Radiological appearances of cytomegalovirus infections

Pneumothorax and pneumomediastinum in patients with COVID-19: A retrospective study from tertiary care institute in India

COVID-19 is associated with rarer extra-parenchymal manifestations, namely pneumothorax (PTX) and pneumomediastinum (PM) leading to complications and increased mortality. The study aims to describe the prevalence, risk factors for mortality, radiological characteristics and outcome of PTX/PM in patients admitted with COVID-19. This was a retrospective, single-centre, observational study in patients with confirmed COVID-19 presenting with non-iatrogenic PTX/PM from April 2020 to May 2021. Details pertaining to demographics, presentation, radiological characteristics, management and outcome were collected. Cases were classified into spontaneous and barotraumatic PTX/PM and a between-group comparison was performed using Chi-square and t-test. A total of 45 cases (mean age: 53.2 years, 82% males) out of 8,294 confirmed COVID-19 patients developed PTX/PM, the calculated incidence being 0.54%. 29 cases had spontaneous PTX/PM and the remaining 17 cases were attributed to barotrauma. The most common comorbidities were diabetes-mellitus (65.3%) and hypertension (42.3%). The majority of the cases had large PTX (62.1%) with tension in 8 cases (27.5%). There were predominant right-sided pneumothoraces and five were diagnosed with bronchopleural fistula. 37.7% of cases had associated subcutaneous emphysema. The median duration of PTX/PM from symptom onset was delayed at 22.5 and 17.6 days respectively. The mean CT severity score (CTSS) was 20.5 (± 4.9) with fibrosis (53.8%), bronchiectatic changes (50%) and cystic-cavitary changes (23%). There was no statistically significant difference between the spontaneous and barotrauma cohort. 71% of cases died and the majority belonged to the barotrauma cohort. It is imperative to consider the possibility of PTX/PM in patients having COVID-19, especially in those with deterioration in the disease course, both in spontaneously breathing and mechanically ventilated patients. These patients may also have a high incidence of death, reflecting the gravity of COVID-19.

Radiological, epidemiological and clinical patterns of pulmonary viral infections

Respiratory viruses are the most common causes of acute respiratory infections. However, identification of the underlying viral pathogen may not always be easy. Clinical presentations of respiratory viral infections usually overlap and may mimic those of diseases caused by bacteria. However, certain imaging morphologic patterns may suggest a particular viral pathogen as the cause of the infection. Although definitive diagnosis cannot be made on the basis of clinical or imaging features alone, the use of a combination of clinical and radiographic findings can substantially improve the accuracy of diagnosis. The purpose of this review is to present the clinical, epidemiological and radiological patterns of lower respiratory tract viral pathogens providing a comprehensive approach for their diagnosis and identification in hospitals and community outbreaks.

Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review

Spontaneous pneumomediastinum (SPM) and pneumothorax (PNX) unrelated to positive pressure ventilation has been recently reported as an unusual complication in cases of severe COVID-19 pneumonia. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. We present a case of COVID-19 pneumonia complicated on day 13 post admission by SPM, PNX and subcutaneous emphysema in a patient with no identifiable risk factors for such complication. The patient received medical treatment for his COVID-19 infection without the use of an invasive or non-invasive ventilator. Moreover, he is a non-smoker with no lung comorbidities and never reported a cough. He was eventually discharged home in stable condition. A comprehensive literature review revealed 15 cases of SPM developing in patients with COVID-19 pneumonia.

Spontaneous subcutaneous emphysema and pneumomediastinum in non-intubated patients with COVID-19

PURPOSE

We describe the presenting characteristics and hospital course of 11 novel coronavirus (COVID-19) patients who developed spontaneous subcutaneous emphysema (SE) with or without pneumomediastinum (SPM) in the absence of prior mechanical ventilation.

MATERIALS AND METHODS

A total of 11 non-intubated COVID-19 patients (8 male and 3 female, median age 61 years) developed SE and SPM between March 15 and April 30, 2020 at a multi-center urban health system in New York City. Demographics (age, gender, smoking status, comorbid conditions, and body-mass index), clinical variables (temperature, oxygen saturation, and symptoms), and laboratory values (white blood cell count, C-reactive protein, D-dimer, and peak interleukin-6) were collected. Chest radiography (CXR) and computed tomography (CT) were analyzed for SE, SPM, and pneumothorax by a board-certified cardiothoracic-fellowship trained radiologist.

RESULTS

Eleven non-intubated patients developed SE, 36% (4/11) of whom had SE on their initial CXR. Concomitant SPM was apparent in 91% (10/11) of patients, and 45% (5/11) also developed pneumothorax. Patients developed SE on average 13.3 days (SD: 6.3) following symptom onset. No patients reported a history of smoking. The most common comorbidities included hypertension (6/11), diabetes mellitus (5/11), asthma (3/11), dyslipidemia (3/11), and renal disease (2/11). Four (36%) patients expired during hospitalization.

CONCLUSION

SE and SPM were observed in a cohort of 11 non-intubated COVID-19 patients without any known cause or history of invasive ventilation. Further investigation is required to elucidate the underlying mechanism in this patient population.

COVID-19 with bilateral pneumothoraces- case report

To the best of our knowledge, there is no case report or data published regarding COVID pneumonitis presenting initially as pneumothorax.There are 3 case reports published to-date (May 30, 2020) reporting secondary pneumothorax as complication in later stages of Acute respiratory distress syndrome (ARDS) secondary to COVID-19 in non-ventilated patients. We present a case of COVID-19 disease presenting as tension pneumothorax after a week of symptoms and developing a second pneumothorax on the contralateral side post mechanical ventilation.

Pneumomediastinum in an HIV-infected patient with cytomegalovirus pneumonitis

A pneumomediastinum is an unusual complication of respiratory infections in HIV-positive patients, usually reported in association with pneumocystis pneumonia. We describe a case of an HIV-positive patient with a pneumomediastinum who had cytomegalovirus pneumonitis. This is an important reminder to clinicians, since cytomegalovirus pneumonitis and pneumocystis pneumonia have a similar clinical and radiological presentation.

Noninvasive positive pressure ventilation treatment for acute respiratory failure in SARS

This study describes the blood gases features and short-term outcomes with noninvasive positive pressure ventilation (NPPV) treatment in the management of acute respiratory failure (ARF) during a severe acute respiratory syndrome (SARS) epidemic. Between April 22 and May 1, 2003, 120 patients meeting clinical criteria for SARS were admitted to a hospital for infectious diseases in Beijing, China. At 6 weeks after onset, 25% of patients (30/120) had experienced ARF. Of interest, 16 of these patients (53%) exhibited hypercapnia (PaCO (2) > 45 mm Hg), and 10 hypercapnic events occurred within 1 week of admission. The occurence of hypencapnia or CO (2) retention and was accompanied by myalgias. NPPV was instituted in 28 patients; one was intolerant of NPPV. In the remaining 27 patients, NPPV was initiated 1.2 +/- 1.6 days after ARF onset. An hour of NPPV therapy led to significant increases in PaO (2) and PaO (2)/FiO (2) and a decrease in respiratory rate ( p < 0.01). Endotracheal intubation was required in one third of the patients (9 of 27) who initially had a favorable response to NPPV. Remarkable pulmonary barotrauma was noticed in 7 of all 120 patients (5.8%) and in 6 of those (22%) on NPPV. The overall fatality rate at 13 weeks was 6.7% (8/120); it was higher (26.7%) in those needing NPPV. No caregiver contracted SARS. We conclude that NPPV is a feasible and appropriate treatment for ARF occurring as a result of a SARS infection.

Thin-Section CT Findings in 32 Immunocompromised Patients with Cytomegalovirus Pneumonia Who Do Not Have AIDS

OBJECTIVE

The aim of this study was to review the thin-section CT findings in 32 immunocompromised patients without AIDS who had proven Cytomegalovirus pneumonia.

MATERIALS AND METHODS

The causes of immunocompromise included bone marrow (n = 25) or solid organ transplantation (n = 5) and corticosteroid therapy (n = 2). The patients included 16 men and 16 women ranging in age from 22 to 70 years (mean age, 43 years). The CT scans were retrospectively reviewed by two thoracic radiologists for the presence, appearance, and distribution of parenchymal abnormalities.

RESULTS

Bilateral abnormalities were seen in all patients. Areas of ground-glass opacification were seen in 21 (66%) of 32 patients. Ground-glass opacification was the predominant CT feature in nine cases (28%). In 19 of 32 patients, ground-glass attenuation was associated with other abnormalities. Multiple nodules were identified in 19 patients (59%). Nodules were bilateral in 15 patients and unilateral in four patients. Nodules were the only CT finding in three patients (9%). Areas of air-space consolidation were identified in 19 patients (59%). Air-space consolidation was the only CT finding in one patient (3%). Other less common CT findings included thickening of the bronchovascular bundles (n = 7) and the tree-in-bud appearance (n = 4). Pleural effusions were seen in seven patients.

CONCLUSION

The thin-section CT manifestations of Cytomegalovirus pulmonary infection usually consist of a mixture of patterns, most commonly ground-glass attenuation, areas of consolidation, and small nodules.

'Benign' hepatic portal venous gas

The presence of portal venous gas within the hepatic parenchyma is usually associated with a guarded prognosis and a mortality rate approaching 75%. However, there are infrequent causes of portal venous gas not associated with dire clinical outcomes. We describe three patients who made uneventful clinical recoveries after presenting with clinical and imaging manifestations of ischaemic bowel and hepatic portal venous gas, two of which had distended but non-necrotic bowel at laparotomy.

Pulmonary complications following bone marrow transplantation

Pulmonary complications account for significant morbidity and mortality in patients following bone marrow transplants (BMT). They are distinct from other immunosuppressed patients in that there is a predictable course of immunosuppresion and therefore of likely pulmonary complications. This is important when interpreting abnormal radiology as the predictable time course will enable narrowing the differential diagnoses to certain pulmonary complications that characteristically occur at a particular time following BMT. Early recognition and correct treatment of the pulmonary complications should minimize the significant mortality and morbidity. This review aims to discuss the role of radiology in the diagnosis and management of pulmonary complications following BMT.

Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study

BACKGROUND

We investigated the temporal progression of the clinical, radiological, and virological changes in a community outbreak of severe acute respiratory syndrome (SARS).

METHODS

We followed up 75 patients for 3 weeks managed with a standard treatment protocol of ribavirin and corticosteroids, and assessed the pattern of clinical disease, viral load, risk factors for poor clinical outcome, and the usefulness of virological diagnostic methods.

FINDINGS

Fever and pneumonia initially improved but 64 (85%) patients developed recurrent fever after a mean of 8.9 (SD 3.1) days, 55 (73%) had watery diarrhoea after 7.5 (2.3) days, 60 (80%) had radiological worsening after 7.4 (2.2) days, and respiratory symptoms worsened in 34 (45%) after 8.6 (3.0) days. In 34 (45%) patients, improvement of initial pulmonary lesions was associated with appearance of new radiological lesions at other sites. Nine (12%) patients developed spontaneous pneumomediastinum and 15 (20%) developed acute respiratory distress syndrome (ARDS) in week 3. Quantitative reverse-transcriptase (RT) PCR of nasopharyngeal aspirates in 14 patients (four with ARDS) showed peak viral load at day 10, and at day 15 a load lower than at admission. Age and chronic hepatitis B virus infection treated with lamivudine were independent significant risk factors for progression to ARDS (p=0.001). SARS-associated coronavirus in faeces was seen on RT-PCR in 65 (97%) of 67 patients at day 14. The mean time to seroconversion was 20 days.

INTERPRETATION

The consistent clinical progression, shifting radiological infiltrates, and an inverted V viral-load profile suggest that worsening in week 2 is unrelated to uncontrolled viral replication but may be related to immunopathological damage.

Life-threatening upper airway obstruction in a child caused by retropharyngeal emphysema

A 2 1/2-year-old boy with acute obstructive lung disease from adenovirus infection developed cough-induced paroxysms of intense dyspnoea leading to respiratory failure. Chest x-ray and fluoroscopy demonstrated retropharyngeal air occluding the airway. The clinical management of this and similar air-leak problems is discussed.

Prognostic significance of pathological chest radiography in transplant patients affected by cytomegalovirus and/or pneumocystis carinii

PURPOSE

In order to evaluate the prognostic significance of chest film findings in connection with cytomegalovirus (CMV) and/or pneumocystis carinii infection (PC), a retrospective review was made of the pulmonary charts of 274 recipients of kidney and/or pancreatic grafts transplanted between April 1987 and December 1990.

MATERIAL, METHODS AND RESULTS

Positive laboratory findings for CMV and/or PC were seen in 92 patients. In 77 patients only CMV was found, 13 patients had both CMV and PC, and 2 patients had only PC. In 57 patients a chest examination was performed. The films were reviewed by 2 radiologists independently. In 32 patients normal chest film findings were seen, while 25 patients demonstrated pathological changes. Of the patients with pathological changes 3 had only pleuritis while the remaining 22 demonstrated parenchymal infiltrations. No deaths occurred among patients infected with CMV and/or PC, when the chest film findings were normal or pleuritis only was seen, but there were 9 deaths in the group of patients with parenchymal infiltrations. Of the patients who died, 2 had only CMV, 5 had both CMV and PC, and 2 had only PC. The overall mortality, regardless of radiological findings, did not exceed 3% in patients with CMV only, but increased to 38% in patients with both CMV and PC. In patients with parenchymal infiltrations the corresponding mortality figures were increased to 18% and 56%, respectively.

CONCLUSION

We conclude that a radiologically verified pneumonia related to the infectious agent influences the prognosis, and that CMV pneumonia has a better prognosis than PC pneumonia.

Cytomegalovirus colitis in AIDS: plain abdominal radiograph findings

The findings on the plain abdominal radiographs of 15 patients with cytomegalovirus (CMV) colitis and AIDS were reviewed and compared to an age, sex, CD4 count and symptom-matched control group. The radiographs were examined for mucosal thickening, bowel dilatation, pneumatosis and perforation. Nodular mucosal lesions were the most significant abnormality in those with CMV colitis being present in seven compared to none in the control group (P = 0.006 two tailed). Differences between the CMV colitis group and the control group as regards the other features were not significant. The finding of pneumatosis is the first time this has been described in patients with CMV colitis and AIDS. No evidence of perforation was demonstrated and this is attributed to a high index of suspicion in those with characteristic signs and symptoms in addition to early sigmoidoscopy and prompt treatment.

Opportunistic pneumonia

Patients with abnormalities in their immune defense mechanisms are frequently encountered in the practice of medicine. These patients have increased susceptibility to infections that often involve the lung. Many of these infections are caused by opportunistic organisms that typically do not produce disease in individuals with a normally functioning immune system. To complicate the evaluation of these patients, they frequently develop noninfectious lung disease, which can have a radiographic appearance that is similar to infection. The purpose of this article is to present an approach to the evaluation of chest radiographic abnormalities in the immunocompromised patient with suspected pneumonia. Clinical information that is pertinent in the evaluation of immunocompromised patients is discussed. The various chest radiographic patterns seen in both infectious and noninfectious diseases that occur in the immunocompromised patient are reviewed. Integration of clinical information and radiographic findings in the development of a list of differential diagnoses is stressed.

The chest radiograph appearances seen following high dose chemotherapy and autologous bone marrow transplantation for resistant malignant lymphoma

The objective of this study was to review and analyse the chest radiograph (CXR) appearances seen following high dose chemotherapy and autologous bone marrow transplantation (ABMT), and to identify any characteristic patterns. Thirty-one patients underwent ABMT between 1984 and 1989 for high grade lymphoma resistant to conventional chemotherapy. Their case notes and CXRs were reviewed in conjunction with the clinicians. In this small sample of patients, an acute interstitial pattern was seen with pulmonary oedema following bone marrow reinfusion in two cases of the 13 patients showing CXR changes (15%). Otherwise, the CXR changes following ABMT were not specific, although they did alert the clinician to the possibilities of recurrent lymphoma or opportunistic infection, enabling appropriate investigations and treatment to be instituted at an early stage. The complications and CXR changes did not differ greatly from those seen following allogeneic bone marrow transplantation.