The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review

Pericardial and Pleural Effusions in Non-ICU Hospitalized Patients with COVID-19-A Retrospective Single-Center Study

Background: Pericardial and pleural effusions are two complications recently described in patients hospitalized with COVID-19 infections. There are several mechanisms that have been proposed and refer to SARS-CoV-2's capacity to bind to cell surfaces via various receptors and its broad tissue tropism that might cause significant complications. The aim of the present study is to evaluate the incidence of pericardial and pleural effusions during COVID-19 infection as well as to determine the risk factors associated with these complications. Methods: We conducted a retrospective single-center study that included 346 patients admitted to the National Institute of Infectious Disease "Prof. Dr. Matei Bals" (Bucharest, Romania), from 1 January to 25 May 2021, during the third wave of the pandemic. Socio-demographic and anthropometric data were collected for each patient. The patients were evaluated clinically, biologically, and radiologically within 48 h of admission. Patients were divided into 3 groups: (1) patients with pericardial effusions-18; (2) patients with pleural effusions-28; (3) patients without pericardial/pleural effusions-294. Results: After exclusion criteria were applied, 337 patients were analyzed. The median age of the participants was 58.26 ± 14.58 years. More than half of the hospitalized patients had associated respiratory failure (61.5%), of which 2.7% had a critical form of the disease and 58.8% had a severe form. The cumulative percentage for pericardial and pleural effusions for the study group was 12.8% (43 patients out of 337). The prevalence of pericardial effusion was 5.3%, twice more frequent among male respondents. Pleural effusion was identified in 8.3% patients. Most patients had unilateral effusion (17), compared to 11 patients who had bilateral involvement. Based on laboratory results, patients with pericardial and pleural effusions exhibited increased levels of C reactive protein, erythrocyte sedimentation rate, NT proBNP, and a higher value of neutrophil/lymphocyte count ratio. In contrast to patients without pleural and pericardial effusions, those with these symptoms experienced a higher frequency of severe or critical illness and longer hospital stays. Conclusions: Pericardial and pleural effusions can complicate COVID-19 infections. In our study, the prevalence of pericardial and pleural effusions in hospitalized patients was low, being associated with the same comorbidities and a number of clinical and biological parameters.

Outcomes of Tube Thoracostomies in COVID-19 Patients: A Retrospective Cohort Study in the University of the Philippines - Philippine General Hospital COVID-19 Referral Center

Objective

To describe the treatment outcomes of patients who underwent tube thoracostomy for pleural complications in patients with COVID-19 and determine the association between patient profile and treatment outcomes.

Methods

A single-institution retrospective review of patients who underwent tube thoracostomy for complications of COVID-19 infection in the University of the Philippines - Philippine General Hospital (UP-PGH) from March 30, 2020, to March 31, 2021, was performed. These patients' demographic and clinical profiles were evaluated using median, frequencies, and percentages. The association between patient profile, and mortality and reintervention rates was assessed using univariable Cox proportional hazards regression analysis.

Results

Thirty-four (34) of 3,397 patients (1.00%) admitted for COVID-19 pneumonia underwent tube thoracostomy. Of these, 34, 47.06% were male, 52.94% were female, the median age was 51.5 years old, 85.29% had comorbid conditions, and 29.41% had a previous or ongoing tuberculous infection. The most common indication for tube thoracostomy was pleural effusion (61.76%), followed by pneumothorax (29.41%), and pneumo-hydrothorax (8.82%). The mortality rate was 38.24%, and the reintervention rate was 14.71%. Intubated patients had 14.84 times higher mortality hazards than those on room air. For every unit increase in procalcitonin levels, the mortality hazards were increased by 1.06 times.

Conclusion

An increasing level of oxygen support on admission and a level of procalcitonin were directly related to mortality risk in COVID-19 patients who underwent tube thoracostomy for pleural complications. There is insufficient evidence to conclude that patient-related, COVID-19 pneumonia-related, and procedure-related factors included in this study were significantly associated with reintervention risk.

Time-dependent CT score-based model for identifying severe/critical COVID-19 at a fever clinic after the emergence of Omicron variant

Rationale and objectives

The computed tomography (CT) score has been used to evaluate the severity of COVID-19 during the pandemic; however, most studies have overlooked the impact of infection duration on the CT score. This study aimed to determine the optimal cutoff CT score value for identifying severe/critical COVID-19 during different stages of infection and to construct corresponding predictive models using radiological characteristics and clinical factors.

Materials and methods

This retrospective study collected consecutive baseline chest CT images of confirmed COVID-19 patients from a fever clinic at a tertiary referral hospital from November 28, 2022, to January 8, 2023. Cohorts were divided into three subcohorts according to the time interval from symptom onset to CT examination at the hospital: early phase (0-3 days), intermediate phase (4-7 days), and late phase (8-14 days). The binary endpoints were mild/moderate and severe/critical infection. The CT scores and qualitative CT features were manually evaluated. A logistic regression analysis was performed on the CT score as determined by a visual assessment to predict severe/critical infection. Receiver operating characteristic analysis was performed and the area under the curve (AUC) was calculated. The optimal cutoff value was determined by maximizing the Youden index in each subcohort. A radiology score and integrated models were then constructed by combining the qualitative CT features and clinical features, respectively, using multivariate logistic regression with stepwise elimination.

Results

A total of 962 patients (aged, 61.7 ± 19.6 years; 490 men) were included; 179 (18.6%) were classified as severe/critical COVID-19, while 344 (35.8%) had a typical Radiological Society of North America (RSNA) COVID-19 appearance. The AUCs of the CT score models reached 0.91 (95% confidence interval (CI) 0.88-0.94), 0.82 (95% CI 0.76-0.87), and 0.83 (95% CI 0.77-0.89) during the early, intermediate, and late phases, respectively. The best cutoff values of the CT scores during each phase were 1.5, 4.5, and 5.5. The predictive accuracies associated with the time-dependent cutoff values reached 88% (vs.78%), 73% (vs. 63%), and 87% (vs. 57%), which were greater than those associated with universal cutoff value (all P < 0.001). The radiology score models reached AUCs of 0.96 (95% CI 0.94-0.98), 0.90 (95% CI 0.87-0.94), and 0.89 (95% CI 0.84-0.94) during the early, intermediate, and late phases, respectively. The integrated models including demographic and clinical risk factors greatly enhanced the AUC during the intermediate and late phases compared with the values obtained with the radiology score models; however, an improvement in accuracy was not observed.

Conclusion

The time interval between symptom onset and CT examination should be tracked to determine the cutoff value for the CT score for identifying severe/critical COVID-19. The radiology score combining qualitative CT features and the CT score complements clinical factors for identifying severe/critical COVID-19 patients and facilitates timely hierarchical diagnoses and treatment.

Pleural fluid characteristics of patients with COVID-19 infection

INTRODUCTION

Pleural effusions are known to occur in many cases of COVID-19. Data on typical characteristics of COVID-19-associated pleural effusions are limited. The goal of this project was to characterize the pleural fluid from patients with COVID-19.

METHODS

We retrospectively collected electronic medical record data from adults hospitalized at a large metropolitan hospital system with COVID-19 infection who had a pleural effusion and a thoracentesis performed. We assessed pleural fluid characteristics and applied Light's criteria.

RESULTS

We identified 128 effusions from 106 unique patients; 45.4% of the effusions had fluid/serum protein ratio greater than 0.5, 33.9% had fluid/serum lactate dehydrogenase (LDH) greater than 0.6, and 56.2% had fluid LDH greater than 2/3 of the serum upper limit of normal. Altogether, 68.5% of effusions met at least one of these three characteristics and therefore were exudative by Light's criteria. The white blood cell (WBC) differential was predominantly lymphocytic (mean 42.8%) or neutrophilic (mean 28.7%); monocytes (mean 12.7%) and eosinophils (mean 2.5%) were less common.

CONCLUSION

We demonstrate that 68.5% of pleural effusions in patients with COVID-19 infection were exudative and hypothesize that COVID-19-associated pleural effusions are likely to be exudative with WBC differential more likely to be predominantly lymphocytic.

Tiny Lungs, Big Differences: Navigating the Varied COVID-19 Landscape in Neonates vs. Infants via Biomarkers and Lung Ultrasound

Due to their susceptibilities, neonates and infants face unique SARS-CoV-2 challenges. This retrospective study will compare the illness course, symptoms, biomarkers, and lung damage in neonates and infants with SARS-CoV-2 infection from February 2020 to October 2023. This study was conducted at two hospitals in Timisoara, Romania, using real-time multiplex PCR to diagnose and lung ultrasonography (LUS) to assess lung involvement. Neonates had a more severe clinical presentation, an increased immune response, and greater lung involvement. Neonates had more PCR-positive tests (p = 0.0089) and longer hospital stays (p = 0.0002). In neonates, LDH, CRP, and ferritin levels were higher, indicating a stronger inflammatory response. Reduced oxygen saturation in neonates indicates respiratory dysfunction. The symptoms were varied. Infants had fever, cough, and rhinorrhea, while neonates had psychomotor agitation, acute dehydration syndrome, and candidiasis. This study emphasizes individualized care and close monitoring for neonatal SARS-CoV-2 infections. Newborn lung ultrasonography showed different variances and severity levels, emphasizing the need for targeted surveillance and therapy. Newborns have high lung ultrasound scores (LUSS), indicating significant lung involvement. Both groups had initial lung involvement, but understanding these modest differences is crucial to improving care for these vulnerable populations.

Automatic deep learning-based pleural effusion segmentation in lung ultrasound images

BACKGROUND

Point-of-care lung ultrasound (LUS) allows real-time patient scanning to help diagnose pleural effusion (PE) and plan further investigation and treatment. LUS typically requires training and experience from the clinician to accurately interpret the images. To address this limitation, we previously demonstrated a deep-learning model capable of detecting the presence of PE on LUS at an accuracy greater than 90%, when compared to an experienced LUS operator.

METHODS

This follow-up study aimed to develop a deep-learning model to provide segmentations for PE in LUS. Three thousand and forty-one LUS images from twenty-four patients diagnosed with PE were selected for this study. Two LUS experts provided the ground truth for training by reviewing and segmenting the images. The algorithm was then trained using ten-fold cross-validation. Once training was completed, the algorithm segmented a separate subset of patients.

RESULTS

Comparing the segmentations, we demonstrated an average Dice Similarity Coefficient (DSC) of 0.70 between the algorithm and experts. In contrast, an average DSC of 0.61 was observed between the experts.

CONCLUSION

In summary, we showed that the trained algorithm achieved a comparable average DSC at PE segmentation. This represents a promising step toward developing a computational tool for accurately augmenting PE diagnosis and treatment.

Novel Risks of Unfavorable Corticosteroid Response in Patients with Mild-to-Moderate COVID-19 Identified Using Artificial Intelligence-Assisted Analysis of Chest Radiographs

The prediction of corticosteroid responses in coronavirus disease 2019 (COVID-19) patients is crucial in clinical practice, and exploring the role of artificial intelligence (AI)-assisted analysis of chest radiographs (CXR) is warranted. This retrospective case-control study involving mild-to-moderate COVID-19 patients treated with corticosteroids was conducted from 4 September 2021, to 30 August 2022. The primary endpoint of the study was corticosteroid responsiveness, defined as the advancement of two or more of the eight-categories-ordinal scale. Serial abnormality scores for consolidation and pleural effusion on CXR were obtained using a commercial AI-based software based on days from the onset of symptoms. Amongst the 258 participants included in the analysis, 147 (57%) were male. Multivariable logistic regression analysis revealed that high pleural effusion score at 6-9 days from onset of symptoms (adjusted odds ratio of (aOR): 1.022, 95% confidence interval (CI): 1.003-1.042, p = 0.020) and consolidation scores up to 9 days from onset of symptoms (0-2 days: aOR: 1.025, 95% CI: 1.006-1.045, p = 0.010; 3-5 days: aOR: 1.03 95% CI: 1.011-1.051, p = 0.002; 6-9 days: aOR; 1.052, 95% CI: 1.015-1.089, p = 0.005) were associated with an unfavorable corticosteroid response. AI-generated scores could help intervene in the use of corticosteroids in COVID-19 patients who would not benefit from them.

COVID-19-Related Pleural Diseases

Coronavirus disease 2019 (COVID-19)-related pleural diseases are now well recognized. Since the beginning of the pandemic, increasing cases of pleural diseases including pneumothorax, pneumomediastinum, and pleural effusion with severe COVID-19 infection have attracted the attention of physicians and are not incidental or due to barotrauma. The complicated course of COVID-19 illness highlights the complex pathophysiological underpinnings of pleural complications. The management of patients with pneumothorax and pneumomediastinum is challenging as the majority require assisted ventilation; physicians therefore appear to have a low threshold to intervene. Conversely, pleural effusion cases, although sharing some similar patient characteristics with pneumothorax and pneumomediastinum, are in general managed more conservatively. The evidence suggests that patients with COVID-19-related pleural diseases, either due to air leak or effusion, have more severe disease with a worse prognosis. This implies that prompt recognition of these complications and targeted management are key to improve outcomes.

The Global Burden of Pleural Diseases

Pleural diseases include a spectrum of disorders broadly categorized into pneumothorax and pleural effusion. They often cause pain, breathlessness, cough, and reduced quality of life. The global burden of diseases reflects regional differences in conditions and exposures associated with pleural disease, such as smoking, pneumonia, tuberculosis, asbestos, cancer, and organ failure. Disease burden in high-income countries is overrepresented given the availability of data and disease burden in lower-income countries is likely underestimated. In the United States, in 2016, there were 42,215 treat-and-discharge visits to the emergency room for pleural diseases and an additional 361,270 hospitalizations, resulting in a national cost of $10.1 billion.

A Case of Acute Purulent Streptococcus pneumoniae Pericarditis Causing Tamponade and Cardiac Arrest in a COVID-19-Infected Patient

Purulent pericarditis due to Streptococcus pneumoniae (S. pneumoniae) has been increasingly rare since the advent of antibiotics; however, it still carries a high mortality rate, especially in the setting of tamponade. Bedside transthoracic echocardiogram (TTE) is a useful, cheap, and underutilized tool that can aid in the diagnosis, treatment, and further management of patients presenting to the emergency department with chest pain, as well as during cardiac resuscitation. In this report, we present a case of an acute purulent S. pneumoniae pericarditis of an unknown primary source in a patient coinfected with coronavirus disease 2019 (COVID-19) pneumonia, resulting in cardiac tamponade and cardiac arrest that resolved with the aid of bedside echocardiography-guided pericardiocentesis. We attempt to highlight the importance of clinicians using echocardiography to aid in their clinical decision-making, demonstrating it as a fast and effective tool capable of providing instantaneous feedback.

Pleural Effusion in COVID-19 Pneumonia: Clinical and Prognostic Implications-An Observational, Retrospective Study

BACKGROUND

COVID-19 presents with a wide spectrum of clinical and radiological manifestations, including pleural effusion. The prevalence and prognostic impact of pleural effusion are still not entirely clear.

PATIENTS AND METHODS

This is a retrospective, single-center study including a population of consecutive patients admitted to the University Hospital of Cisanello (Pisa) from March 2020 to January 2021 with a positive SARS-CoV-2 nasopharyngeal swab and SARS-CoV-2-related pneumonia. The patients were divided into two populations based on the presence (n = 150) or absence (n = 515) of pleural effusion on chest CT scan, excluding patients with pre-existing pleural effusion. We collected laboratory data (hemoglobin, leukocytes, platelets, C-reactive protein, procalcitonin), worst PaO₂/FiO₂ ratio as an index of respiratory gas exchange impairment, the extent of interstitial involvement related to SARS-CoV-2 pneumonia and data on intensity of care, length of stay and outcome (discharge or death).

RESULTS

The prevalence of pleural effusion was 23%. Patients with pleural effusion showed worse gas exchange (p < 0.001), longer average hospital stay (p < 0.001), need for more health care resources (p < 0.001) and higher mortality (p < 0.001) compared to patients without pleural effusion. By multivariate analysis, pleural effusion was found to be an independent negative prognostic factor compared with other variables such as increased C-reactive protein, greater extent of pneumonia and older age. Pleural effusion was present at the first CT scan in most patients (68%).

CONCLUSIONS

Pleural effusion associated with SARS-CoV-2 pneumonia is a relatively frequent finding that is confirmed to be a negative prognostic factor. Identifying early prognostic factors in an endemic-prone disease such as COVID-19 is necessary to optimize its clinical management. Further clinical studies aimed at better characterizing pleural effusion in these patients will be appropriate in order to clarify its pathogenetic role.

A Single-Center Experience on the Treatment Outcomes of Patients with COVID-19-Pleural Disorders: Lessons for the Future

Background

Pleural disorders in novel coronavirus disease 2019 (COVID-19), responsible for the deaths of more than 6.7 million people worldwide, are relatively uncommon and underappreciated findings. The severity of the pleural disease in these patients correlates with the treatment outcome and overall prognosis.

Objective

We aim to review our experience with treatment modalities and prognosis in 45 patients with COVID-19, who were treated at our Clinic between April 2020 and October 2021.

Methods

We conducted a retrospective, single-center, cross-sectional study. Demographic data, the type of thoracosurgical intervention(s), and treatment outcome for 45 patients included in this study were recorded for every patient. We analyzed the type and number of treatment modalities according to the pleural disorder, and the outcome of the treatment.

Results

Pneumothorax was the most common COVID-19-related pleural disorder, followed by the pleural effusion. Tube thoracostomy was the mainstay of treatment, performed in 84.4% of patients with unilateral pleural complications. In total, 20% of our patients were on mechanical ventilation, and all of them had a fatal outcome. We found statistical significance in comparison to the percentage of fatal outcomes between patients treated with and without mechanical ventilation (p=0.000).

Conclusion

COVID-19-related pleural disorders are prognostic markers of disease progression. Mechanically ventilated patients who require tube thoracostomy have an unfavorable prognosis.

Automatic deep learning-based consolidation/collapse classification in lung ultrasound images for COVID-19 induced pneumonia

Our automated deep learning-based approach identifies consolidation/collapse in LUS images to aid in the identification of late stages of COVID-19 induced pneumonia, where consolidation/collapse is one of the possible associated pathologies. A common challenge in training such models is that annotating each frame of an ultrasound video requires high labelling effort. This effort in practice becomes prohibitive for large ultrasound datasets. To understand the impact of various degrees of labelling precision, we compare labelling strategies to train fully supervised models (frame-based method, higher labelling effort) and inaccurately supervised models (video-based methods, lower labelling effort), both of which yield binary predictions for LUS videos on a frame-by-frame level. We moreover introduce a novel sampled quaternary method which randomly samples only 10% of the LUS video frames and subsequently assigns (ordinal) categorical labels to all frames in the video based on the fraction of positively annotated samples. This method outperformed the inaccurately supervised video-based method and more surprisingly, the supervised frame-based approach with respect to metrics such as precision-recall area under curve (PR-AUC) and F1 score, despite being a form of inaccurate learning. We argue that our video-based method is more robust with respect to label noise and mitigates overfitting in a manner similar to label smoothing. The algorithm was trained using a ten-fold cross validation, which resulted in a PR-AUC score of 73% and an accuracy of 89%. While the efficacy of our classifier using the sampled quaternary method significantly lowers the labelling effort, it must be verified on a larger consolidation/collapse dataset, our proposed classifier using the sampled quaternary video-based method is clinically comparable with trained experts' performance.

A severe presentation of breakthrough infection caused by the Omicron variant with radiological findings of COVID-19 pneumonia in an elderly woman

Omicron variant of COVID-19 is characterized by exceptional transmissibility and by immune evasion with the ability infect people with naturally acquired or vaccine-induced immunity. However, lung involvement is poorly reported in patients who resulted positive by this new COVID-19 variant. COVID-19 breakthrough infections are defined as COVID-19 infection in fully vaccinated patients. Herein, we present a case of breakthrough infection in an elderly woman who came in emergency with dyspnea and with findings of COVID-19 pneumonia on chest computed tomography. The patient was vaccinated with a booster dose of an mRNA vaccine some months earlier and the Omicron variant was detected on real-time reverse-transcription polymerase chain reaction. However, the patient's condition remained stable. For our knowledge we report the first case with lung involvement due to Omicron variant in an elderly after the booster dose of mRNA vaccine. This case highlights as COVID-19 breakthrough infections may represent some concerns in the elderly patients in presence of virus variants.

Correlation of Lung Damage on CT Scan with Laboratory Inflammatory Markers in COVID-19 Patients: A Single-Center Study from Romania

(1) Background: This study aims to evaluate the association of CRP, NLR, IL-6, and Procalcitonin with lung damage observed on CT scans; (2) Methods: A cross-sectional study was performed among 106 COVID-19 patients hospitalized in Timisoara Municipal Emergency Hospital. Chest CT and laboratory analysis were performed in all patients. The rank Spearmen correlation was used to assess the association between inflammatory markers and lung involvement. In addition, ROC curve analysis was used to determine the accuracy of inflammatory markers in the diagnosis of severe lung damage; (3) Results: CRP, NLR, and IL-6 were significantly positively correlated with lung damage. All inflammatory markers had good accuracy for diagnosis of severe lung involvement. Moreover, IL-6 has the highest AUC- ROC curve; (4) Conclusions: The inflammatory markers are associated with lung damage and can be used to evaluate COVID-19 severity.

Abnormal Chest Computed Tomography Findings among Admitted Symptomatic COVID-19 Patients in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

COVID-19 has emerged as a pandemic and has varied clinical presentation. Computed Tomography scans of the chest play an important role in evaluating the lung parenchymal changes and aids in better planning the management of COVID-19 patients. The purpose of this study was to find the prevalence of abnormal chest computed tomography findings among admitted symptomatic COVID-19 patients in a tertiary care centre.

Methods

This descriptive cross-sectional study was conducted from 25 October 2020 to January 2021 in a tertiary care hospital. Ethical approval was taken from the Institutional Review Committee (Registration number: 348). Convenience sampling method was used. Chest computed tomography findings of the admitted symptomatic COVID-19 patients were evaluated for abnormal findings. Point estimate and 95% Confidence Interval were calculated.

Results

Among 153 patients, abnormal chest computed tomography findings were seen in 147 (96.07%) (92.99-99.15, 95% Confidence Interval). The findings of ground-glass opacities with consolidations were seen in 78 (53.06%) patients.

Conclusions

The prevalence of abnormal chest findings among symptomatic COVID-19 patients in our study was similar to the studies done in other countries in similar settings. Majority of the symptomatic COVID-19 patients showed abnormal chest computed tomography scan findings in the form of ground glass opacities and consolidations.

Keywords

COVID-19; Nepal; pneumonia; prevalence.

Thrombocytosis, haemorrhagic pleural effusion and fibro-infiltrative patches with cavitary lung lesions in a child with COVID-19 pneumonia

COVID-19 infection in children is relatively mild and is associated with fewer complications compared with adults. Here we report the case of a previously healthy preteen girl who presented with active COVID-19 and shock. On day 1, ultrasound of the thorax revealed a right-sided pleural effusion with haemorrhagic pus on diagnostic tap, which improved clinically with appropriate hospital treatment. Even at discharge, the chest X-ray barely changed, indicating a fibrotic area and a collapsed lung. The patient had persistent thrombocytosis, her inflammatory markers (C reactive protein, ESR, interleukin 6, serum ferritin, D-dimer and procalcitonin) were elevated, and a high-resolution CT scan of the thorax at discharge revealed fibro-infiltrative patches with cavitary lesions in COVID-19 pneumonia, which are unusual findings. The patient was discharged on clinical improvement and was doing fine on follow-up after 2 weeks.

Comparison between Suspected and Confirmed COVID-19 Respiratory Patients: What Is beyond the PCR Test

COVID-19 modified the healthcare system. Nasal-pharyngeal swab (NPS), with real-time reverse transcriptase-polymerase (PCR), is the gold standard for the diagnosis; however, there are difficulties related to the procedure that may postpone it. The study aims to evaluate whether other elements than the PCR-NPS are reliable and confirm the diagnosis of COVID-19. This is a cross-sectional study on data from the Lung Unit of Pavia (confirmed) and at the Emergency Unit of Palermo (suspected). COVID-19 was confirmed by positive NPS, suspected tested negative. We compared clinical, laboratory and radiological variables and performed Logistic regression to estimate which variables increased the risk of COVID-19. The derived ROC-AUCcurve, assessed the accuracy of the model to distinguish between COVID-19 suspected and confirmed. We selected 50 confirmed and 103 suspected cases. High Reactive C-Protein (OR: 1.02; CI95%: 0.11–1.02), suggestive CT-images (OR: 11.43; CI95%: 3.01–43.3), dyspnea (OR: 10.48; CI95%: 2.08–52.7) and respiratory failure (OR: 5.84; CI95%: 1.73–19.75) increased the risk of COVID-19, whereas pleural effusion decreased the risk (OR: 0.15; CI95%: 0.04–0.63). ROC confirmed the discriminative role of these variables between suspected and confirmed COVID-19 (AUC 0.91). Clinical, laboratory and imaging features predict the diagnosis of COVID-19, independently from the NPS result.

CHARACTERIZATION OF PATIENTS IN THE POST-ACUTE PHASE OF COVID-19 WHO PRESENTED THEMSELVES TO AN EMERGENCY DEPARTMENT

BACKGROUND

Patients that recovered from COVID-19 may remain with symptoms which can persist for an uncertain period of time.

AIM

The purpose of this study was to investigate the reasons why patients who passed the acute phase of COVID-19 presented themselves to the Emergency Department.

PATIENTS AND METHODS

We selected 87 patients admitted to the Emergency Department of the Bucharest University Emergency Hospital between 01.01.2021-31.05.2021. Patients had pulmonary fibrosis (11.49%), pleural effusion (16.09%) or a history of hypertension (73.56%), type 2 diabetes (42.53%), stroke (24.14%), malignant diseases (10.34%).

RESULTS

Association between neutrophil levels and acute stroke and between fibrinogen levels and alveolar condensation were identified. The percentage of deaths was significantly higher in the subgroup of subjects that had maxim 11 days of hospitalization (p=0.004); we observed a trend of association between the age of more than 51 years old and admission in the Emergency Unit at less than a month after the SARS Cov2 infection, the positive result at the RT-PCR test or a lung damage of over 30% (p<0.05).

CONCLUSION

A significant percentage of patients that were admitted to the Emergency Unit post COVID-19 had chronic pathologies and their characteristics were associated with neutrophilia, high fibrinogen levels or length of hospitalization.

Pulmonary Procedures in the COVID-19 Era

Purpose of Review

The purpose of this review is to discuss the impact of the COVID-19 pandemic on pulmonary procedures, including new guidelines, restrictions, techniques, and overall effect on patient care.

Recent Findings

SARS-CoV-2 predominately impacts the pulmonary system and can result in a severe lower respiratory tract infection. Early guidelines based largely on data from the SARS epidemic recommended significant restrictions on procedure volume out of concern for healthcare worker safety. Newer data suggests relative safety in performing airway and pleural procedures as long as appropriate precautions are followed and new techniques are utilized. The introduction of effective vaccines and more reliable testing has led to a re-expansion of elective procedures.

Summary

Many guidelines and expert statements exist for the management and practice of pulmonary procedures during the COVID-19 pandemic. A flexible and individualized approach may be necessary as our understanding of COVID-19 continues to evolve.

Uma Apresentação Rara de COVID-19 com Embolia Pulmonar

A doença de coronavírus 2019 (COVID-19) foi relatada em quase todos os países do mundo desde dezembro de 2019. A infecção por SARS-CoV-2 é frequentemente assintomática ou com sintomas leves, mas também pode levar à hipóxia, um estado hiperinflamatório e coagulopatia. Os parâmetros de coagulação anormais estão associados a complicações trombóticas, incluindo embolia pulmonar na COVID-19, mas pouco se sabe sobre os mecanismos. A semelhança dos sintomas iniciais de ambas as doenças também pode ser confusa, portanto, os médicos devem estar cientes do potencial para condições concomitantes. Apresentamos aqui um caso que não apresentava opacidades em vidro fosco nos pulmões, mas apresentava embolia pulmonar e derrame pleural em associação com infecção por COVID-19.

Hydropneumothorax With Persistent Air Leak in a Patient With Mild COVID-19 Disease

COVID-19 is a pandemic viral disease with a catastrophic global impact. The severity of COVID-19 symptoms ranges from very mild to severe and affects mainly the respiratory system. Spontaneous pneumothorax and pleural effusion are rarely seen in spontaneously breathing COVID-19 patients. We herein report a case of a patient with mild COVID-19 disease presenting to the emergency department with hydropneumothorax. Due to persistent air leak, the patient was managed with video-assisted thoracoscopic surgery (VATS) bullectomy and talc pleurodesis. Clinicians managing these patients should be alert to early diagnose this complication.

Bilateral parapneumonic pleural effusion with pneumothorax in a patient with covid 19 pneumonia: case report

Recurrent pyogenic effusion combined with bilateral pneumothorax is a rare complication associated with the COVID−19 infection. Current article presents the case report of a 68-year-old male with the severe community-acquired bilateral polysegmental viral COVID−19 pneumonia. Chest radiography on the 15th day after admission to the hospital showed the presence of air and pleural effusion in the right pleural cavity with collapse of the right lung. Thoracentesis and thoracostomy in the sixth intercostal space on the mid-axillary line were performed. About 1400 ml of a yellowish opaque liquid were evacuated from the pleural cavity. Pleural fluid analysis confirmed an exudative lymphocytic-rich effusion with no growth of acid-fast bacteria (AFB). In the pleural fluid such gram-negative bacteria as Acinetobacter baumannii and Pseudomonas aeruginosa were cultured. Chest computed tomography obtained on the third day after thoracentesis showed radiological sings of bilateral hydropneumothorax. Needle thoracocentesis and new pleural drainage in the second intercostal space on the right midclavicular line were established. Five days later after the second drainage of the pleural space was initiated the patient was diagnosed with pleural empyema and transferred to the Surgical Clinic. This case report highlights that in patients with COVID-19 recurrent pyogenic effusion combined with bilateral pneumothorax may occur.

[Recommendations for SARS-CoV-2/COVID-19 during Pregnancy, Birth and Childbed - Update November 2021 (Long Version)]

Since the onset of the SARS-CoV-2 pandemic, the German Society of Gynecology and Obstetrics and the Society for Peri-/Neonatal Medicine have published and repeatedly updated recommendations for the management of SARS-CoV-2 positive pregnancies and neonates. As a continuation of existing recommendations, the current update addresses key issues related to the prenatal, perinatal, and postnatal care of pregnant women, women who have given birth, women who have recently given birth, women who are breastfeeding with SARS-CoV-2 and COVID-19, and their unborn or newborn infants, based on publications through September 2021. Recommendations and opinions were carefully derived from currently available scientific data and subsequently adopted by expert consensus. This guideline - here available in the long version - is intended to be an aid to clinical decision making. Interpretation and therapeutic responsibility remain with the supervising local medical team, whose decisions should be supported by these recommendations. Adjustments may be necessary due to the rapid dynamics of new evidence. The recommendations are supported by the endorsement of the professional societies: German Society for Perinatal Medicine (DGPM), German Society of Gynecology and Obstetrics (DGGG), German Society for Prenatal and Obstetric Medicine (DGPGM), German Society for Pediatric Infectiology (DGPI), Society for Neonatology and Pediatric Intensive Care Medicine (GNPI).

Is Lung Ultrasound Helpful in COVID-19 Neonates?-A Systematic Review

Background: The SARS-CoV-2 infection has occurred in neonates, but it is a fact that radiation exposure is not recommended given their age. The aim of this review is to assess the evidence on the utility of lung ultrasound (LUS) in neonates diagnosed with COVID-19. Methods: A systematic literature review was performed so as to find a number of published studies assessing the benefits of lung ultrasound for newborns diagnosed with COVID and, in the end, to make a comparison between LUS and the other two more conventional procedures of chest X-rays or CT exam. The key terms used in the search of several databases were: “lung ultrasound”, “sonography”, “newborn”, “neonate”, and “COVID-19′. Results: In total, 447 studies were eligible for this review, and after removing the duplicates, 123 studies referring to LU were further examined, but only 7 included cases of neonates. These studies were considered for the present research paper. Conclusions: As a non-invasive, easy-to-use, and reliable method for lung lesion detection in neonates with COVID-19, lung ultrasound can be used as a useful diagnosis tool for the evaluation of COVID-19-associated lung lesions. The benefits of this method in this pandemic period are likely to arouse interest in opening new research horizons, with immediate practical applicability.

Nonthyroidal illness syndrome (NTIS) in severe COVID-19 patients: role of T3 on the Na/K pump gene expression and on hydroelectrolytic equilibrium

Background

Nonthyroidal Illness Syndrome (NTIS) can be detected in many critical illnesses. Recently, we demonstrated that this condition is frequently observed in COVID-19 patients too and it is correlated with the severity the disease. However, the exact mechanism through which thyroid hormones influence the course of COVID-19, as well as that of many other critical illnesses, is not clear yet and treatment with T4, T3 or a combination of both is still controversial. Aim of this study was to analyze body composition in COVID-19 patients in search of possible correlation with the thyroid function.

Methods and findings

We report here our experience performed in 74 critically ill COVID-19 patients hospitalized in the intensive care unit (ICU) of our University Hospital in Rome. In these patients, we evaluated the thyroid hormone function and body composition by Bioelectrical Impedance Analysis (BIA) during the acute phase of the disease at admission in the ICU. To examine the effects of thyroid function on BIA parameters we analyzed also 96 outpatients, affected by thyroid diseases in different functional conditions. We demonstrated that COVID-19 patients with low FT3 serum values exhibited increased values of the Total Body Water/Free Fat Mass (TBW/FFM) ratio. Patients with the lowest FT3 serum values had also the highest level of TBW/FFM ratio. This ratio is an indicator of the fraction of FFM as water and represents one of the best-known body-composition constants in mammals. We found an inverse correlation between FT3 serum values and this constant. Reduced FT3 serum values in COVID-19 patients were correlated with the increase in the total body water (TBW), the extracellular water (ECW) and the sodium/potassium exchangeable ratio (Na_e:K_e), and with the reduction of the intracellular water (ICW). No specific correlation was observed in thyroid patients at different functional conditions between any BIA parameters and FT3 serum values, except for the patient with myxedema, that showed a picture similar to that seen in COVID-19 patients with NTIS. Since the Na⁺/K⁺ pump is a well-known T3 target, we measured the mRNA expression levels of the two genes coding for the two major isoforms of this pump. We demonstrated that COVID-19 patients with NTIS had lower levels of mRNA of both genes in the peripheral blood mononuclear cells (PBMC)s obtained from our patients during the acute phase of the disease. In addition, we retrieved data from transcriptome analysis, performed on human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM)s treated with T3 and we demonstrated that in these cells T3 is able to stimulate the expression of these two genes in a dose-dependent manner.

Conclusions

In conclusion, we demonstrated that measurement of BIA parameters is a useful method to analyze water and salt retention in COVID-19 patients hospitalized in ICU and, in particular, in those that develop NTIS. Our results indicate that NTIS has peculiar similarities with myxedema seen in severe hypothyroid patients, albeit it occurs more rapidly. The Na⁺/K⁺ pump is a possible target of T3 action, involved in the pathogenesis of the anasarcatic condition observed in our COVID-19 patients with NTIS. Finally, measurement of BIA parameters may represent good endpoints to evaluate the benefit of future clinical interventional trials, based on the administration of T3 in patients with NTIS.

Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema

Patients with SARS-CoV-2 pneumonia can suffer from pneumothorax and persistent air leak (PAL). The pneumothorax occurs with or without pre-existing lung disease. PAL refers to air leak lasting more than 5-7 days and arises due to bronchopleural or alveolopleural fistula. The management of PAL can be challenging as a standard management guideline is lacking. Here we present the case of a 42-year-old smoker with COVID-19 who presented to the hospital with fever, cough, acute left-sided chest pain and shortness of breath. He suffered from a large left-sided pneumothorax requiring immediate chest tube drainage. Unfortunately, the air leak persisted for 13 days before one-way endobronchial valve (EBV) was used with complete resolution of the air leak. We also review the literature regarding other cases of EBV utilisation for PAL in patients with COVID-19.

Pleural abnormalities in COVID-19: a narrative review

Objective

This narrative review aims to provide a detailed overview of pleural abnormalities in patients with coronavirus disease 19 or COVID-19.

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) is a novel beta coronavirus responsible for COVID-19. Although pulmonary parenchymal and vascular changes associated with COVID-19 are well established, pleural space abnormalities have not been the primary focus of investigations.

Methods

Narrative overview of the medical literature regarding pleural space abnormalities in COVID-19. The appropriate manuscripts were identified by searching electronic medical databases and by hand searching the bibliography of the identified papers. Pleural abnormalities on transverse and ultrasound imaging are discussed. The incidence, clinical features, pathophysiology, and fluid characteristics of pleural effusion are reviewed. Studies reporting pneumothorax and pneumomediastinum are examined to evaluate for pathogenesis and prognosis. A brief comparative analysis of pleural abnormalities among patients with COVID-19, severe acute respiratory syndrome (SARS), and Middle Eastern respiratory syndrome (MERS) has been provided.

Conclusions

Radiologic pleural abnormalities are common in COVID-19, but the incidence of pleural effusion appears to be low. Pneumothorax is rare and does not independently predispose the patient to worse outcomes. SARS-CoV-2 infects the pleural space; however, whether the pleural fluid can propagate the infection is unclear.

Culture-negative pleural empyema after Coronavirus disease-19 resolution - A case report

Even after more than a year, novel Coronavirus disease-19 (COVID-19) clinical presentation and complications are still being reported. We present a 75-year-old patient with culture-negative pleural empyema a month after COVID-19 resolution without re-infection. We hypothesize that culture-negative empyema can be present in patients with immune defect, e.g., elderly or diabetic patients, and prior antibiotic exposure. Empyema after COVID-19 resolution may be related to delayed inflammation improvement in chronic disease, which resulted in the patient's more vulnerability to secondary infection.

Loculated Empyema and SARS-CoV-2 Infection: A Report of Two Cases and Review of the Literature

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clinical manifestations are diverse and can vary from mild respiratory symptoms to severe hypoxic respiratory failure. In severe cases, infection can cause gastrointestinal, renal, cardiac, neurological and haematological complications and result in multi-organ failure. There are very few reports of parapneumonic effusion in patients with COVID-19. We describe two patients with COVID-19 who had loculated empyema and discuss the clinical course and therapeutic options.

LEARNING POINTS

The clinical manifestations of COVID-19 vary from mild to severe disease and can result in multi-organ failure.Pleural empyema is usually treated with a combination of antibiotics and surgical drainage of the pleural cavity.