly patients, patients with secondary bacterial infections, or patients with neutrophilia, lymphopenia.

Common pulmonary computed tomography signs and their clinical relevance: A review

With the advent of computed tomography (CT) in respiratory medicine, a greater delineation of the respiratory structures has been possible in the two-dimensional space. The various CT techniques used by pulmonologists include the high-resolution computed tomography (HRCT) thorax with expiratory scans, contrast-enhanced CT (CECT) thorax, CT thorax, CT pulmonary angiography (CTPA) and rarely a CT aortography/angiography. Each of the imaging techniques presents stronger and weaker points. In this paper, radiological lesions are classified according to their location. Such abnormalities are observed in the airways, in the lung parenchyma, in the interstitium and last but not least in the pleura. The review mainly addresses radiological lesions with higher specificity because they are key elements in establishing a definitive diagnosis. In conclusion, performing a chest CT is vital in the diagnosis and management of respiratory conditions.

Treatment of COVID-19 Patients: Insights into the Use of Bone Marrow-Derived Mesenchymal Stem Cells

Patients with SARS-CoV-2 may be affected by the acute respiratory distress syndrome (ARDS), which has been associated with high mortality rate. As no specific drugs are available for ARDS, mesenchymal stem cells (MSC) seems to be a promising cell therapy due to immunomodulatory effects on reducing and healing inflammation-induced lung and other tissue injuries. The goal of this Phase I clinical trial was to explore the safety and efficacy of bone marrow-derived MSC (BM-MSC) infusions in patients with COVID-19 ARDS. The inclusions criteria were age between 18 to 70 years and PaO2/FiO2≤200mmHg. The BM-MSC infusions were as follow: one to 3 infusions intravenous doses of BM-MSC of 1x10 6 cells/kg; each dose could be administered with an interval between 3 to 7 days. The primary endpoint was safety (adverse events) within 6 hours; cardiac arrest or death within 24 hours post-infusion. The secondary endpoint includes patient survival at 30 days after the first infusion. Six patients were included in the trial and treated with at least one infusion of BM-MSC. The median age was 60,3 years (54 to 69), 5 were male. The median time between the worsening of respiratory distress and the BM-MSC infusion was 10 days (3 to 31 days). The median of PaO2/FiO2 before infusion was 151.86 (127.80-164.44) and median PaCO2 was 63,85 (39 to 117). One patient was treated with 3 MSC doses, two patients with 2 doses and 3 patients one dose. No serious adverse effects were observed within 24 hours post-infusion; only one death was observed following 30 days of cell administration. None of them showed adverse events during BM-MSC infusion. Only one patient showed signs of pulmonary infection one week after first BM-MSC infusion. This patient was at increased risk for infection due to prolonged intubation and a high dose of corticosteroid. Therefore, it was not possible to conclude its association with BM-MSC treatment. Only two patients showed clinical improvement after BM-MSC infusion. Patient 1 had BM-MSC infusion 72 hours after worsening of respiratory parameters, and thorax CT suggested the hypothesis of cryptogenic organizing pneumonia, which led to decision of using methylprednisolone 125mg I.V. for 3 days and carry on with MSC infusion. We observed a decrease in CRP levels from 126 to 67 mg/dL on day 1 after the first infusion, and PaO2/FiO2 ratio improved from 155 to 297 mmHg on day 5. He received the second dose within 7 days interval and by day 11 of the first infusion a new thorax TC showed complete resolution of alveolar consolidation areas in both lungs (Figure 1A and 1B). Patient 2 had BM-MSC administration 11 days after respiratory worsening and also presented improvement of PaO2/FiO2 ratio (148 to 215 mmHg after 2 days of infusion) and had thorax CT images suggesting cryptogenic organizing pneumonia with administration of methylprednisolone 250mg I.V. Nevertheless, the second dose was not administered due to ventilator-associated pneumonia and urinary infection. Four patients showed a non-sustained increase of PaO2/FiO2 ratio, with higher median PCO2 levels of 69,3 mmHg (range, 61,2 to 117) comparing to 39 and 47,3 mmHg of patients 1 and 2, respectively. PCO2 parameter could be a marker to indicate a worse response to MSC treatment, since it could point out chronic phases of COVID-19 disease. The patients died due to COVID-19 complications. No difference in inflammatory markers, such as interleukin 6, C-protein reactive test, procalcitonin, ferritin was observed before and after treatment. Inclusion criteria did not defined interval between respiratory worsening and first BM-MSC infusion. Four patients had chronic phase of COVID-19 without inflammatory markers and hypercapnia. It could be related to severity of pulmonary disease, such as reported in chronic obstructive pulmonary disease. Two patients were discharged after MSC treatment and they received methylprednisolone to treat cryptogenic organizing pneumonia. There are only a few clinical trials and observational studies evaluating the use of high-dose of glucocorticoid for severe COVID-19 pneumonia. Therefore, it is not possible to conclude that use of glucocorticoid has contributed to favorable outcomes. In conclusion, BM-MSC showed to be a secure therapeutic option for severe COVID-19 pneumonia, possibly with superior benefit in acute phases and lower PCO2 levels. Further studies involving a large cohort or randomized controlled trials are warranted. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Adhesiolysis and Decortication for Reccurent Hydropneumothorax Associated with Pleural Tuberculosis

Introduction: Pleural tuberculosis is a pleural infection of tuberculosis caused by Mycobacterium tuberculosis which commonly manifests as hydropneumothorax. Initial treatment with anti-tuberculosis drugs is aimed to prevent progression of the disease and relieve patient’s symptoms. Indication of adhesiolysis and decortication is to remove layer of fibrous tissue and allow the lung to reexpand. Case: A 60 year old woman with shortness of breath, cough, and right-sided chest pain. She had a history of treatment with first-line anti-tubercular drugs for a year stop in September 2016. She was identified with recurrent right-sided hydropneumothorax by chest imaging and thorax CT-scan. Adhesiolysis and decortication were performed on her. Two months later she was diagnosed again with recurrent right-sided hydropneumothorax. VATS (Video-Assisted Thoracoscopic Surgery) revealed fistula involving inferior lobe of the lung. Then, she was treated with second-line anti tuberculosis drugs. After four times reccurent hydropneumothorax, patient showed significant improvement in clinical condition, radiology finding, and lung function test after she finished the tuberculosis treatment. Discussion: Definitive diagnosis of pleural tuberculosis is by the finding of mycobacterium tuberculosis in pleural biopsy, or Mtb culture, and it was difficult to perform. In this case pleural fluid analysis revealed that cause of recurrent right-sided hydropneumothorax was tuberculosis infection. Summary: A 60 year old woman with four times reccurent right-sided hydropneumothorax, and the pleural fluid analysis suggested it was tuberculosis infection. Providing anti-tuberculosis medication based on clinically diagnosed tuberculosis based on flowchart of tuberculosis diagnosis from national tuberculosis programmed are essential to prevent progression of the disease.

Ability of Laboratory Findings Upon Admission to Predict Lung Involvement and Its Severity in COVID-19 Patients Requiring Hospitalization

Background: The struggle of humanity with Coronavirus disease 2019 (COVID-19) infection, which affected the whole world and caused severe social and health crises, continues without deceleration. Objectives: This study aimed to determine the relationship between the abnormal laboratory parameters upon admission and the intensity of lung involvement using chest computerized tomography severity score (CT-SS). Methods: This single-center study evaluated a total of 242 patients who were admitted to our hospital due to COVID-19 with positive polymerase chain reaction (PCR) test results. The patients were divided into three groups of no involvement on thorax CT images, mild involvement, and moderate-severe involvement. Results: The mean ages of groups 1 (n=42), 2 (n=123), and 3 (n=77) were 38±10.6, 56.3±16, and 61±15.6 years, respectively (P<0.001). The three groups showed significant differences in terms of hypertension, diabetes mellitus, heart rate, oxygen saturation, lymphocyte count, platelet-lymphocyte ratio (PLR), systemic immune inflammation index (SII), ferritin, troponin-I, erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP) values (P<0.001). The CRP (R=0.545, P<0.001), ferritin (R=0.481, P<0.001), and SII (R=0.473, P<0.001) were moderately and positively correlated with CT-SS, while neutrophil-lymphocyte ratio (R=0.404, P<0.001), PLR (R=0.371, P<0.001), and ESR (R=0.327, P<0.001) were mildly and positively correlated with CT-SS. Conclusion: The results of the present study showed that elevation in CRP, as well as ferritin and SII values upon admission to the hospital was significantly correlated with CT-SS. The results also revealed that the presence of lung parenchyma involvement might be predicted in PCR positive COVID-19 patients without the need for thorax CT. Furthermore, it is believed that this information will provide great convenience to the clinicians who first welcome the patient in terms of predicting COVID-19 lung involvement.

The Relationship between CRP at Admission and Thorax CT Findings in Patients Diagnosed with COVID-19

Introduction: The current study aims to evaluate the relationship between C-reactive protein (CRP) levels, thorax CT findings and CT-SS in patients presenting to the emergency department with COVID-19. Methods: Patients diagnosed with COVID-19 by nasopharyngeal rt-PCR (+) in the emergency department were included in the study. In addition to the CRP, ferritin and D-dimer examinations of patients at admission, thorax CT involvement findings and CT-SS results were recorded. The relationship of CRP value with CT-SS and clinical outcome was evaluated. Results: A total of 974 COVID-19 patients, 572 males (58.7%) and 402 females (41.3%), with a mean age of 59.64±17.34 years, were included in the study. The CRP values of the patients who needed intensive care and needed respiratory support were also significantly higher at admission (95.1 mg/dL vs. 31.05 mg/dL) (p<0.001). The CRP values of the patients who developed any complications during the treatment of COVID-19 were higher (79.9 mg/dL vs. 41.85 mg/dL) (p<0.001). In the case of CRP >124.5, a thorax CT density score 7.35 times higher was determined to be severe. In addition, it was determined that there was a 9.09-fold increase in the incidence of negative imaging findings in terms of COVID-19 in cases where the CRP value was <12.5 mg/dL. Conclusion: The CRP levels of COVID-19 patients measured upon admission to the emergency room are correlated with the severity of lung involvement and are an important predictor of clinical outcomes.