Appearance and management of COVID-19 laryngo-tracheitis: two case reports

An ABC approach to cardiothoracic complications and sequelae of COVID-19: a tertiary centre experience

The Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused unprecedented challenges to healthcare professionals (HCPs) worldwide. HCPs faced an unknown disease causing many complications, including now well-established acute respiratory distress syndrome (ARDS) and pulmonary artery thromboembolic disease, and some not so well known, for instance, tracheobronchomalacia, tracheal tear or dehiscence, granulation tissue formation and pulmonary hypertension. Many of these complications require highly specialist care warranting early recognition of complications and involvement of appropriately trained professionals. Here, we review the complications and sequelae encountered at our tertiary care centre with follow-up data and potential management strategies using the A (Airway), B (Breathing), C (Circulation) approach. This will not only familiarise HCPs with the different complications of COVID-19, but also arm them with a systematic approach to these complications.

Acute laryngotracheitis caused by COVID-19: A case report and literature review

Introduction

Presentation of case

Clinical findings and investigations

Interventions and outcome

Conclusion

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A 52-year-old woman presented to the ER with a two-day history of shortness of breath and inspiratory stridor.

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The patient was admitted to the ICU for possible surgical airway. she tested positive for COVID-19 by polymerase chain reaction testing of nasopharyngeal samples.

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A regimen of ceftriaxone, nebulized racemic epinephrine, and dexamethasone was initiated.

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The patient’s symptoms started to improve over the next few days. On day 4 of hospitalization, she moved to a level 1 bed, and a week later, she was discharged

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Early diagnostic testing for SARS-Cov-2 are strongly recommended even when symptoms are not typical of COVID-19

Inflammatory Profiles of Tracheal Biopsies From SARS-CoV-2 Patients

Purpose

An increasing number of laryngotracheal complications in mechanically ventilated COVID-19 patients has been reported in the last few months. Many etiopathogenetic hypotheses were proposed but no clear explanation of these complications was identified. In this paper we evaluated the possibility that the tracheal mucosa could be a high viral replication site that could weaken the epithelium itself.

Methods

Subjects for the COVID-19 group and the control group were selected retrospectively according to specific criteria. Patients’ basic and clinical data were recorded and analyzed. Tracheal samples of both groups were collected during surgical tracheostomies and then analyzed from a histological and genetic-transcriptional point of view.

Results

Four COVID-19 patients were enrolled in this study and compared with four non-COVID-19 patients. No laryngotracheal complications were identified in both groups. The SARS-CoV-2 was detected in one out of four COVID-19 samples. A subepithelial inflammatory lymphomonocyte infiltrate was observed in all patients but two cases of the COVID-19 group showed vasculitis of small subepithelial vessels associated with foci of coagulative necrosis. Two gene sets (HALLMARK_INFLAMMATORY_RESPONSE and HALLMARK_ESTROGEN_RESPONSE_LATE) were significantly deregulated in COVID-19 patients compared to the control group.

Conclusion

The altered inflammatory response of the COVID-19 patients could be another possible explanation of the increasing number of laryngotracheal complications.

Histological findings of tracheal samples from COVID-19 positive critically ill mechanically ventilated patients

Objectives

This study examines the histological findings of tracheal tissue samples obtained from COVID‐19 positive mechanically ventilated patients, to assess the degree of tracheal inflammation/ulceration present.

Design and participants

Retrospective single‐centre observational cohort study. All patients admitted to Adult Intensive Care Unit (AICU) with COVID‐19 infection, requiring mechanical ventilation and surgical tracheostomy between 1 April and 1 May 2020, were included (Group 1). Tracheal windows excised at tracheostomy underwent histological analysis. Comparison was made with: tracheal windows from COVID‐19 positive AICU ventilated patients admitted between 1 January and 1 March 2021 (Group 2); tracheal windows from COVID‐19 negative AICU ventilated patients (Group 3); and, tracheal autopsy samples from COVID‐19 positive patients that died without undergoing prolonged mechanical ventilation (Group 4).

Results

Group 1 demonstrated mild/moderate inflammation (tracheitis) in nearly all samples (15/16, 93.8%), with infrequent micro‐ulceration (2/16, 12.5%). Group 2 demonstrated similar mild/moderate inflammation in all samples (17/17, 100%), with no ulceration. Histological findings of Groups 1 and 2 COVID‐19 positive patients were similar to Group 3 COVID‐19 negative patients, which demonstrated mild/moderate inflammation (5/5, 100%), with uncommon superficial erosion (1/5, 20%). Group 4 demonstrated mild chronic inflammation or no significant inflammation, with uncommon micro‐ulceration (1/4, 25%).

Conclusions

Severe tracheal inflammation was not demonstrated in mechanically ventilated COVID‐19 positive patients at the level of the second/third tracheal rings, at the stage of disease patients underwent tracheostomy. Histological findings were similar between mechanically ventilated COVID‐19 positive and negative patients. Tracheal ulceration may be a feature of early or severe COVID‐19 disease.

Biology and Pathogenesis of SARS-CoV-2: Understandings for Therapeutic Developments against COVID-19

Coronaviruses are positive sense, single-stranded, enveloped, and non-segmented RNA viruses that belong to the Coronaviridae family within the order Nidovirales and suborder Coronavirinae. Two Alphacoronavirus strains: HCoV-229E and HCoV-NL63 and five Betacoronaviruses: HCoV-HKU1, HCoV-OC43, SARS-CoV, MERS-CoV, and SARS-CoV-2 have so far been recognized as Human Coronaviruses (HCoVs). Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is currently the greatest concern for humanity. Despite the overflow of research on SARS-CoV-2 and other HCoVs published every week, existing knowledge in this area is insufficient for the complete understanding of the viruses and the diseases caused by them. This review is based on the analysis of 210 published works, and it attempts to cover the basic biology of coronaviruses, including the genetic characteristics, life cycle, and host-pathogen interaction, pathogenesis, the antiviral drugs, and vaccines against HCoVs, especially focusing on SARS-CoV-2. Furthermore, we will briefly discuss the potential link between extracellular vesicles (EVs) and SARS-CoV-2/COVID-19 pathophysiology.

Croup Is One of the Clinical Manifestations of Novel Coronavirus in Children

The manifestations of novel coronavirus are diverse and can manifest through respiratory, gastrointestinal, and even nervous symptoms. Respiratory involvement is usually an upper tract infection or pneumonia but can also present as other forms of pulmonary disorders. A 3-year-old boy presented with cough, hoarseness, and stridor. He was treated with dexamethasone and nebulized adrenaline and a clinical diagnosis of croup was established. After treatment, his symptoms improved for a short time, but suddenly cough exacerbated and was accompanied by respiratory failure and seizures. He was then intubated and mechanically ventilated. Because of the coronavirus epidemic, Reverse-Transcription Polymerase Chain Reaction (RT-PCR) assay was taken from the pharyngeal secretions and was positive. The child was isolated. Due to excessive respiratory secretions and worsening of the general condition, bronchoscopy was performed depicting an image compatible with bacterial tracheitis. He was treated with broad-spectrum antibiotics, antivirals, and supportive care. Finally, after 4 weeks of treatment, the child was discharged in good general condition. Croup is one of the respiratory symptoms of novel coronavirus and can be a risk factor for bacterial tracheitis. Therefore, the presence of clinical manifestations of croup indicates the need for coronavirus PCR testing.

SARS-CoV-2: Pathogenic Mechanisms and Host Immune Response

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped, positive-sense RNA coronavirus responsible for the COVID-19 pandemic. Since December 2019, coronavirus disease 2019 (COVID-19) has affected more than 127 million people, 2.7 million deaths globally (as per WHO dashboard, dated 31 March, 2020), the virus is capable of transmitting from human to human via inhalation of infected respiratory droplets or aerosols or contact with infected fomites. Clinically, patients with COVID-19 present with severe respiratory distress syndrome, which is very similar to the presentation of other respiratory viral infections. A huge variation in the host response exists, with the resulting symptoms varying from mild to moderate. Comorbidities such as cardiovascular disease, hypertension, diabetes, coagulation dysfunction, stroke, malignant tumor and multiple organ dysfunction syndrome, as well as age and sex, are associated with severe COVID-19 cases. So far, no targeted therapies have been developed to treat this disease and existing drugs are being investigated for repurposing. This chapter discusses the epidemiology, clinical features of COVID-19, pathogenesis and the innate and adaptive immune response mounted by the host to the SARS-CoV-2 infection. A deeper understanding of the host-pathogen interaction is fundamental to the development of a vaccine.

Plant Sources Responsible for the Chemical Composition and Main Bioactive Properties of Poplar-Type Propolis

Propolis is a resinous mixture, made by the honeybees from substances collected from tree or other plant buds, plant exudates, or resins found in the stem, branches, or leaves of different plants. The geographical origin of propolis is given by plant sources from respective areas. Different studies have classified this bee product according to the vegetal material from the same areas. Poplar-type propolis has the widest spread in the world, in the temperate zones from Europe, Asia, or North America. The name is given by the main plant source from where the bees are collecting the resins, although other vegetal sources are present in the mentioned areas. Different Pinus spp., Prunus spp., Acacia spp. and also Betula pendula, Aesculus hippocastanum, and Salix alba are important sources of resins for "poplar-type" propolis. The aim of this review is to identify the vegetal material's chemical composition and activities of plant resins and balms used by the bees to produce poplar-type propolis and to compare it with the final product from similar geographical regions. The relevance of this review is to find the similarities between the chemical composition and properties of plant sources and propolis. The latest determination methods of bioactive compounds from plants and propolis are also reviewed.

Host-pathogen interaction in COVID-19: Pathogenesis, potential therapeutics and vaccination strategies

The current coronavirus pandemic, COVID-19, is the third outbreak of disease caused by the coronavirus family, after Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome. It is an acute infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This severe disease is characterised by acute respiratory distress syndrome, septic shock, metabolic acidosis, coagulation dysfunction, and multiple organ dysfunction syndromes. Currently, no drugs or vaccines exist against the disease and the only course of treatment is symptom management involving mechanical ventilation, immune suppressants, and repurposed drugs. The severe form of the disease has a relatively high mortality rate. The last six months have seen an explosion of information related to the host receptors, virus transmission, virus structure-function relationships, pathophysiology, co-morbidities, immune response, treatment and the most promising vaccines. This review takes a critically comprehensive look at various aspects of the host-pathogen interaction in COVID-19. We examine the genomic aspects of SARS-CoV-2, modulation of innate and adaptive immunity, complement-triggered microangiopathy, and host transmission modalities. We also examine its pathophysiological impact during pregnancy, in addition to emphasizing various gaps in our knowledge. The lessons learnt from various clinical trials involving repurposed drugs have been summarised. We also highlight the rationale and likely success of the most promising vaccine candidates.