Pleural effusion as an indicator for the poor prognosis of COVID-19 patients

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.

Pleural Disease in Acute COVID-19 Pneumonia: A Single Center Retrospective Cohort Study

BACKGROUND

Pleural diseases encompass pleural effusion and pneumothorax (PTX), both of which were uncommon in coronavirus disease of 2019 (COVID-19). We aimed to describe the frequency, characteristics, and main outcomes of these conditions in patients with COVID-19 pneumonia.

METHODS

We performed a retrospective cohort analysis of inpatients with COVID-19 pneumonia between January 1, 2020 and January 1, 2022, at Beth Israel Deaconess Medical Center in Boston, Massachusetts.

RESULTS

Among 4419 inpatients with COVID-19 pneumonia, 109 (2.5%) had concurrent pleural disease. Ninety-four (2.1%) had pleural effusion (50% seen on admission) and 15 (0.3%) had PTX, both with higher rates of underlying conditions such as heart failure, liver disease, kidney disease, and malignancy. A total of 28 (30%) pleural effusions were drained resulting in 32% being exudative, 43% pseudoexudative, and 25% transudative. Regarding PTX, 5 (33%) were spontaneous and 10 (67%) were due to barotrauma while on mechanical ventilation. We found that the presence of underlying lung disease was not associated with an increased risk of developing PTX. In addition, patients with pleural disease had a higher incidence of severe or critical illness as represented by intensive care unit admission and intubation, longer hospital and intensive care unit stay, and a higher mortality rate as compared with patients without the pleural disease.

CONCLUSION

Pleural effusions and pneumothoraces are infrequent findings in patients admitted due to COVID-19 pneumonia, worsened outcomes in these patients likely reflect an interplay between the severity of inflammation and parenchymal injury due to COVID-19 disease and underlying comorbidities.

Post-acute sequelae of COVID-19 in older persons: multi-organ complications and mortality

INTRODUCTION

Evidence on long-term associations between coronavirus disease 2019 (COVID-19) and risks of multi-organ complications and mortality in older population is limited. This study evaluates these associations.

RESEARCH DESIGN AND METHODS

The cohorts included patients aged ≥60 year diagnosed with COVID-19 infection (cases), between 16 March 2020 and 31 May 2021 from the UK Biobank; and between 01 April 2020 and 31 May 2022 from the electronic health records in Hong Kong. Each patient was randomly matched with individuals without COVID-19 infection based on year of birth and sex and were followed for up to 18 months until 31 August 2021 for UKB, and up to 28 months until 15 August 2022 for HK cohort. Patients with COVID-19 infection over 6 months after the date of last dose of vaccination and their corresponding controls were excluded from our study. Characteristics between cohorts were further adjusted with Inverse Probability Treatment Weighting. For evaluating long-term association of COVID-19 with multi-organ disease complications and mortality after 21-days of diagnosis, Cox regression was employed.

RESULT

10,759 (UKB) and 165,259 (HK) older adults with COVID-19 infection with matched 291,077 (UKB) and 1,100,394 (HK) non-COVID-19-diagnosed older adults were recruited. Older adults with COVID-19 were associated with a significantly higher risk of cardiovascular outcomes [major cardiovascular disease (stroke, heart failure and coronary heart disease): hazard ratio(UKB): 1.4 (95% Confidence interval: 1.1,1.6), HK:1.2 (95% CI: 1.1,1.3)]; myocardial infarction: HR(UKB): 1.8 (95% CI: 1.3,2.4), HK:1.2 (95% CI: 1.0,1.4)]; respiratory outcomes [interstitial lung disease: HR(UKB: 3.4 (95% CI: 2.5,4.5), HK: 4.0 (95% CI: 1.3,12.8); chronic pulmonary disease: HR(UKB): 1.7 (95% CI: 1.3,2.2), HK:1.6 (95% CI: 1.3,2.1)]; neuropsychiatric outcomes [seizure: HR(UKB): 2.6 (95% CI: 1.7,4.1), HK: 1.6 (95% CI: 1.2,2.1)]; and renal outcomes [acute kidney disease: HR(UKB): 1.4 (95% CI: 1.1,1.6), HK:1.6 (95% CI: 1.3,2.1)]; and all-cause mortality [HR(UKB): 4.9 (95% CI: 4.4,5.4), HK:2.5 (95% CI: 2.5,2.6)].

CONCLUSION

COVID-19 is associated with long-term risks of multi-organ complications in older adults (aged ≥ 60). Infected patients in this age-group may benefit from appropriate monitoring of signs/symptoms for developing these complications.

A Possible Association Between COVID-19 Vaccine and Complicated Pleural Effusion: A Case Report

As COVID-19 vaccines gain more prevalence, previously unrecognized side effects continue to be reported. We report a case of 78 male with no significant past medical history who was found to have a unilateral pleural effusion with symptoms that started two days after the administration of a COVID-19 vaccine. The initial presumption was bacterial pneumonia with parapneumonic effusion. However, the lack of clinical response prompted surgical intervention, and a diagnosis of empyema was established. No evidence of infectious etiology was found. This case helps to support the previously limited evidence in the recent medical literature that suggests a possible association between COVID-19 vaccines and pleurisy/effusion.

Unilateral Pleural Effusion after Third Dose of BNT162b2 mRNA Vaccination: Case Report

Vaccination remains the best strategy against coronavirus disease 2019 (COVID-19) in terms of prevention. The efficacy and safety of COVID-19 vaccines is supported by well-designed clinical trials that recruited many participants. It is well-known that vaccination is associated with local side effects related to the injection site, and mild, systemic side effects. However, there has been an increase in the occurrence of what is known as infrequent adverse effects in the population of vaccinated individuals in real life. We present the case of a 46-year-old woman with no past medical history, who presented with a sharp chest pain with deep inspiration, a few days after receiving the third dose of the Pfizer-BioNTech COVID-19 mRNA vaccine (BNT162b2). There is an association between the BNT16b2 vaccination and myocarditis, pericarditis, and even bilateral pleural effusions. To the best of our knowledge, this is the first report featuring a unilateral pleural effusion in a patient with no known past medical history, who did not develop cardiac involvement nor have any viral infection. The aim of our report is to inform health professionals of the possibility of encountering this rare adverse event in their daily practice, as the population of individuals who are receiving additional vaccine doses is increasing steadily.

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.

Proteomic Analysis of Pleural Effusions from COVID-19 Deceased Patients: Enhanced Inflammatory Markers

Critically ill COVID-19 patients with pleural effusion experience longer hospitalization, multisystem inflammatory syndrome, and higher rates of mortality. Generally, pleural effusion can serve as a diagnostic value to differentiate cytokine levels. This study aimed to evaluate the pleural effusions of COVID-19 deceased patients for 182 protein markers. Olink^® Inflammation and Organ Damage panels were used to determine the level of 184 protein markers, e.g., ADA, BTC, CA12, CAPG, CD40, CDCP1, CXCL9, ENTPD2, Flt3L, IL-6, IL-8, LRP1, OSM, PD-L1, PTN, STX8, and VEGFA, which were raised significantly in COVID-19 deceased patients, showing over-stimulation of the immune system and ravaging cytokine storm. The rises of DPP6 and EDIL3 also indicate damage caused to arterial and cardiovascular organs. Overall, this study confirms the elevated levels of CA12, CD40, IL-6, IL-8, PD-L1, and VEGFA, proposing their potential either as biomarkers for the severity and prognosis of the disease or as targets for therapy. Particularly, this study reports upregulated ADA, BTC, DPP6, EDIL3, LIF, ENTPD2, Flt3L, and LRP1 in severe COVID-19 patients for the first time. Pearson's correlation coefficient analysis indicates the involvement of JAK/STAT pathways as a core regulator of hyperinflammation in deceased COVID-19 patients, suggesting the application of JAK inhibitors as a potential efficient treatment.

Homogeneous ensemble models for predicting infection levels and mortality of COVID-19 patients: Evidence from China

Background

Persistence of long-term COVID-19 pandemic is putting high pressure on healthcare services worldwide for several years. This article aims to establish models to predict infection levels and mortality of COVID-19 patients in China.

Methods

Machine learning models and deep learning models have been built based on the clinical features of COVID-19 patients. The best models are selected by area under the receiver operating characteristic curve (AUC) scores to construct two homogeneous ensemble models for predicting infection levels and mortality, respectively. The first-hand clinical data of 760 patients are collected from Zhongnan Hospital of Wuhan University between 3 January and 8 March 2020. We preprocess data with cleaning, imputation, and normalization.

Results

Our models obtain AUC = 0.7059 and Recall (Weighted avg) = 0.7248 in predicting infection level, while AUC=0.8436 and Recall (Weighted avg) = 0.8486 in predicting mortality ratio. This study also identifies two sets of essential clinical features. One is C-reactive protein (CRP) or high sensitivity C-reactive protein (hs-CRP) and the other is chest tightness, age, and pleural effusion.

Conclusions

Two homogeneous ensemble models are proposed to predict infection levels and mortality of COVID-19 patients in China. New findings of clinical features for benefiting the machine learning models are reported. The evaluation of an actual dataset collected from January 3 to March 8, 2020 demonstrates the effectiveness of the models by comparing them with state-of-the-art models in prediction.

Can Lung Ultrasound Be the Ideal Monitoring Tool to Predict the Clinical Outcome of Mechanically Ventilated COVID-19 Patients? An Observational Study

Background: During the COVID-19 pandemic, lung ultrasound (LUS) has been widely used since it can be performed at the patient’s bedside, does not produce ionizing radiation, and is sufficiently accurate. The LUS score allows for quantifying lung involvement; however, its clinical prognostic role is still controversial. Methods: A retrospective observational study on 103 COVID-19 patients with respiratory failure that were assessed with an LUS score at intensive care unit (ICU) admission and discharge in a tertiary university COVID-19 referral center. Results: The deceased patients had a higher LUS score at admission than the survivors (25.7 vs. 23.5; p-value = 0.02; cut-off value of 25; Odds Ratio (OR) 1.1; Interquartile Range (IQR) 1.0−1.2). The predictive regression model shows that the value of LUSt0 (OR 1.1; IQR 1.0–1.3), age (OR 1.1; IQR 1.0−1.2), sex (OR 0.7; IQR 0.2−3.6), and days in spontaneous breathing (OR 0.2; IQR 0.1–0.5) predict the risk of death for COVID-19 patients (Area under the Curve (AUC) 0.92). Furthermore, the surviving patients showed a significantly lower difference between LUS scores at admission and discharge (mean difference of 1.75, p-value = 0.03). Conclusion: Upon entry into the ICU, the LUS score may play a prognostic role in COVID-19 patients with ARDS. Furthermore, employing the LUS score as a monitoring tool allows for evaluating the patients with a higher probability of survival.

Extrapulmonary CT Findings Predict In-Hospital Mortality in COVID-19. A Systematic Review and Meta-Analysis

RATIONALE AND OBJECTIVES

Several prognostic factors have been identified for COVID-19 disease. Our aim was to elucidate the influence of non-pulmonary findings of thoracic computed tomography (CT) on unfavorable outcomes and in-hospital mortality in COVID-19 patients based on a large patient sample.

MATERIALS AND METHODS

MEDLINE library, Cochrane and SCOPUS databases were screened for the associations between CT-defined features and mortality in COVID-19 patients up to June 2021. In total, 22 studies were suitable for the analysis, and included into the present analysis. Overall, data regarding 4 extrapulmonary findings could be pooled: pleural effusion, pericardial effusion, mediastinal lymphadenopathy, and coronary calcification.

RESULTS

The included studies comprised 7859 patients. The pooled odds ratios for the effect of the identified extrapulmonary findings on in-hospital mortality are as follows: pleural effusion, 4.60 (95% CI 2.97-7.12); pericardial effusion, 1.29 (95% CI 0.83-1.98); coronary calcification, 2.68 (95% CI 1.78-4.04); mediastinal lymphadenopathy, 2.02 (95% CI 1.18-3.45).

CONCLUSION

Pleural effusion, mediastinal lymphadenopathy and coronary calcification have a relevant association with in-hospital mortality in COVID-19 patients and should be included as prognostic biomarker into clinical routine.

Prevalence and clinical outcomes of pleural effusion in COVID-19 patients: A systematic review and meta-analysis

Observational studies indicate that pleural effusion has an association with risk and the clinical prognosis of COVID-19 disease; however, the available literature on this area is inconsistent. The objective of this systematic review and meta-analysis is to evaluate the correlation between COVID-19 disease and pleural effusion. A rigorous literature search was conducted using multiple databases. All eligible observational studies were included from around the globe. The pooled prevalence and associated 95% confidence interval (CI) were calculated using the random effect model. Mantel-Haenszel odds ratios were produced to report overall effect size using random effect models for severity and mortality outcomes. Funnel plots, Egger regression tests, and Begg-Mazumdar's rank correlation test were used to appraise publication bias. Data from 23 studies including 6234 COVID-19 patients was obtained. The overall prevalence of pleural effusion in COVID-19 patients was 9.55% (95% CI, I2  = 92%). Our findings also indicated that the presence of pleural effusions associated with increased risk of severity of disease(OR = 5.08, 95% CI 3.14-8.22, I2  = 77.4%) and mortality due to illness(OR = 4.53, 95% CI 2.16-9.49, I2  = 66%) compared with patients without pleural effusion. Sensitivity analyses illustrated a similar effect size while decreasing the heterogeneity. No significant publication bias was evident in the meta-analysis. The presence of pleural effusion can assist as a prognostic factor to evaluate the risk of worse outcomes in COVID-19 patients hence, it is recommended that hospitalized COVID-19 patients with pleural effusion should be managed on an early basis.

Time to hospitalisation, CT pulmonary involvement and in-hospital death in COVID-19 patients in an Emergency Medicine Unit

BACKGROUND

Patients with coronavirus disease 2019 (COVID-19) are often treated at home given the limited healthcare resources. Many patients may have sudden clinical worsening and may be already compromised at hospitalisation. We investigated the burden of lung involvement according to the time to hospitalisation.

METHODS

In this observational cohort study, 55 consecutive COVID-19-related pneumonia patients were admitted to the Emergency Medicine Unit. Groups of lung involvement at computed tomography were classified as follows: 0 (<5%), 1 (5%-25%), 2 (26%-50%), 3 (51%-75%) and 4 (>75%). We also investigated in-hospital death and the predictive value of Yan-XGBoost model and PREDI-CO scores for death.

RESULTS

The median age was 74 years and 34 were men. Time to admission increased from 2 days in group 0 to 8.5-9 days in groups 3 and 4. A progressive increase in LDH, CRP and d-dimer was found across groups, while a decrease of lymphocytes paO₂ /FiO₂ ratio and SpO₂ was found. Ten (18.2%) patients died during the in-hospital staying. Patients who died were older, with a trend to lower lymphocytes, a higher d-dimer, creatine phosphokinase and troponin T. The Yan-XGBoost model did not accurately predict in-hospital death with an AUC of 0.57 (95% confidence interval [CI] 0.37-0.76), which improved after the addition of the lung involvement groups (AUC 0.68, 95%CI 0.45-0.90). Conversely, a good predictive value was found for the original PREDI-CO score with an AUC of 0.76 (95% CI 0.58-0.93) which remained similar after the addition of the lung involvement (AUC 0.76, 95% CI 0.57-0.94).

CONCLUSION

We found that delayed hospital admission is associated with higher lung involvement. Hence, our data suggest that patients at risk for more severe disease, such as those with high LDH, CRP and d-dimer, should be promptly referred to hospital care.

Chest CT performance and features of COVID-19 in the region of Abu Dhabi, UAE: a single institute study

Objective

We aim to investigate high-resolution CT features of COVID-19 infection in Abu Dhabi, UAE, and to compare the diagnostic performance of CT scan with RT-PCR test.

Methods

Data of consecutive patients who were suspected to have COVID-19 infection and presented to our hospital were collected from March 2, 2020, until April 12, 2020. All patients underwent RT-PCR test; out of which 53.8% had chest CT scan done. Using RT-PCR as a standard reference, the sensitivity and specificity of the CT scan were calculated. We also analyzed the most common imaging findings in patients with positive RT-PCR results.

Results

The typical HRCT findings were seen in 50 scans (65.8%) out of total positive ones; 44 (77.2%) with positive RT-PCR results and 6 (31.6%) with negative results. The peripheral disease distribution was seen in 86%, multilobe involvement in 70%, bilateral in 82%, and posterior in 82% of the 50 scans. The ground glass opacities were seen in 50/74 (89.3%) of the positive RT-PCR group. The recognized GGO patterns in these scans were: rounded 50%, linear 38%, and crazy-paving 24%. Using RT-PCR as a standard of reference, chest HRCT scan revealed a sensitivity of 68.8% and specificity of 70%.

Conclusion

The commonest HRCT findings in patients with COVID-19 pneumonia were peripheral, posterior, bilateral, multilobe rounded ground-glass opacities. The performance of HRCT scan can vary depending on multiple factors.