High density of IgG4-secreting plasma cells in the fibrotic tissue from a surgically resected tracheal ring impaired by complex subglottic stenosis post-tracheostomy as immune expression of a Th2 response due to severe COVID-19

COVID-19 Related Tracheal Stenosis Requiring Tracheal Resection: A Case Series

OBJECTIVE

To characterize the preoperative and intraoperative findings of symptomatic tracheal stenosis associated with COVID-19 related respiratory failure requiring tracheal resection.

METHOD

We performed a retrospective review identifying all patients with a history of tracheal stenosis secondary to COVID-19 related respiratory failure who subsequently received a tracheal resection at our institution between January 2020 and June 2023. Clinical, radiological, pathological, and surgical characteristics were recorded to describe and characterize pre-operative and intraoperative findings associated with tracheal stenosis in the setting of a previous COVID-19 infection.

RESULTS

We retrospectively reviewed 11 patients with COVID-19 related tracheal stenosis that required open tracheal or cricotracheal resection. The mean age was 54.1. Patients were hospitalized for a mean of 49.5 days related to COVID-19 complications. Tracheotomy was completed in 10 patients (90.9%) during their initial hospitalization with COVID-19 related respiratory failure. Patients were intubated a mean of 18.6 days prior to tracheotomy completion. Ten patients (90.9%) underwent endoscopic operative interventions for their tracheal stenosis prior to open resection. Intraoperatively, the mean stenosis length was 3.33 cm. The mean tracheal resection length was 3.96 cm. Patients were hospitalized for a mean of 8.27 days post operatively with no significant post operative complications.

CONCLUSIONS

Symptomatic tracheal stenosis in the setting of prolonged intubation due to COVID-19 is an under-described etiology. This is one of the largest single institution retrospective reviews that identifies 11 patients with prolonged intubation who developed symptomatic tracheal stenosis refractory to conservative management and ultimately requiring tracheal resection.

Endoscopic Management of Benign Airway Stenosis in Coronavirus Disease 2019 Patients

BACKGROUND

 The aims of this study were to evaluate the results of endoscopic dilation for simple benign airway stenosis in coronavirus disease 2019 (COVID-19) patients and whether COVID-19 infection was associated with higher rate of recurrence compared with a control group.

METHODS

 It was an observational multicenter study including consecutive patients with simple benign airway stenosis undergoing endoscopic dilatation with at least 6 months of follow-up. The outcome of patients with COVID-19 infection was compared with that of a control group in relation to patient and stenosis characteristics, and procedure type. Then, univariable and multivariable analyses identified the risk factors for recurrence.

RESULTS

 Seventy-nine patients were included in the study; 56 (71%) of these developed airway stenosis after COVID-19 infection. COVID-19 patients presented a higher rate of stenosis due to prolonged intubation (82 vs. 43%; p = 0.0014); no other differences were found regarding demographic data, characteristics of stenosis, and procedure type. Twenty-four (30%) patients had recurrence after first dilatation (32% for No-COVID-19 vs. 26% for COVID-19 group; p = 0.70), and in 11 (35%) of these, the stenosis recurred after repeated endoscopic treatment (65% for No-COVID-19 vs. 45% for COVID-19 group; p = 0.40). Subglottic stenosis (p = 0.013) and the use of laser (p = 0.016) were significant predictive factors for stenosis recurrence.

CONCLUSION

 COVID-19 infection did not affect the outcome of endoscopic treatment of simple airway stenosis, and the treatment of these subsets of patients should not differ from that of general population.

A case of IgG4-related ophthalmic disease after SARS-CoV-2 vaccination: case report and literature review

Coronavirus disease 19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is affecting the world with a surge in cases. A variety of autoimmune diseases occur after SARS-CoV-2 infection or vaccination, of which IgG4-related disease (IgG4-RD) is an important type. IgG4-RD can involve multiple organs of the body. The ocular manifestation of IgG4-RD is called IgG4-related ophthalmic disease (IgG4-ROD). We herein report a patient diagnosed with IgG4-ROD. The patient developed ptosis and vision loss after SARS-CoV-2 vaccination, and the symptoms worsened after SARS-CoV-2 infection. After excluding other diseases like myasthenia gravis and Eaton-Lambert syndrome that may cause ptosis, the diagnosis of IgG4-ROD was confirmed by pathological examination. We discussed the predisposing factors, diagnosis and treatment of this patient to provide a more empirical and theoretical basis for clinical diagnosis and treatment. We conducted a literature review of previously reported cases of IgG4-RD following SARS-CoV-2 infection or vaccination. We retrieved a total of 9 cases, of which 5 developed symptoms after vaccination and 4 after infection. Demographic and clinical characteristics were summarized. In conclusion, our case represents the first case of proven IgG4-ROD after COVID-19 vaccination. We believe that IgG4-ROD and SARS-CoV-2 infection or vaccination are closely related, and the immune system disorder caused by SARS-CoV-2 infection or vaccination may be a key factor in the pathogenesis of IgG4-RD. But for now, there is no direct evidence that there is a causal relationship between SARS-CoV-2 infection or vaccination and IgG4-ROD, which still needs more research and exploration to confirm.

A rare case of IgG4-associated disease caused by COVID-19: Case report and literature review

An increasing number of cases have reported that coronavirus disease 2019 (COVID-19) can lead to immune system dysregulation and induce autoimmune diseases, but the mechanism is unclear. We treated a patient who presented with an unknown fever after infection with the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2023. After excluding the possibility of infection, malignancy, and other connective tissue diseases, we considered the diagnosis of IgG4-related disease in consideration of the patient's pathology and clinical findings. In this article, we summarize our diagnostic experience and summarize the case reports of IgG4-related diseases associated with SARS-CoV-2 infections since the COVID-19 pandemic.

IgG4-infiltrate in post-intubation tracheal stenosis: a call to interventional pulmonologist and thoracic surgeons

BACKGROUND

Since December 2019, Sars-CoV2 infection has become a pandemic health emergency. The most severe manifestation of COVID-19 is acute respiratory distress syndrome requiring intensive care unit admission and mechanical ventilation. The most serious, although rare, complication of prolonged MV is post-intubation tracheal stenosis. We hypothesized that, in addition to recognized risk factors in COVID-19 patients, additional factors may promote airways injury.

METHODS

We analyzed data from 13 patients with PITS referred to our Thoracic Surgery Department from 2020 to 2022 divided in two groups: 8 ex-COVID-19 patients (in MV for ARDS during Sars-Cov2 positivity) and 5 non-COVID-19 patients (in MV for other reasons). Computer-tomography and bronchoscopy were performed to confirm diagnosis of PITS. Surgical treatment including tracheal resection and end-to-end anastomosis was performed in all patients. Tracheal samples were histologically analyzed to define the existence of any difference between the two groups.

RESULTS

The presence of total immunoglobulin G (IgG) and immunoglobulin G4 (IgG4) were tested. IgG infiltrate was present in both groups. IgG4-infiltrate was significantly represented in the tracheal sample of ex-COVID-19 patients and absent in the non-COVID-19 cohort of patients.

CONCLUSIONS

It is suggested that COVID-19 patients have almost double the risk of developing tracheal injuries. This work supports the idea of a major predisposition for such injuries in COVID-19 patients due to a possible immune-mediated mechanism leading to aberrant and fibrotic wound healing following a trigger insult (in this case MV with oro-tracheal tube). In the near future an increasing incidence of PITS is expected. Interventional pulmonologist and thoracic surgeons might be called to deal with this possibility. Clarification of the physiopathology of PITS is needed to prevent excessive tracheal scarring following prolonged endotracheal intubation and recurrence after endoscopic and/or surgical treatment. Careful prevention, early detection and effective management of this life-threatening condition are warranted.

Asthma and COVID-19: a controversial relationship

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection induces a spectrum of clinical manifestations that depend on the immune response of the patient, i.e., from an asymptomatic form to an inflammatory response with multiorgan deterioration. In some cases, severe cases of SARS-CoV-2 are characterized by an excessive, persistent release of inflammatory mediators known as a cytokine storm. This phenomenon arises from an ineffective T helper (Th)-1 response, which is unable to control the infection and leads to a reinforcement of innate immunity, causing tissue damage. The evolution of the disease produced by SARS-CoV2, known as COVID-19, has been of interest in several research fields. Asthma patients have been reported to present highly variable outcomes due to the heterogeneity of the disease. For example, the Th2 response in patients with allergic asthma is capable of decreasing Th1 activation in COVID-19, preventing the onset of a cytokine storm; additionally, IL-33 released by damaged epithelium in the context of COVID-19 potentiates either Th1 or T2-high responses, a process that contributes to poor outcomes. IL-13, a T2-high inflammatory cytokine, decreases the expression of angiotensin converting enzyme-2 (ACE2) receptor, hindering SARS-CoV-2 entry; finally, poor outcomes have been observed in COVID-19 patients with severe neutrophilic asthma. In other contexts, the COVID-19 lockdown has had interesting effects on asthma epidemiology. The incidence of asthma in the most populated states in Mexico, including Tamaulipas, which has the highest asthma incidence in the country, showed similar tendencies independent of how strict the lockdown measures were in each state. As described worldwide for various diseases, a decrease in asthma cases was observed during the COVID-19 lockdown. This decrease was associated with a drop in acute respiratory infection cases. The drop in cases of various diseases, such as diabetes, hypertension or depression, observed in 2020 was restored in 2022, but not for asthma and acute respiratory infections. There were slight increases in asthma cases when in-person classes resumed. In conclusion, although many factors were involved in asthma outcomes during the pandemic, it seems that acute respiratory infection is intimately linked to asthma cases. Social distancing during remote learning, particularly school lockdown, appears to be an important cause of the decrease in cases.

Tracheal resection in post COVID-19 patients is associated with high reintervention rate and early restenosis

Objectives

A remarkable increase in the number of patients presenting with tracheal complications after prolonged endotracheal intubation and mechanical ventilation for the management of the severe COVID-19 - associated respiratory failure has been observed. In this study, we assessed the postoperative outcomes of tracheal resection in COVID-19 patients.

Methods

We conducted a retrospective study in which all patients with a history of prolonged invasive mechanical ventilation due to COVID-19 infection, who were treated with tracheal resection and reconstruction, were included. The primary objective was in-hospital mortality and postoperative reintervention rate. The secondary objective was the time to tracheal restenosis.

Results

During the 16-month study period, 11 COVID-19 patients with tracheal complications underwent tracheal resection with end-to-end anastomosis. Mean patient age was 51.5 ± 9 years, and the majority were male (9 patients). Eight patients were referred for management of post-intubation tracheal stenosis and 3 for tracheoesophageal fistula. Eight patients had a history of tracheostomy during the COVID-19 infection hospitalization. There was one in-hospital death (9.1%) due to septicemia in the Intensive Care Unit, approximately two months after the operation. Postoperatively, 32 reinterventions were required for tracheal restenosis due to granulation tissue formation. The risk for reintervention was higher during the first 3 months after the index operation. Four patients developed tracheal restenosis (36.4%) and two of them required endotracheal stent placement during the follow up period.

Conclusions

Tracheal resection and reconstruction after COVID-19 infection is associated with a high reintervention rate postoperatively. Such patients require close follow up in expert interventional pulmonology units and physicians should be on high alert for the early diagnosis and optimal management of tracheal restenosis.

Management of COVID-19 related tracheal stenosis: The state of art

Tracheal stenosis (TS) is a debilitating disease promoted by pathologic narrowing of the trachea. The acute respiratory distress syndrome caused by COVID-19 has been demonstrated to trigger enhanced inflammatory response and to require prolonged invasive mechanical ventilation as well as high frequency of re-intubation or emergency intubation, thus increasing the rate and complexity of TS. The standard-of-care of COVID-19-related tracheal complications has yet to be established and this is a matter of concern. This review aims at collecting latest evidence on this disease, providing an exhaustive overview on its distinctive features and open issues, and investigating different diagnostic and therapeutic strategies to handle COVID-19-induced TS, focusing on endoscopic versus open surgical approach. The former encompasses bronchoscopic procedures: electrocautery or laser-assisted incisions, ballooning dilation, submucosal steroid injection, endoluminal stenting. The latter consists of tracheal resection with end-to-end anastomosis. As a rule, traditionally, the endoscopic management is restricted to short, low-grade, and simple TS, whereas the open techniques are employed in long, high-grade, and complex TS. However, the critical conditions or extreme comorbidities of several COVID-19 patients, as well as the marked inflammation in tracheal mucosa, have led some authors to apply endoscopic management also in complex TS, recording acceptable results. Although severe COVID-19 seems to be an issue of the past, its long-term complications are still unknown and considering the increased rate and complexity of TS in these patients, we strongly believe that it is worth to focus on it, attempting to find the best management strategy for COVID-19-related TS.

An Unusual Presentation of Immunoglobulin G4-Related Disease (IgG4-RD) Causing Subglottic Stenosis

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that is known to involve multiple organs and was first described as an entity in 2003. It is characterized by lesions with a dense lymphoplasmacytic infiltrate, IgG4-positive plasma cells, storiform fibrosis, and frequently elevated serum IgG4 levels. Organs that are commonly involved include the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, retroperitoneum, lungs, pleura, thyroid, aorta, and lymph nodes. Rarer manifestations of IgG4-RD include central nervous system (CNS) involvement, prostatitis, mastitis, midline destructive disease, and nasopharyngeal disease. In this report, we discuss an atypical case of a young woman with laryngeal subglottic involvement leading to stenosis and airway obstruction, which was ultimately successfully managed with systemic immunosuppression. 

COVID-19 Patients Presenting with Post-Intubation Upper Airway Complications: A Parallel Epidemic?

During the current pandemic, we witnessed a rise of post-intubation tracheal stenosis (PITS) in patients intubated due to COVID-19. We prospectively analyzed data from patients referred to our institution during the last 18 months for severe symptomatic post-intubation upper airway complications. Interdisciplinary bronchoscopic and/or surgical management was offered. Twenty-three patients with PITS and/or tracheoesophageal fistulae were included. They had undergone 31.85 (±22.7) days of ICU hospitalization and 17.35 (±7.4) days of intubation. Tracheal stenoses were mostly complex, located in the subglottic or mid-tracheal area. A total of 83% of patients had fracture and distortion of the tracheal wall. Fifteen patients were initially treated with rigid bronchoscopic modalities and/or stent placement and eight patients with tracheal resection-anastomosis. Post-treatment relapse in two of the bronchoscopically treated patients required surgery, while two of the surgically treated patients required rigid bronchoscopy and stent placement. Transient, non-life-threatening post-treatment complications developed in 60% of patients and were all managed successfully. The histopathology of the resected tracheal specimens didn’t reveal specific alterations in comparison to pre-COVID-era PITS cases. Prolonged intubation, pronation maneuvers, oversized tubes or cuffs, and patient- or disease-specific factors may be pathogenically implicated. An increase of post-COVID PITS is anticipated. Careful prevention, early detection and effective management of these iatrogenic complications are warranted.