Limb Ischemia Associated With Covid-19 and Its Treatment With Above-Knee Amputation

An 84-year-old male patient with no known comorbidity was admitted to the emergency department with complaints of dyspnea and respiratory distress. The patient was referred to the COVID outpatient clinic, laboratory and radiology tests were performed. Thoracic CT scan of the patient showed large peripheral patchy ground glass densities observed in the lower lobes of both lungs. CT imaging findings were evaluated by an experienced radiologist and reported as COVID-19 pneumonia. The patient, who was self-isolated at home for 5 days, presented to the emergency department again on the fifth day with complaints of respiratory distress, fever, bruising with cough, and loss of peripheral pulse in the left lower extremity. Necessary tests were performed on the patient. An above-knee amputation was performed when a diagnosis of limb ischemic necrosis was made and no revascularization attempt was considered by the CVS department. This case study describes the coexistence of sudden lower extremity thrombosis and Covid-19 in our case without a known chronic disease.

Giant pulmonary hydatid cyst in children

Hydatid disease is still endemic in Tunisia. It is mostly seen in young people less than 40 years and children are affected in one third of cases. The lungs are the predominant location in children. Our study aims to define the particularities of children PHC's (pulmonary hydatic cyst) management, the characteristics of giant cyst and to study predictive factors of complications. We included retrospectively 105 children with PHC followed between 1999 and 2019. Patients were aged less than 16 years with surgically confirmed diagnosis of PHC. Two groups of cysts were defined: giant cysts which were 10 cm across or more, and no giant cysts.The sex-ratio was 1,38 with a mean age of 10.5±3 years. The symptomatology was dominated by cough (59%), thoracic pain (51%) and hemoptysis (46%). Giant cysts were observed in 24 (22.9%) patients. Dyspnea (29% vs 5% p<0.001) and thoracic pain (88% vs .41% p<0.001) were significantly more frequently reported in giant cysts. Eighty-six patients had a single cyst (83%) and 19 had multiple cysts (17%). Giant cysts accounted for 22,9% (24 cases). Thoracic ultrasonography was diagnostic in 77.4%. The thoracic CT scan was performed in 27 children with inaccessible cysts in thoracic ultrasonography or in diagnostic doubt.Patients were all treated surgically. Surgical procedures consisted of cystectomy (59%), pericystectomy (18%) and pulmonary resection when parenchyma was destroyed (23%). Parenchymal resection was more often performed in complicated cysts (27% vs 20% p>0.05) and in giant cysts (41% vs 18% p<0.05). A two-stage thoracotomy was performed in the 4 patients with bilateral cysts. Thirteen patients presented immediate post-operative complications which occurred more frequently in complicated and giant cysts. Hospital stay was longer in complicated cysts (16±9 days vs 7±3 days; p<0.001) and in giant cysts (14±9 days vs 11±8 days; p>0.05). In endemic regions, the diagnosis of PHC in children should be based on the combination of thoracic radiography and ultrasonography which are effective, not costly, safe and accessible. Complicated and giant PHC cause lung damage leading to extensive parenchymal resection. They are more associated with post-operative complications prolonging hospital stay and increasing expenses.

Cytomegalovirus Pulmonary Involvement in an Immunocompetent Adult

Introduction. Cytomegalovirus (CMV) is a linear double-stranded DNA virus that may cause severe and potentially fatal infection in immunocompromised hosts. In immunocompetent individuals, the infection is typically mild or asymptomatic. However, in the last years, some cases of severe cytomegalovirus infection in immunocompetent individuals have been described. Clinical Presentation. The authors present a male patient aged 42 years, without specific medical history, who presented a 15-day history of fever, headache, night sweats, odynophagia, and bilateral otalgia, without improvement after four days of therapy with amoxicillin/clavulanic acid. Blood count and biochemistry were performed with liver cytolysis pattern. Chest teleradiography showed diffuse interstitial infiltrate. Thoracic CT scan revealed areas in a ground glass with a cross-linking component in the left and right upper lung lobes compatible with an inflammatory/infectious process. Blood serology was positive for CMV IgG and IgM. The detection on blood and bronchoalveolar lavage of CMV DNA by polymerase chain reaction (PCR) was also positive. Ganciclovir was started based on the clinical features and the result of CMV serology. After 48 hours, there was a significant clinical improvement, with remission of fever, and he was discharged on the 13th day of hospitalization with oral valganciclovir, completing a 21-day antiviral course at home. Conclusion. With this clinical case, the authors highlight the importance of considering CMV infection in evaluating patients with pneumonia, even in immunocompetent ones, particularly in those with no clinical improvement with antibiotics instituted for bacterial pneumonia, and when other causes have been ruled out.

Influence of breathing state on the accuracy of automated patient positioning in thoracic CT using a 3D camera for body contour detection

Objective To assess the influence of breathing state on the accuracy of a 3D camera for body contour detection and patient positioning in thoracic CT. Materials and methods Patients who underwent CT of the thorax with both an inspiratory and expiratory scan were prospectively included for analysis of differences in the ideal table height at different breathing states. For a subgroup, an ideal table height suggestion based on 3D camera images at both breathing states was available to assess their influence on patient positioning accuracy. Ideal patient positioning was defined as the table height at which the scanner isocenter coincides with the patient’s isocenter. Results The mean (SD) difference of the ideal table height between the inspiratory and the expiratory breathing state among the 64 included patients was 10.6 mm (4.5) (p < 0.05). The mean (SD) positioning accuracy, i.e., absolute deviation from the ideal table height, within the subgroup (n = 43) was 4.6 mm (7.0) for inspiratory scans and 7.1 mm (7.7) for expiratory scans (p < 0.05) when using corresponding 3D camera images. The mean (SD) accuracy was 14.7 mm (7.4) (p < 0.05) when using inspiratory camera images on expiratory scans; vice versa, the accuracy was 3.1 mm (9.5) (p < 0.05). Conclusion A 3D camera allows for accurate and precise patient positioning if the camera image and the subsequent CT scan are acquired in the same breathing state. It is recommended to perform an expiratory planning image when acquiring a thoracic CT scan in both the inspiratory and expiratory breathing state. Key Points • A 3D camera for body contour detection allows for accurate and precise patient positioning if the camera image and the subsequent CT scan are acquired in the same breathing state. • It is recommended to perform an expiratory planning image when acquiring a thoracic CT scan in both the inspiratory and expiratory breathing state.

Acute Respiratory Distress Revealing an Unrecognized Tracheostomy Cannula at the Bronchial Level in the Pandemic COVID Era

The tracheostomy is a surgical opening of the trachea which is made at the level of its anterior face, 2 cm above the sternal fork permitting the placement of a tracheostomy cannula in a temporary or definitive way and this according to the indication of its realization. The tracheostomy is the surgical connection of the trachea to the skin. The prolonged wearing of a tracheostomy cannula at the level of the tracheostomy orifice can expose to certain complications which can prove to be serious. It presents risks of postoperative complications, especially late ones. The most frequent are granulomas, tracheal stenosis, infections, and fistulas. Tracheal or tracheobronchial migration of the tracheostomy cannula remains exceptional. We present a very rare case of an elderly subject followed for Parkinson's disease with a dementia syndrome, who underwent a total laryngectomy 3 years ago with prolonged placement of a tracheostomy cannula at the tracheostomy orifice. The patient presented to the emergency room with progressively worsening respiratory distress and desaturation, evolving in a febrile context, suggesting a sars cov19 infection in the current epidemiological context. A thoracic CT scan rectified the diagnosis by showing a pneumopathy on an unrecognized tracheotomy cannula at the tracheobronchial level. Indeed, this complication is secondary to the embrittlement of the cannula following poor maintenance. The use of a tracheostomy cannula for a long period of time requires a regular and particular surveillance, a rigorous maintenance and care of the cannula to avoid the occurrence of complications which can be seriousThe tracheostomy is a surgical opening of the trachea which is made at the level of its anterior face, 2 cm above the sternal fork permitting the placement of a tracheostomy cannula in a temporary or definitive way and this according to the indication of its realization. The tracheostomy is the surgical connection of the trachea to the skin. The prolonged wearing of a tracheostomy cannula at the level of the tracheostomy orifice can expose to certain complications which can prove to be serious. It presents risks of postoperative complications, especially late ones. The most frequent are granulomas, tracheal stenosis, infections, and fistulas. Tracheal or tracheobronchial migration of the tracheostomy cannula remains exceptional. We present a very rare case of an elderly subject followed for Parkinson's disease with a dementia syndrome, who underwent a total laryngectomy 3 years ago with prolonged placement of a tracheostomy cannula at the tracheostomy orifice. The patient presented to the emergency room with progressively worsening respiratory distress and desaturation, evolving in a febrile context, suggesting a sars cov19 infection in the current epidemiological context. A thoracic CT scan rectified the diagnosis by showing a pneumopathy on an unrecognized tracheotomy cannula at the tracheobronchial level. Indeed, this complication is secondary to the embrittlement of the cannula following poor maintenance. The use of a tracheostomy cannula for a long period of time requires a regular and particular surveillance, a rigorous maintenance and care of the cannula to avoid the occurrence of complications which can be serious.

Pulmonary Alveolar Microlithiasis - Report of Two New Cases and Review of the Literature

INTRODUCTION: Pulmonary alveolar microlithiasis (PAM) is a rare autosomal recessive disease characterized by the intra-alveolar accumulation of spherical calcified microliths, of a phospho-calcium nature, in the absence of any problem of phosphocalcium metabolism. The majority of patients are asymptomatic. The disease is often diagnosed on routine radiological examination.CASE REPORTS: We report two cases of PAM; A 17-year-old girl with three generations of consanguinity, who consulted for bronchial syndrome. Auscultation revealed very fine diffuse ronchi. The X-ray showed a bilateral alveolar syndrome, especially on the right, a bilateral bronchointerstitial syndrome, and diffuse bilateral calcifications. The thoracic CT scan showed calcified micro and macronodules with thickening of the septa, middle section involvement with fibrosing remodeling, fibrosis, and tractional bronchiectasis of the bases, pleural and pericardial calcifications. Respiratory function tests showed a restrictive syndrome with a vital capacity of 70% and normal GDS. This radiological and scanographic picture made us think of PAM. We then decided to carry out a family investigation with chest radiographs. All family members had normal radiographs, except for a sister who was three years old, with no particular history, no functional respiratory signs, and no particular complaints. Her chest radiograph showed the famous sandstorm appearance of microcalcifications, with pulmonary distension at the apexes and retractions at the bases. Spirometry and blood gases were normal. Chest CT found microcalcifications, with bilaterally distributed and diffuse ground-glass aspects, with a slight right-hand predominance.CONCLUSION: MLA is known to be radio-clinically dissociative. The diagnosis can be made by radiology alone in typical cases; sometimes, Transbronchial or surgical lung biopsies are needed. The prognosis is compromised in the long term. The only effective treatment nowadays is lung transplantation.

P147 Safety of AbatacePt in Rheumatoid arthritis associated Interstitial Lung disease (APRIL)

Background/Aims Interstitial lung disease (ILD) is the commonest extra-articular complication of rheumatoid arthritis (RA) and is associated with a median survival of 3-8 years. Although biologic therapies are effective for synovitis, they can exacerbate the ILD. RA patients with significant ILD but minimal synovitis have limited therapeutic options. Case reports and retrospective analyses suggest that Abatacept may have efficacy in RA-ILD. However, use of potent immunosuppression in patients with chronic lung disease may increase the incidence of lower respiratory tract infection (LRTI). The purpose of this prospective study was to evaluate the safety of Abatacept in patients with progressive RA-ILD. Methods This was a prospective, open-label, study of 19 RA patients (2010 ACR/EULAR criteria) with ILD. Patients were included if either serial thoracic computed tomography (CT) or pulmonary function tests (PFT) indicated progressive ILD over the preceding 14 months. Intravenous Abatacept was administered at baseline, 2, 4, 8, 12, 16 and 20 weeks. PFTs, thoracic CT scan and questionnaires were performed at baseline and week 20. The number of LRTI was recorded. Primary outcome: change in Forced Vital Capacity (FVC). Secondary outcomes: Transfer Factor (TLCOc), King’s Brief Interstitial Lung Disease (K-BILD) Questionnaire, the Leicester Cough Questionnaire (LCQ) and radiological scores (percentage involvement of lung fields scored separately for ground-glass opacification, fibrosis, honeycombing and consolidation). Results Preliminary data from the study are reported. Ten patients completed the study: 6 male, 6 ex-smokers, mean age 68±8.21 years, mean RA duration 6±5.4 years. The APRIL study was terminated due to safety concerns in the context of COVID-19 pandemic; nine patients were withdrawn for this reason. LRTI occurred in 4 patients (one patient had 2 LRTI). There were no serious adverse reactions. The mean FVC remained stable during the course of the study. There was a trend towards improvement in the LCQ and improvement in the K-BILD score. ILD-related changes on thoracic CT were stable in 9 of the patients. Conclusion Our data indicates that abatacept has an acceptable safety profile in progressive pulmonary fibrosis associated with RA-ILD. This small dataset also suggests that ILD has not progressed during the period of treatment. P147 Table 1:Summary of outcomes after 20 weeks’ treatment with Abatacept in RA patients with progressive interstitial lung diseaseN = 10Baseline20 WeekFVC (L)2.78 ± 0.903.0 ± 0.89TLCOc (mmol/min/kPa)3.75 ± 1.033.72 ± 1.00K-BILD49.10 ± 5.5054.40 ± 6.0LCQ4.78 ± 1.514.82 ± 1.32 Disclosure T. Gudu: None. C. Stober: None. M. Fifield: None. J. Babar: None. A. Ostor: None. H. Parfrey: None. F. Hall: Grants/research support; FH has received a grant of £168k from Bristol Myers Squibb for the APRIL study.

The Spontaneous Retropharyngeal Space Hematoma: How to Manage?

Introduction: Spontaneous Retropharyngeal Hematoma (SRH) is a rare affection which occurs without traumatism. Case report: A 68 years old woman brought to the emergency department with a cervico-thoracic swelling rapidly increasing in size without any previous traumatic history or anticoagulant medication. Complicated by dysphagia and dysphonia without signs of dyspnea. The clinical examination revealed a painful anterior cervico-thoracic swelling with an ecchymotic cupboard on it. Cervico-thoracic CT scan found a voluminous retro-pharyngeal collection, spontaneously hyperdense, extended to the oropharynx and antero-superior mediastinum without further lesions. Biological assessment was without abnormalities. The diagnosis of retropharyngeal hematoma was retained. The treatment was based on corticosteroids and antibiotics drugs with strict clinical and radiological monitoring. With conservative treatment, the evolution was favorable, marked by progressive regression of the hematoma until its disappearance and an absence of recurrence after a retreat of one year. Conclusion: The clinical presentation of a retropharyngeal hematoma out of an evocative context is misleading and lead to radiological investigation without delaying the treatment which varies from supervision to surgery according to respiratory status and evolution under strict control.

Circulating Vitamin D levels status and clinical prognostic indices in COVID-19 patients

Background Several immune mechanisms activate in COVID-19 pathogenesis. Usually, coronavirus infection is characterized by dysregulated host immune responses, interleukine-6 increase, hyper-activation of cytotoxic CD8 T lymphocytes. Interestingly, Vitamin D deficiency has been often associated with altered immune responses and infections. In the present study, we evaluated Vitamin D plasma levels in patients affected with different lung involvement during COVID-19 infection. Methods Lymphocyte phenotypes were assessed by flow cytometry. Thoracic CT scan involvement was obtained by an image analysis program. Results Vitamin D levels were deficient in (80%) of patients, insufficient in (6.5%) and normal in (13.5%). Patients with very low Vitamin D plasma levels had more elevated D-Dimer values, a more elevated B lymphocyte cell count, a reduction of CD8 + T lymphocytes with a low CD4/CD8 ratio, more compromised clinical findings (measured by LIPI and SOFA scores) and thoracic CT scan involvement. Conclusions Vitamin D deficiency is associated with compromised inflammatory responses and higher pulmonary involvement in COVID-19 affected patients. Vitamin D assessment, during COVID-19 infection, could be a useful analysis for possible therapeutic interventions. Trial registration: 'retrospectively registered'.

Impact of Coronavirus Disease 2019 in a French Cohort of Myasthenia Gravis

ObjectiveTo describe the clinical characteristics and outcomes of coronavirus disease 2019 (COVID-19) among patients with myasthenia gravis (MG) and identify factors associated with COVID-19 severity in patients with MG.MethodsThe CO-MY-COVID registry was a multicenter, retrospective, observational cohort study conducted in neuromuscular referral centers and general hospitals of the FILNEMUS (Filière Neuromusculaire) network (between March 1, 2020, and June 8, 2020), including patients with MG with a confirmed or highly suspected diagnosis of COVID-19. COVID-19 was diagnosed based on a PCR test from a nasopharyngeal swab or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serology, thoracic CT scan, or typical symptoms. The main outcome was COVID-19 severity based on location of treatment/management (home, hospitalized in a medical unit, or in an intensive care unit). We collected information on demographic variables, general history, and risk factors for severe COVID-19. Multivariate ordinal regression models were used to identify factors associated with severe COVID-19 outcomes.ResultsAmong 3,558 patients with MG registered in the French database for rare disorders, 34 (0.96%) had COVID-19. The mean age at COVID-19 onset was 55.0 ± 19.9 years (mean MG duration: 8.5 ± 8.5 years). By the end of the study period, 28 patients recovered from COVID-19, 1 remained affected, and 5 died. Only high Myasthenia Gravis Foundation of America (MGFA) class (≥IV) before COVID-19 was associated with severe COVID-19 (p = 0.004); factors that were not associated included sex, MG duration, and medium MGFA classes (≤IIIb). The type of MG treatment had no independent effect on COVID-19 severity.ConclusionsThis registry-based cohort study shows that COVID-19 had a limited effect on most patients, and immunosuppressive medications and corticosteroids used for MG management are not risk factors for poorer outcomes. However, the risk of severe COVID-19 is elevated in patients with high MGFA classes (odds ratio, 102.6 [4.4–2,371.9]). These results are important for establishing evidence-based guidelines for the management of patients with MG during the COVID-19 pandemic.