Lung ultrasound as a tool for monitoring the interstitial changes in recently hospitalised patients with COVID-19 pneumonia - The COVIDLUS study

Background Long-term respiratory effects can occur after COVID-19 pneumonia (CP). The COVID Lung Ultrasound Study (COVIDLUS) aimed to investigate the utility of serial lung ultrasound (LUS) to track functional and physiological recovery after hospitalisation in patients with CP. Methods Between April 2021 and April 2022, 21 patients were recruited at discharge (D0). LUS was performed on D0, day 41 (D41) and day 83 (D83). CT Thorax was performed on D83. Lymphocyte count, Ferritin, Lactate Dehydrogenase, Troponin, CRP, and D-dimers were measured at D0, D41 and D83. 6 minute walking test (6MWT) was performed on D83 and quality of life questionnaires and spirometry completed on D41 and D83. Results 19 subjects completed the study (10 males [52%]; mean age: 52 years [range:37-74]). 1 patient died. LUS scores were significantly higher at D0, compared to D41 and D83 (Mean score:10.9 [D0]/2.8 [D41]/1.5 [D83]; p < 0.0001). LUS scores correlated poorly with CT at D83 (Pearson r² = 0.28). Mean lymphocyte counts were lower at D0 but increased at D41 and D83. Mean serum Ferritin was significantly lower at D41 and D83, as compared to D0. The mean 6MWT distance was 385 m (130-540 m). Quality of life measures did not differ at D41 and D83. Lung function increased between D41 and D83 with mean increase in FEV₁ and FVC of 160 ml and 190 ml respectively. Conclusion LUS can monitor the early recovery of lung interstitial changes from CP. The utility of LUS to predict development of subsequent lung fibrosis post-COVID deserves further study.

Clinical and molecular aspects of glucocorticoid resistant asthma

This paper is an overview of the diagnosis, differential diagnosis and cellular and molecular mechanisms of glucocorticoid resistant asthma. It addresses the clinical definition and rationale for the diagnosis of therapy resistant asthma. It purports that, since glucocorticoid resistant asthmatics are not globally physiologically glucocorticoid resistant, then the phenomenon is most likely acquired, probably in immune cells (and most probably in T cells and monocyte/macrophages), as a result of local inflammatory and environmental influences. The molecular mechanisms which have been uncovered to date which could account for glucocorticoid resistance are discussed, in particular the roles of AP-1 and p38 MAP kinase signaling, the role of the beta-isoform of the glucocorticoid receptor and the role of histone proteins and DNA folding. Finally, there are suggestions for clinical management of these patients based on accumulated evidence.

Do Expandable Metallic Airway Stents Have a Role in the Management of Patients With Benign Tracheobronchial Disease?

BACKGROUND

With increasing availability many centers are deploying expandable metallic stents to manage patients with diverse endobronchial disorders. Although these devices have an important role in malignant disease their usefulness in benign large airway disorders is less defined.

METHODS

Between 1997 and 2005, 31 patients aged 34 to 83 years with benign large airway compromise secondary to tracheomalacia (n = 7), posttracheostomy stricture (n = 8), posttracheostomy rupture (n = 2), postpneumonectomy bronchopleural fistula (n = 2), stricture after lung transplantation (n = 3), lobectomy, tuberculosis, traumatic injury to right main bronchus (n = 1 patient each), and external compression of the airway secondary to achalasia, multinodular goiter, aortic aneurysm, right brachiocephalic artery aneurysm, right interrupted aortic arch, and dissecting aneurysm (n = 1 patient each) who were medically unfit for formal surgical intervention were treated by Ultraflex stent deployment. The range of follow-up was 1 week to 96 months. Stents were deployed under anesthesia using rigid bronchoscopy.

RESULTS

Complications included granulation tissue formation (n = 11) treated with Nd: YAG laser ablation, stent migration (n = 1; stent removed, another deployed), metal fatigue (n = 1), stent removal (n = 1), mucus plugging (n = 2), and halitosis (n = 6) difficult to treat despite antibiotics. Thirteen patients died of unrelated causes between 1 week and 15 months after stent deployment.

CONCLUSIONS

Endobronchial metallic stents should be considered only for selected patients with large airway compromise secondary to benign airway diseases for whom other medical comorbidities contraindicate formal airway surgery. Once deployed, they are difficult to remove, are associated with significant complications, and require prospective bronchoscopic surveillance and often further therapeutic intervention.

Systemic glucocorticoid reduces bronchial mucosal activation of activator protein 1 components in glucocorticoid-sensitive but not glucocorticoid-resistant asthmatic patients

BACKGROUND

Overexpression of the transcriptional regulatory factor activator protein 1 might contribute to T-cell glucocorticoid (GC) refractoriness in GC-resistant asthma.

OBJECTIVE

We sought to address the hypothesis that clinically GC-resistant asthma is accompanied by failure of systemic GCs to inhibit phosphorylation of c-jun and c-jun N-terminal kinase (JNK) in bronchial mucosal cells.

METHODS

We performed enumeration of total (CD45+) leukocytes and cells expressing c-fos and total and phosphorylated c-jun and JNK in bronchial biopsy sections from 9 GC-sensitive and 17 GC-resistant asthmatic patients taken before and after oral prednisolone (40 mg/1.72 m(2) body surface area daily for 14 days) using specific antibodies, immunohistochemistry, and image analysis.

RESULTS

At baseline, mean total (CD45+) mucosal leukocytes, total cells expressing phosphorylated c-jun and JNK, and mean percentages of cells in which these molecules were phosphorylated were similar in both groups, whereas mean total numbers of c-fos-immunoreactive cells were increased in the GC-resistant asthmatic subjects (P = .04). After prednisolone, the mean total cells expressing phosphorylated c-jun and JNK and the mean percentages of cells in which these molecules were phosphorylated were significantly reduced in the GC-sensitive (P < or = .02) but not the GC-resistant asthmatic subjects. Mean total CD45+ leukocytes and c-fos-immunoreactive cells were not significantly altered in either group.

CONCLUSION

Clinical GC responsiveness in asthma is accompanied by reduced phosphorylation of bronchial mucosal c-jun and JNK, a phenomenon not seen in resistant patients.

CLINICAL IMPLICATIONS

Dysregulation of activator protein 1 activation leading to clinical GC resistance might reflect identifiable environmental influences and is a target for future therapy.

A potential role for sildenafil in the management of pulmonary hypertension in patients with parenchymal lung disease

BACKGROUND

Sildenafil offers potential to treat patients with pulmonary hypertension by selectively inhibiting phosphodiesterase type five pathways in the lung. It is recommended for selected patients with pulmonary arterial hypertension, but its role in the management of pulmonary hypertension associated with parenchymal lung disease is unclear.

PATIENTS AND METHODS

Seven patients (68-86 years) with end stage chronic obstructive pulmonary disease (COPD, 4) and idiopathic pulmonary fibrosis (IPF, 3) were referred to our unit. All patients had a long-term history of chronic lung disease and were on maximal appropriate therapy prescribed by their referring pulmonologist. Thromboembolic disease was excluded by pulmonary angiography and all patients had had high resolution thoracic CT scan. At assessment right heart catheterisation, 2D echocardiography and 6-min walk test were performed prior to commencement of sildenafil 50mg tds. Their medication was otherwise unchanged. After 8 weeks treatment, right heart catheterisation, 2D echocardiography and 6-min walk test were repeated.

RESULTS

The pulmonary vascular resistance was reduced in six patients (from 13, 3, 3, 6.5, 3.5 and 10.5 wood units to 9.7, 2.5, 2.8, 4.4, 2.5 and 5.4 wood units, respectively). Six-minute walk test increased in six patients (from 110 m, 210 m, 80 m, 30 m, 210 m and 80 m to 130 m, 312 m, 120 m, 82 m, 244 m and 100 m, respectively). One patient with COPD did not demonstrate a favourable response although their cardiac output increased on sildenafil therapy. 2D echocardiography showed a reduction in estimated PA pressure in six patients with an improvement in right ventricular systolic function in two COPD patients.

CONCLUSION

Our results suggest that sildenafil may have a role for selected patients with COPD and IPF who have pulmonary hypertension.

Reversing the defective induction of IL-10-secreting regulatory T cells in glucocorticoid-resistant asthma patients

We previously reported that human CD4+ Tregs secrete high levels of IL-10 when stimulated in the presence of dexamethasone and calcitriol (vitamin D3). We now show that following stimulation by allergen, IL-10-secreting Tregs inhibit cytokine secretion by allergen-specific Th2 cells in an IL-10-dependent manner. A proportion of patients with severe asthma fail to demonstrate clinical improvement upon glucocorticoid therapy, and their asthma is characterized as glucocorticoid resistant (SR, abbreviation derived from "steroid resistant"). Dexamethasone does not enhance secretion of IL-10 by their CD4+ T cells. Addition of vitamin D3 with dexamethasone to cultures of SR CD4+ T cells enhanced IL-10 synthesis to levels observed in cells from glucocorticoid-sensitive patients cultured with dexamethasone alone. Furthermore, pretreatment with IL-10 fully restored IL-10 synthesis in these cells in response to dexamethasone. Vitamin D3 significantly overcame the inhibition of glucocorticoid-receptor expression by dexamethasone while IL-10 upregulated glucocorticoid-receptor expression by CD4+ T cells, suggesting potential mechanisms whereby these treatments may overcome poor glucocorticoid responsiveness. We show here that administration of vitamin D3 to healthy individuals and SR asthmatic patients enhanced subsequent responsiveness to dexamethasone for induction of IL-10. This strongly suggests that vitamin D3 could potentially increase the therapeutic response to glucocorticoids in SR patients.

Glucocorticoid-resistant asthma

Glucocorticoids are currently the most effective anti-inflammatory therapy for asthma. However, a small subset of asthma sufferers do not respond to clinically relevant doses of glucocorticoids and are termed "glucocorticoid resistant." These patients are characterized by increased bronchial hyperreactivity, lower morning peak expiratory flow rates, and a longer total duration of symptoms. The definition of glucocorticoid resistance is arbitrary, and a dosage and duration of oral glucocorticoid therapy that represent a completely adequate therapeutic trial have yet to be established. For research purposes, glucocorticoid-resistant asthma is defined on the basis of a lack of improvement in airway obstruction (FEV1) following a 2-week course of oral glucocorticoid therapy. Glucocorticoid resistance is associated with in vivo and in vitro alterations in cellular responses to exogenous glucocorticoids. We have implicated abnormal regulation of the activator protein I in the molecular mechanism of glucocorticoid resistance, a phenomenon that may be confined to T cells and monocytes. The identification of an alternatively spliced isoform of the glucocorticoid receptor (GR beta) has sparked interest in the functional role of this isoform and its potential involvement in the pathology of glucocorticoid resistance. Alternative therapies for this condition will have to await a better understanding of the mechanisms of glucocorticoid action.

Adult adrenal haemorrhage: an unrecognised complication of renal vein thrombosis

There are many predisposing factors for neonatal adrenal haemorrhage but the causative factors are different in adults. Several cases of neonatal adrenal haemorrhage have been reported in association with renal vein thrombosis. This complication has not been documented in the adults. The presence of an adrenal mass in the setting of renal vein thrombosis should raise the possibility of adrenal haemorrhage even though this is extremely uncommon in adults.

Sporadic bilateral adrenal medullary hyperplasia: apparent false positive MIBG scan and expected MRI findings

Adrenal medullary hyperplasia is a rare cause of clinical symptoms and biochemical findings identical to pheochromocytoma occurring mostly in multiple endocrine neoplasia patients. The scenario of positive MIBG scan, but no focal lesion found on CT and MRI led to diagnostic and management difficulties. Like pheochromocytoma, surgical excision can lead to clinical and biochemical recovery. We report this unusual case of sporadic bilateral adrenal medullary hyperplasia, with hypertension and biochemical abnormalities alleviated after surgical adrenalectomy. Based on T2 values reported in literature, high signal focal lesions may not appear on T2-weighted MRI images until development of frank pheochromocytoma. MIBG scan remains the most sensitive imaging modality for this condition.

Angiomatosis of the hand demonstrated by contrast-enhanced magnetic resonance angiogram

Contrast-enhanced digital subtraction dynamic MR angiography has been applied to lower limb arteries, with accuracy comparable to that of conventional angiography. Application of this technique to hands has not been reported. A 2-year-old girl with a diffuse haemangioma of the right hand elegantly demonstrated by MR angiogram is presented. The feeding vessel and the relationship with surrounding palmar blood vessels were clearly identified. This provided essential preoperative information facilitating surgical resection, yet without the technical difficulties and morbidity associated with conventional angiography.

Acute suppurative thyroiditis due to foreign body-induced retropharyngeal abscess presented as thyrotoxicosis

Acute suppurative thyroiditis is an uncommon condition. Most patients have preexisting oropharyngeal fistulae. Penetrating oropharyngeal injuries resulting from swallowed foreign bodies provide an acquired channel of infection spreading into the relatively resistant thyroid gland. The authors describe a patient with infective thyroiditis complicating retropharyngeal abscess caused by a chicken bone that perforated the upper esophagus. Transient thyrotoxicosis complicating acute suppurative thyroiditis is very rare. Pertechnetate and Ga-67 scans confirmed extensive inflammation of the thyroid gland and the release of hormones as the cause, as distinct from concurrent Graves' disease. Awareness of this unusual complication is important to avoid inappropriate treatment for hyperthyroid disease.

Aggressive thoracic actinomycosis complicated by vertebral osteomyelitis and epidural abscess leading to spinal cord compression

STUDY DESIGN

Report of a successfully diagnosed and treated case of spinal cord compression due to epidural actinomycosis.

OBJECTIVE

To illustrate that proper use of imaging strategy can greatly facilitate diagnosis and management of this rare condition.

SUMMARY OF BACKGROUND DATA

Spinal actinomycosis causing epidural abscess and significant spinal cord compression is an uncommon condition. Although diagnosis is difficult, favorable results are widely reported when specific therapy is instituted.

METHODS

A 32-year-old Chinese man had extensive dorsal thoracic soft tissue swelling and lower limb weakness. Collapse of the T5 vertebral body was found on plain radiographs with mediastinal infiltrates on chest radiograph. It took magnetic resonance imaging (MRI) to fully delineate the epidural abscess and dorsal muscular abscesses, which were not depicted by computed tomographic (CT) scan. Diagnosis was made by examination of CT-guided aspirate and tissue recovered during surgery by a microbiologist. The patient received high-dose intravenous penicillin and prompt spinal decompression once diagnosis of actinomycosis was confirmed.

RESULTS

The dorsal muscular abscesses and upper thoracic epidural abscess resolved rapidly after intravenous antibiotics and surgical drainage. This was well documented by follow-up MRI and the full recovery of motor power and lower limb sensation in the patient.

CONCLUSIONS

High clinical suspicion and proper use of imaging data led to timely diagnosis of this rare case of mediastinal, epidural, and intramuscular thoracic actinomycosis. Specific antibiotic therapy and timely, well-targeted surgical intervention greatly improve the outcome of this condition.

Multiple symmetric lipomatosis in the Chinese: ultrasound, CT and MR imaging

We report four cases of multiple symmetric lipomatosis in the Chinese population. We believe that multiple symmetric lipomatosis in the Chinese is not uncommon and may be related to the increasing incidence of alcoholism. The ultrasound appearances of these lipomatous masses are presented for the first time. Heterogeneous echogenic masses with fine fibrous strands that insinuate around fascial planes, lymph nodes and vascular tissues are typical findings. Unlike diseases affecting the Western population, multiple symmetric lipomatosis in the Chinese appears to be limited to the head and neck.

Retroperitoneal ancient schwannoma: review of clinico-radiological features

A case is reported here of an ancient schwannoma in the retroperitoneum. The findings of abdominal ultrasound and CT in a patient with a retroperitoneal ancient schwannoma are presented, and the clinical and radiological features of this unusual tumour are reviewed. The presence of a large, well-delineated complex cystic mass in the deep soft tissues should raise the possibility of an ancient schwannoma. It is important to recognize these tumours as benign with excellent prognosis so as to avoid unnecessary radical surgery.

Spinal cord compression caused by thoracic vertebral hemangioma involving only the posterior elements of two contiguous vertebrae

An unusual case of symptomatic thoracic vertebral hemangioma involving two contiguous vertebrae but confined to the posterior elements is presented. The lesion displaced and compressed the cord. The diagnosis was not considered prior to biopsy. There was uncontrolled bleeding at biopsy. Only partial surgical resection was performed, with incomplete relief of motor weakness after initial surgery. The patient refused further surgical resection. Motor power was gradually recovered after a course of postoperative radiotherapy.

Comparison of two oral evacuants (Citromag and Golytely) for bowel preparation before barium enema

Oral regimens for bowel preparation before barium enema examination are routinely used because of their convenience and simplicity, rather than the traditional method of colonic wash-out. We performed a prospective study comparing the side-effects and efficacy of two commonly used oral bowel evacuants (Citromag and Golytely) for bowel preparation before barium enema examination in 102 patients. The side-effects associated with the agents were assessed by analysing a questionnaire completed by the patients. There was no significant difference in the side-effects between the two agents although more patients taking Golytely (45.5%) deemed its taste unacceptable than those taking Citromag (25.9%). The results of the bowel preparation were assessed by two independent radiologists giving scores on the amount of faecal residue and the quality of mucosal coating. The amount of faecal residue was less in the Golytely group (p < 0.05). The quality of mucosal coating by barium was also better in the Golytely group than the Citromag group (p < 0.05).

Case report: Krukenberg tumours arising from a primary duodenojejunal adenocarcinoma

We report a case of a bilateral Krukenberg tumour of the ovaries arising from a primary adenocarcinoma of the duodenojejunal flexure. Adenocarcinoma of the small bowel is uncommon, representing 1% of all primary malignant tumours of the gastrointestinal tract [1]. Krukenberg tumours arising from a primary duodenojejunal adenocarcinoma are even more unusual. To our knowledge there are less than five reported cases in the English literature [2,3]. Mazur et al. reviewing 325 cases of metastases to the female genital tract over 31 years, found only one case of ovarian metastasis from a primary small bowel carcinoma [2]. Most small bowel adenocarcinomas tend to metastasize to regional lymph nodes and the liver.

Magnetic resonance imaging of tuberculous spinal infection

The magnetic resonance imaging (MRI) characteristics of 15 cases of tuberculous (TB) spinal infection were reviewed. The commonest site was the lumbar spine (53.3%), often with three or more contiguous vertebrae involved (47%). Destruction of the vertebral body and the presence of paraspinal soft-tissue masses were noted in 73.3%. Posterior element abnormalities, which is a significant finding, were seen in 40%, a slightly lower incidence rate than in other reported series. Epidural disease (53.3%) and disc abnormalities (73%) were more frequent than was realized. The role of intravenous contrast is discussed. Intravenous gadolinium is useful because it increases diagnostic confidence by characterizing and delineating the disease process, detects reactivation in old and healed TB, helps in treatment management and may prove valuable in monitoring therapy. Magnetic resonance imaging should be considered to be the imaging modality of choice for patients with suspected tuberculous spinal infection.

The imaging diagnosis of hepatic schistosomiasis japonicum sequelae

We reviewed the ultrasound (US) and computed tomography (CT) examinations of the liver in 21 patients with hepatic schistosomiasis japonicum (HSJ), to assess the role of imaging in its diagnosis. Thirteen patients had histopathological evidence of hepatic ova deposition. A 'network' pattern was present in 14 of 17 (82%) patients on US, and 'turtle-back' calcification in 11 of 13 (85%) patients on non-contrast CT (NCCT). The combination of US and NCCT was positive for HSJ in all nine patients subjected to both investigations. These findings are specific for HSJ and we discuss how they differ from the imaging findings reported in hepatic Schistosoma mansoni (HSM). We conclude that the sequelae of HSJ infection create an imaging diagnosis. Although an uncommon incidental finding at liver imaging, the combined US and CT appearances are so characteristic that in the majority of patients biopsy can potentially be avoided.

MRI of intraspinal nerve sheath tumours presenting with sciatica

The magnetic resonance imaging (MRI) characteristics of 14 intraspinal nerve sheath tumours (NST) presenting with sciatica were reviewed. The group comprised seven schwannomas, six neurofibromas and one perineuroma. The tumours were either iso- or hypointense with respect to spinal cord on T1-weighted (T1W) images; almost all tumours were hyperintense compared with spinal cord on T2-weighted (T2W) images. The tumours were all detectable on unenhanced T1W images. Nine NST were scanned following Gadolinium-Diethylenetriamine penta acetic acid (DTPA) injection and all showed intense enhancement. This aids differentiation from sequestrated disc fragments. Tumours were more likely to show homogeneous enhancement unless they were recurrent tumours. Rim enhancement occurs more commonly in schwannomas and this can be used to differentiate these from neurofibromas. However, on unenhanced images, schwannomas cannot be distinguished from neurofibromas. Four tumours occurred at T11-T12. There was poor correlation of the site of the lesion with the clinical findings. MRI studies in patients with sciatica should include the lower thoracic region especially if no protruded disc was found in the lumbar region.

Ultrasound of Kimura's disease

Kimura's disease is found almost exclusively in Orientals. It commonly affects the head and neck region and mainly involves the major salivary glands and regional lymph nodes. Its appearances can be mistaken for malignant disease. We present two patients with Kimura's disease. In one patient the disease involved the soft tissues and parotid gland, and in another the submandibular gland. Both patients demonstrated lymphadenopathy in the submandibular, submental areas and upper cervical region. Both patients had ultrasound examination of the salivary glands and neck. One of the patients also had contrast-enhanced CT and MRI. The clinical, pathological and imaging findings of Kimura's disease are discussed.