Spectrum of atypical pulmonary manifestations of COVID-19 on computed tomography

Spontaneous tension pneumomediastinum with pneumothorax and subcutaneous emphysema as a complication of COVID-19 disease

Recently spontaneous tension pneumomediastinum (STM), were reported as infrequent complications in coronavirus disease 2019 (COVID-19) patients but pneumothorax (PT), and subcutaneous emphysema (SE) are more frequently seen in COVID-19 patients. PT and SE may present after PTM in COVID-19. The aim of this presentation is to show the complications of STM in an Iranian patients with COVID-19 disease with PT and SE, who were hospitalized in Arya hospital, Rasht, Iran. For 3 months, we followed these patients and their condition was good. STM are uncommon complications in COVID-19 patients and were reported frequently in male patients. Early diagnosis and treatment could save the patients as these complications are related to poor prognosis and prolonged hospitalization. Patients with mild COVID-19 and mild pulmonary damage may have a favorable outcome.

Necrotizing pneumonia due to Pseudomonas aeruginosa secondary to severe COVID-19 pneumonia

Necrotizing pneumonia (NP) can occur as a secondary infection even if the clinical course of COVID-19 pneumonia is favorable, particularly in patients on mechanical ventilation and under immunosuppression.

CT severity score: an imaging biomarker to estimate the severity of COVID-19 pneumonia in vaccinated and non-vaccinated population

Background

In India, two vaccines received emergent use authorization, namely Covishield (a brand of the Oxford—Astra Zeneca vaccine manufactured by the Serum institute of India) and Covaxin (developed by Bharat Biotech) against COVID-19 disease. Chest CT is an objective way to assess the extent of pulmonary parenchymal involvement. This study aims to estimate the disease severity and outcome due to COVID-19 among vaccinated and non-vaccinated symptomatic patients and compare the same in Covishield versus Covaxin recipients using CT severity score.

Results

A total of 306 patients were retrospectively evaluated. The mean age was 62.56 ± 8.9 years, and males [n-208 (67.97%)] were commonly affected. Of 306 patients, 143 were non-vaccinated (47%), 124 were partially vaccinated (40%), and 39 were completely vaccinated (13%). CT severity scores were reduced in both Covishield and Covaxin recipients in comparison with the non-vaccinated group [χ² (2) = 16.32, p < 0.001]. There is a reduction in LOS among the vaccinated group, predominantly among the Covishield recipients.

Conclusion

Vaccination confers protection from severe SARS-CoV2 infection and is associated with an overall reduction in mortality.

Atypical chest radiological features in Covid 19: Case based review

Chest imaging plays an important role in the diagnosis and management of patients with COVID-19. Some patients may have atypical lesions on chest image. Awareness about the atypical imaging features is essential to avoid misdiagnosis/delayed diagnosis. Atypical chest imaging features in COVID-19 include central involvement, peribronchovascular involvement, isolated upper lobe involvement, nodular involvement, lobar consolidation, solitary involvement, unilateral lung involvement, interstitial emphysema, pneumomediastinum, subcutaneous emphysema, pneumothorax, hydropneumothorax, mediastinal adenopathy, cavitory lesions, bulls eye sign, necrotizing pneumonia with abscess, empyema, pleural and pericardial effusion, and subpleural sparing. In patients with atypical chest imaging features, when RT-PCR test results are positive diagnosis is certain. Diagnostic difficulty may arise when RT-PCR test results are negative. In such cases a proper epidemiologic history, typical clinical features, and exclusion of other causes for a similar chest imaging features may help in diagnosis. Causes for atypical chest imaging features include early stage of the disease when lesion can be unilateral or focal or single, late stage of the disease when lesions regress, coexisting diseases/conditions, preexisting lung parenchymal diseases, fluid overload, complications like other bacterial/ fungal infection/tuberculosis/barotrauma or involvement of other organs like kidney, heart, or liver which may lead to pleural effusion. Iatrogenic trauma, barotrauma, or drug-induced immunosuppression leading to opportunistic infections can also lead to chest imaging features. Some of the CT features like cavitory lesion, mediastinal adenopathy, and pleural and pericardial effusion may be due to complications during the course of the disease or coexistent diseases. In this pictorial essay we discuss some atypical chest images with salient learning points from each case. Awareness about the atypical chest imaging features is essential to avoid misdiagnosis/delayed diagnosis. Some of the atypical features may require further evaluation/follow up and management.

Pulmonary cavitation in follow-up COVID 2019 cases: An etiological perspective

Background

The current COVID-19 pandemic is an ongoing global healthcare challenge that has caused morbidity and mortality at unprecedented levels. Since the post-COVID pulmonary complications are evolving and challenging, a study was carried out to assess pulmonary cavitation in follow-up COVID cases from an etiological perspective. The aim of this study was to assess the incidence of pulmonary cavitation and describe its etiology and evolution in moderate and severe post-COVID pneumonia patients.

Methods

A prospective observational study of all patients admitted to our institution with moderate or severe COVID pneumonia was carried out. Some of these patients again became symptomatic after discharge and developed pulmonary cavitation on imaging.

Results

6.2% (n = 37) out of 589 patients admitted to our institution with moderate or severe COVID pneumonia developed pulmonary cavitation on follow-up. We describe the imaging characteristics of post-COVID cavitation and present these patients' clinical, laboratory, and microbiological parameters.

Conclusion

Cavitary lung disease in patients with moderate to severe COVID-19 disease is not uncommon, and an etiological workup is necessary to institute timely and correct therapy.

Spontaneous tension pneumothorax as a complication of Coronavirus disease 2019: Case report and literature review

Primary spontaneous tension pneumothorax (STP) is a rare and life‐threatening condition. We report a case of COVID‐19‐pneumonia patient who developed STP as a complication. He had a prolonged hospital stay and was ultimately discharged asymptomatic. A systematic literature search was performed to review studies (N=12) reporting STP in the setting of COVID‐19.

The Presence of Either Typical or Atypical Radiological Changes Predicts Poor COVID-19 Outcomes in HIV-Positive Patients from a Multinational Observational Study: Data from Euroguidelines in Central and Eastern Europe Network Group

HIV-positive patients may present lungs with multiple infections, which may hinder differential diagnoses and the choice of treatment in the course of COVID-19, especially in countries with limited access to high-standard healthcare. Here, we aim to investigate the association between radiological changes and poor COVID-19 outcomes among HIV-positive patients from Central and Eastern Europe. Between November 2020 and May 2021, the Euroguidelines in Central and Eastern Europe Network Group started collecting observational data on HIV and COVID-19 co-infections. In total, 16 countries from Central and Eastern European submitted data (eCRF) on 557 HIV-positive patients. The current analyses included patients who had a radiological examination performed. Logistic regression models were used to identify the factors associated with death, ICU admission, and partial recovery (poor COVID-19 outcomes). Factors that were significant in the univariate models (p < 0.1) were included in the multivariate model. Radiological data were available for 224 (40.2%) patients, 108 (48.2%) had computed tomography, and 116 (51.8%) had a chest X-ray. Of these, 211 (94.2%) were diagnosed using RT-PCR tests, 212 (94.6%) were symptomatic, 123 (55.6%) were hospitalized, 37 (16.6%) required oxygen therapy, and 28 (13.1%) either died, were admitted to ICU, or only partially recovered. From the radiologist’s description, 138 (61.6%) patients had typical radiological changes, 18 (8.0%) atypical changes, and 68 (30.4%) no changes. In the univariate models, CD4 count (OR = 0.86 [95% CI: 0.76−0.98]), having a comorbidity (2.33 [1.43−3.80]), HCV and/or HBV co-infection (3.17 [1.32−7.60]), being currently employed (0.31 [0.13−0.70]), being on antiretroviral therapy (0.22 [0.08−0.63]), and having typical (3.90 [1.12−13.65]) or atypical (10.8 [2.23−52.5]) radiological changes were all significantly associated with poor COVID-19 outcomes. In the multivariate model, being on antiretroviral therapy (OR = 0.20 [95% CI:0.05−0.80]) decreased the odds of poor COVID-19 outcomes, while having a comorbidity (2.12 [1.20−3.72]) or either typical (4.23 [1.05−17.0]) or atypical (6.39 [1.03−39.7]) radiological changes (vs. no changes) increased the odds of poor COVID-19 outcomes. Among HIV patients diagnosed with symptomatic SARS-CoV-2 infection, the presence of either typical or atypical radiological COVID-19 changes independently predicted poorer outcomes.

COVID-19 and Mucormycosis Coinfection: How Challenging It Is

Recently, cases of rhinoorbital mucormycosis in people diagnosed with COVID-19 have been reported from India particularly. Diabetes mellitus though happens to be an independent risk factor both for severe COVID-19 and mucormycosis, administration of steroids is attributed as a precipitating factor for acquiring the comorbid condition. This opportunistic fungal infection is highly angioinvasive in nature because of which, clinical outcome of infection is invariably poor, especially with rhinocerebral or rhinoorbitocerebral variety of mucormycosis. However, effective management depends upon timely and accurate diagnosis and parenteral administration of amphotericin B. At the same time, judicious use of steroids is a key factor. In addition, glycemic control in those who are severely diabetic is strongly advocated. Exenteration of an eyeball may be indicated if cavernous sinus and intracranial spread are anticipated. Therefore, in order to facilitate faster healing and better penetration of antifungal drugs, surgical debridement of the paranasal sinus cavities and removal of dead tissue from the sinuses are recommended.

Cystic Lung Disease as a Sequela of Severe COVID-19: Case Series

Coronavirus disease 2019 (COVID-19) presented in December 2019 and has persisted since. The global pandemic has given rise to a novel acute disease process with a continually rapidly increasing prevalence of chronic disease and associated complications. There is minimal information on the long-term pulmonary complications of this disease. We present a series of 9 patient case reports and their respective imaging admitted with COVID-19 acute respiratory distress syndrome (ARDS) to highlight the cystic lung disease complications which may arise due to severity and disease progression. Our aim is to raise awareness of the sequela of COVID-19 ARDS, including its potentially catastrophic long-term consequences to the respiratory tract involving cystic lung disease.

Early CT features of COVID-19 pneumonia, association with patients’ age and duration of presenting complaint

Background

Coronavirus disease (COVID-19) is a respiratory syndrome with a variable degree of severity. Imaging is a vital component of disease monitoring and follow-up in coronavirus pulmonary syndromes. The study of temporal changes of CT findings of COVID-19 pneumonia can help in better understanding of disease pathogenesis and prediction of disease prognosis. In this study, we aim to determine the typical and atypical CT imaging features of COVID-19 and discuss the association of typical CT imaging features with the duration of the presenting complaint and patients’ age.

Results

The lesions showed unilateral distribution in 20% of cases and bilateral distribution in 80% of cases. The lesions involved the lower lung lobes in 30% of cases and showed diffuse involvement in 58.2% of cases. The lesions showed peripheral distribution in 74.5% of cases. The most common pattern was multifocal ground glass opacity found in 72.7% of cases. Atypical features like cavitation and pleural effusion can occur early in the disease course. There was significant association between increased number of the lesions, bilaterality, diffuse pattern of lung involvement and older age group (≥ 50 years old) and increased duration of presenting complaint (≥ 4 days). There was significant association between crazy-paving pattern and increased duration of presenting complaint. No significant association could be detected between any CT pattern and increased patient age.

Conclusion

The most common CT feature of COVID-19 was multifocal ground glass opacity. Atypical features like cavitation and pleural effusion can occur early in the course of the disease. Our cases showed more extensive lesions with bilateral and diffuse patterns of distribution in the older age group and with increased duration of presenting complaint. There was a significant association between crazy-paving pattern and increased duration of presenting complaint. No significant association could be detected between any CT pattern and increased patient age.

Pulmonary Cystic Disease Associated With COVID 19 Pneumonia: An Emerging Atypical Manifestation

Chest tomography has played an essential role during the coronavirus disease 2019 (COVID-19) pandemic since it has allowed to suspect and diagnose the disease early and to assess the severity of lung involvement, predict the disease's course, and detect the complications associated with it. Certain chest CT findings have been reported in more than 70% of reverse transcription polymerase chain reaction (RT-PCR) test-proven COVID-19 cases, including ground-glass opacities, vascular enlargement, bilateral abnormalities, lower lobe involvement, and posterior predilection. In COVID-19-endemic regions, observing these chest CT findings should raise the suspicion of a possible COVID-19 diagnosis. Rare reported CT findings in RT-PCR test-proven COVID-19 cases include pleural effusion, lymphadenopathy, tree-in-bud sign, central lesion distribution, pericardial effusion, and cavitating lung lesions. The observation of one or more of these findings suggests an alternative diagnosis, although COVID-19 cannot be excluded from the differential diagnosis. Here, we report an interesting case of a patient with no relevant history presenting a COVID-19 infection which, as a complication, presented cystic lesions; we discuss its etiology briefly.

The Multifaceted COVID-19: CT Aspects of Its Atypical Pulmonary and Abdominal Manifestations and Complications in Adults and Children. A Pictorial Review

Our daily experience in a COVID hospital has allowed us to learn about this disease in many of its changing and unusual aspects. Some of these uncommon manifestations, however, appeared more frequently than others, giving shape to a multifaceted COVID-19 disease. This pictorial review has the aim to describe the radiological aspects of atypical presentations and of some complications of COVID-19 disease in adults and children and provide a simple guide for radiologists to become familiar with the multiform aspects of this disease.

Post-COVID-19 Necrotizing Pneumonia in Patients on Invasive Mechanical Ventilation

(1) Background: Few reports of necrotizing pneumonia in patients with COVID-19 have been published. We have observed an elevated incidence at two hospitals in our city, suggesting this complication is not uncommon, and may have been overlooked. (2) Methods: This article presents a retrospective, descriptive cohort study that was undertaken from 22 March 2020 to 15 June 2021 in two tertiary care hospitals in Medellín, Colombia. All adult patients admitted to the intensive care unit (ICU) for respiratory failure related to confirmed COVID-19, on invasive mechanical ventilation (IMV), with imaging or surgical findings documenting necrotizing pneumonia (NP) were included. (3) Results: Of 936 patients with COVID-19 that required IMV, 42 (4.5%) developed NP. Overall mortality was 57% and in-hospital mortality was 71%, occurring 15–79 days after COVID-19 diagnosis. NP was diagnosed at a median of 27 days after COVID-19 symptom onset and 15.5 days after initiation of IMV. Infections were polymicrobial in 52.4% of patients. Klebsiella pneumoniae (57%) and Pseudomonas aeruginosa (33%) were the most common etiologic agents. Pulmonary embolism (PE) was documented in 13 patients overall (31%), and in 50% of patients who underwent an angioCT. Drainage and/or surgical procedures were performed on 19 patients (45.2%) with a 75% mortality rate. (4) Conclusions: In our experience, NP is a relatively common, albeit neglected, complication in mechanically ventilated COVID-19 patients, possibly originating in poorly vascularized areas of lung parenchyma. Associated mortality is high. Although drainage procedures did not seem to favorably impact patient outcomes, diagnosis and treatment were late events in the overall disease course, suggesting that early recognition and timely treatment could have a positive impact on prognosis.