Differential diagnoses of COVID-19 pneumonia: the current challenge for the radiologist-a pictorial essay

Nosocomial Bacterial Bronchopneumonia and SARS-CoV-2 Pneumonia in Patients with Traumatic Injuries: Imaging Aspects and Macroscopic and Microscopic Findings of Lung Tissue

BACKGROUND

Patients with traumatic injuries often represent the best hosts for healthcare-associated infections, especially pneumonia or bronchopneumonia. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic raised serious problems in the diagnosis and treatment of patients that had a SARS-CoV-2 infection and associated nosocomial bacterial bronchopneumonia. In forensic medicine, these aspects need to be considered when establishing the cause of death and the distinction between the two types of bronchopneumonia is of particular importance.

METHODS

We present nine cases that were autopsied at the Institute of Forensic Medicine Timisoara between 1 June 2020 and 31 December 2021, that presented traumatic injuries, a SARS-CoV-2 infection, and bronchopneumonia.

RESULTS

We focused on the main findings of the macroscopic and microscopic aspects of lung tissues.

CONCLUSIONS

We consider that the aspects we highlighted in this study, can be very useful in forensic practice in cases with a pluri-factorial pathology.

Evaluating Acute Pulmonary Changes of Coronavirus 2019: Comparative Analysis of the Pertinent Modalities

This review explores imaging's crucial role in acute Coronavirus Disease 2019 (COVID-19) assessment. High Resolution Computer Tomography is especially effective in detection of lung abnormalities. Chest radiography has limited utility in the initial stages of COVID-19 infection. Lung Ultrasound has emerged as a valuable, radiation-free tool in critical care, and Magnetic Resonance Imaging shows promise as a Computed Tomography alternative. Typical and atypical findings of COVID-19 by each of these modalities are discussed with emphasis on their prognostic value. Considerations for pediatric and immunocompromised cases are outlined. A comprehensive diagnostic approach is recommended, as radiological diagnosis remains challenging in the acute phase.

Catalase: A Potential Pharmacologic Target for Hydrogen Peroxide in the Treatment of COVID-19

BACKGROUND

Acute respiratory distress syndrome in the elderly with COVID-19 complicated by airway obstruction with sputum and mucus, and cases of asphyxia with blood, serous fluid, pus, or meconium in newborns and people of different ages can sometimes cause hypoxemia and death from hypoxic damage to brain cells, because the medical standard does not include intrapulmonary injections of oxygen-producing solutions. The physical-chemical repurposing of hydrogen peroxide from an antiseptic to an oxygen-producing antihypoxant offers hope for the development of new drugs.

METHODS

This manuscript is a meta-analysis performed according to PRISMA guidelines.

RESULTS

It is shown that replacement of the traditional acidic activity of hydrogen peroxide solutions by alkaline activity with pH 8.4 and heating the solutions to the temperature of +37 - +42 °C allows to repurpose hydrogen peroxide from antiseptics into inhalation and intrapulmonary mucolytics, pyolytics and antihypoxants releasing oxygen. The fact is that warm alkaline hydrogen peroxide solution (WAHPS) in local interaction with sputum, mucus, pus, blood and meconium provides optimal conditions for the metabolism of hydrogen peroxide to oxygen gas under the action of the enzyme catalase, always present in these tissues. It was established that WAHPS liquefies these biological masses due to alkaline saponification of lipid and protein-lipid complexes and simultaneously transforms dense masses into soft oxygen foam due to active enzymatic metabolism of hydrogen peroxide to oxygen gas, the rapidly appearing bubbles of which are formed by the type of "cold boiling" and literally explode these masses. The results of the first experiments showed that inhalation and intrapulmonary injections of WAHPS can significantly optimize the treatment of suffocation and hypoxemia.

DISCUSSION

The results showed that catalase, which is found in sputum, mucus, pus, and blood, may be a target for localized WAHPS because this enzyme provides an intensive metabolism of hydrogen peroxide to oxygen gas up to the formation of the cold boiling process.

CONCLUSION

These data provide a new perspective way for intrapulmonary drugs and new technologies for the emergency increase of blood oxygenation through the lungs in asphyxia with thick sputum, mucus, pus, meconium and blood.

A Pictorial Essay Describing the CT Imaging Features of COVID-19 Cases throughout the Pandemic with a Special Focus on Lung Manifestations and Extrapulmonary Vascular Abdominal Complications

With the Omicron wave, SARS-CoV-2 infections improved, with less lung involvement and few cases of severe manifestations. In this pictorial review, there is a summary of the pathogenesis with particular focus on the interaction of the immune system and gut and lung axis in both pulmonary and extrapulmonary manifestations of COVID-19 and the computed tomography (CT) imaging features of COVID-19 pneumonia from the beginning of the pandemic, describing the typical features of COVID-19 pneumonia following the Delta variant and the atypical features appearing during the Omicron wave. There is also an outline of the typical features of COVID-19 pneumonia in cases of breakthrough infection, including secondary lung complications such as acute respiratory distress disease (ARDS), pneumomediastinum, pneumothorax, and lung pulmonary thromboembolism, which were more frequent during the first waves of the pandemic. Finally, there is a description of vascular extrapulmonary complications, including both ischemic and hemorrhagic abdominal complications.

A Retrospective Assessment of Sputum Samples and Antimicrobial Resistance in COVID-19 Patients

Data on bacterial or fungal pathogens and their impact on the mortality rates of Western Romanian COVID-19 patients are scarce. As a result, the purpose of this research was to determine the prevalence of bacterial and fungal co- and superinfections in Western Romanian adults with COVID-19, hospitalized in in-ward settings during the second half of the pandemic, and its distribution according to sociodemographic and clinical conditions. The unicentric retrospective observational study was conducted on 407 eligible patients. Expectorate sputum was selected as the sampling technique followed by routine microbiological investigations. A total of 31.5% of samples tested positive for Pseudomonas aeruginosa, followed by 26.2% having co-infections with Klebsiella pneumoniae among patients admitted with COVID-19. The third most common Pathogenic bacteria identified in the sputum samples was Escherichia coli, followed by Acinetobacter baumannii in 9.3% of samples. Commensal human pathogens caused respiratory infections in 67 patients, the most prevalent being Streptococcus penumoniae, followed by methicillin-sensitive and methicillin-resistant Staphylococcus aureus. A total of 53.4% of sputum samples tested positive for Candida spp., followed by 41.1% of samples with Aspergillus spp. growth. The three groups with positive microbial growth on sputum cultures had an equally proportional distribution of patients admitted to the ICU, with an average of 30%, compared with only 17.3% among hospitalized COVID-19 patients with negative sputum cultures (p = 0.003). More than 80% of all positive samples showed multidrug resistance. The high prevalence of bacterial and fungal co-infections and superinfections in COVID-19 patients mandates for strict and effective antimicrobial stewardship and infection control policies.

Severe COVID-19 versus multisystem inflammatory syndrome: comparing two critical outcomes of SARS-CoV-2 infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with diverse host response immunodynamics and variable inflammatory manifestations. Several immune-modulating risk factors can contribute to a more severe coronavirus disease 2019 (COVID-19) course with increased morbidity and mortality. The comparatively rare post-infectious multisystem inflammatory syndrome (MIS) can develop in formerly healthy individuals, with accelerated progression to life-threatening illness. A common trajectory of immune dysregulation forms a continuum of the COVID-19 spectrum and MIS; however, severity of COVID-19 or the development of MIS is dependent on distinct aetiological factors that produce variable host inflammatory responses to infection with different spatiotemporal manifestations, a comprehensive understanding of which is necessary to set better targeted therapeutic and preventative strategies for both.

Clinical Features of COVID-19 and Differentiation from Other Causes of CAP

Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, one of the most common reasons for infection-related death worldwide. Causes of CAP include numerous viral, bacterial, and fungal pathogens, though frequently no specific organism is found. Beginning in 2019, the COVID-19 pandemic has caused incredible morbidity and mortality. COVID-19 has many features typical of CAP such as fever, respiratory distress, and cough, and can be difficult to distinguish from other types of CAP. Here, we highlight unique clinical features of COVID-19 pneumonia such as olfactory and gustatory dysfunction, lymphopenia, and distinct imaging appearance.

Targeted plasma proteomics reveals signatures discriminating COVID-19 from sepsis with pneumonia

BACKGROUND

COVID-19 remains a major public health challenge, requiring the development of tools to improve diagnosis and inform therapeutic decisions. As dysregulated inflammation and coagulation responses have been implicated in the pathophysiology of COVID-19 and sepsis, we studied their plasma proteome profiles to delineate similarities from specific features.

METHODS

We measured 276 plasma proteins involved in Inflammation, organ damage, immune response and coagulation in healthy controls, COVID-19 patients during acute and convalescence phase, and sepsis patients; the latter included (i) community-acquired pneumonia (CAP) caused by Influenza, (ii) bacterial CAP, (iii) non-pneumonia sepsis, and (iv) septic shock patients.

RESULTS

We identified a core response to infection consisting of 42 proteins altered in both COVID-19 and sepsis, although higher levels of cytokine storm-associated proteins were evident in sepsis. Furthermore, microbiologic etiology and clinical endotypes were linked to unique signatures. Finally, through machine learning, we identified biomarkers, such as TRIM21, PTN and CASP8, that accurately differentiated COVID-19 from CAP-sepsis with higher accuracy than standard clinical markers.

CONCLUSIONS

This study extends the understanding of host responses underlying sepsis and COVID-19, indicating varying disease mechanisms with unique signatures. These diagnostic and severity signatures are candidates for the development of personalized management of COVID-19 and sepsis.

Challenges in the Differential Diagnosis of COVID-19 Pneumonia: A Pictorial Review

COVID-19 pneumonia represents a maximum medical challenge due to the virus's high contagiousness, morbidity, and mortality and the still limited possibilities of the health systems. The literature has primarily focused on the diagnosis, clinical-radiological aspects of COVID-19 pneumonia, and the most common possible differential diagnoses. Still, few studies have investigated the rare differential diagnoses of COVID-19 pneumonia or its overlap with other pre-existing lung pathologies. This article presents the main radiological features of COVID-19 pneumonia and the most common alternative diagnoses to establish the vital radiological criteria for a differential diagnosis between COVID-19 pneumonia and other lung pathologies with similar imaging appearance. The differential diagnosis of COVID-19 pneumonia is challenging because there may be standard radiologic features such as ground-glass opacities, crazy paving patterns, and consolidations. A multidisciplinary approach is crucial to define a correct final diagnosis, as an overlap of COVID-19 pneumonia with pre-existing lung diseases is often possible and suggests possible differential diagnoses. An optimal evaluation of HRTC can help limit the clinical evolution of the disease, promote therapy for patients and ensure an efficient allocation of human and economic resources.

Computed Tomographic Imaging Features of COVID-19 Pneumonia Caused by the Delta (B.1.617.2) and Omicron (B.1.1.529) Variant in a German Nested Cohort Pilot Study Group

Background: The aim of this study was to evaluate CT (computed tomography) imaging differences for the Delta and the Omicron variant in COVID-19 infection. Methods: The study population was derived from a retrospective study cohort investigating chest CT imaging patterns in vaccinated and nonvaccinated COVID-19 patients. CT imaging patterns of COVID-19 infection were evaluated by qualitative and semiquantitative scoring systems, as well as imaging pattern analysis. Results: A total of 60 patients (70.00% male, 62.53 ± 17.3 years, Delta: 43 patients, Omicron: 17 patients) were included. Qualitative scoring systems showed a significant correlation with virus variants; “typical appearance” and “very high” degrees of suspicion were detected more often in patients with Delta (RSNA: p = 0.003; CO-RADS: p = 0.002; COV-RADS: p = 0.001). Semiquantitative assessment of lung changes revealed a significant association with virus variants in univariate (Delta: 6.3 ± 3.5; Omicron: 3.12 ± 3.2; p = 0.002) and multivariate analysis. The vacuolar sign was significantly associated with the Delta variant (OR: 14.74, 95% CI: [2.32; 2094.7], p = 0.017). Conclusion: The Delta variant had significantly more extensive lung involvement and showed changes classified as “typical” more often than the Omicron variant, while the Omicron variant was more likely associated with CT findings such as “absence of pulmonary changes”. A significant correlation between the Delta variant and the vacuolar sign was observed.

Vexas Syndrome Presenting As Long Covid-19

Objective VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described systemic inflammatory syndrome caused by somatic mutations of UBA1. COVID-19 is a viral infection that was described in 2019 and spread widely and quickly all around the world. Constitutional, thrombotic and pulmonary symptoms of these two conditions are similar, which is why cases of VEXAS syndrome may be misdiagnosed as a COVID infection.

Case report We introduced a case report of a 72-year-old male patient with VEXAS syndrome who had fever, fatigue, deep vein thrombosis and a cough and was thought to have a long COVID-19 infection for one year. Then we diagnosed him with VEXAS syndrome with vacuoles in myelomonocytic cells, skin lesions and a mutation of the UBA-1 gene.

Conclusion VEXAS and long COVID are two new conditions with overlapping clinical presentations. Physicians must be aware of these clinical conditions because of their different treatment strategy and prognosis.

Fungal infection mimicking COVID-19 infection - A case report

For the last 2 years, one of the most frequent causes of respiratory failure is coronavirus disease 2019 (COVID-19). The symptoms are not specific. Imaging diagnostics, especially high-resolution computed tomography, is a diagnostic method widely used in the diagnosis of this disease. It is important to emphasize that not only SARS-CoV-2 infection may manifest as interstitial pneumonia. Other diseases such as other viral, fungal, atypical bacterial pneumonia, autoimmune process, and even cancer can also manifest as ground-glass opacities or consolidations in the imaging of the lungs. In this case report, we described a patient who manifested many symptoms that seemed to be COVID-19. However, all performed antigen and polymerase chain reaction tests were negative. The diagnostics must have been extended. Microbiological and mycological blood cultures and sputum cultures were performed. Blood cultures were negative but in sputum, Candida albicans and Candida glabrata were identified. Targeted therapy with fluconazole was implemented with a satisfactory result. The patient was discharged from the hospital in a good general condition with no complaints.

Performances of clinical characteristics and radiological findings in identifying COVID-19 from suspected cases

BACKGROUND

To identify effective factors and establish a model to distinguish COVID-19 patients from suspected cases.

METHODS

The clinical characteristics, laboratory results and initial chest CT findings of suspected COVID-19 patients in 3 institutions were retrospectively reviewed. Univariate and multivariate logistic regression were performed to identify significant features. A nomogram was constructed, with calibration validated internally and externally.

RESULTS

239 patients from 2 institutions were enrolled in the primary cohort including 157 COVID-19 and 82 non-COVID-19 patients. 11 features were selected by LASSO selection, and 8 features were found significant using multivariate logistic regression analysis. We found that the COVID-19 group are more likely to have fever (OR 4.22), contact history (OR 284.73), lower WBC count (OR 0.63), left lower lobe involvement (OR 9.42), multifocal lesions (OR 8.98), pleural thickening (OR 5.59), peripheral distribution (OR 0.09), and less mediastinal lymphadenopathy (OR 0.037). The nomogram developed accordingly for clinical practice showed satisfactory internal and external validation.

CONCLUSIONS

In conclusion, fever, contact history, decreased WBC count, left lower lobe involvement, pleural thickening, multifocal lesions, peripheral distribution, and absence of mediastinal lymphadenopathy are able to distinguish COVID-19 patients from other suspected patients. The corresponding nomogram is a useful tool in clinical practice.

COVID-19 Pneumonia and Lung Cancer: A Challenge for the Radiological Review of the Main Radiological Features, Differential Diagnosis and Overlapping Pathologies

The COVID-19 pneumonia pandemic represents the most severe health emergency of the 21st century and has been monopolizing health systems’ economic and human resources world-wide. Cancer patients have been suffering from the health systems’ COVID-19 priority management with evidence of late diagnosis leading to patients’ poor prognosis and late medical treatment. The radiologist plays a pivotal role as CT represents a non-invasive radiological technique which may help to identify possible overlap and differential diagnosis between COVID-19 pneumonia and lung cancer, which represents the most frequent cancer histology in COVID-19 patients. Our aims are: to present the main CT features of COVID-19 pneumonia; to provide the main differential diagnosis with lung cancer, chemotherapy-, immunotherapy-, and radiotherapy-induced lung disease; and to suggest practical tips and key radiological elements to identify possible overlap between COVID-19 pneumonia and lung cancer. Despite similarities or overlapping findings, the combination of clinics and some specific radiological findings, which are also identified by comparison with previous and follow-up CT scans, may guide differential diagnosis. It is crucial to search for typical COVID-19 pneumonia phase progression and typical radiological features on HRTC. The evidence of atypical findings such as lymphadenopathies and mediastinal and vessel invasion, as well as the absence of response to therapy, should arouse the suspicion of lung cancer and require contrast administration. Ground-glass areas and/or consolidations bound to radiotherapy fields or pneumonitis arising during and after oncological therapy should always arouse the suspicion of radiation-induced lung disease and chemo/immunotherapy-induced lung disease. The radiological elements we suggest for COVID-19 and lung cancer differential diagnosis may be used to develop AI protocols to guarantee an early and proper diagnosis and treatment to improve patients’ quality of life and life expectancy.

Idiopathic Interstitial Pneumonias and COVID-19 Pneumonia: Review of the Main Radiological Features and Differential Diagnosis

COVID-19 pneumonia represents a challenging health emergency, due to the disproportion between the high transmissibility, morbidity, and mortality of the virus and healthcare systems possibilities. Literature has mainly focused on COVID-19 pneumonia clinical-radiological diagnosis and therapy, and on the most common differential diagnoses, while few papers investigated rare COVID-19 pneumonia differential diagnoses or the overlapping of COVID-19 pneumonia on pre-existing lung pathologies. This article presents the main radiological characteristics of COVID-19 pneumonia and Idiopathic Interstitial Pneumonias (IIPs) to identify key radiological features for a differential diagnosis among IIPs, and between IIPs and COVID-19 pneumonia. COVID-19 pneumonia differential diagnosis with IIPs is challenging, since these entities may share common radiological findings as ground glass opacities, crazy paving patterns, and consolidations. Multidisciplinary discussion is crucial to reach a final and correct diagnosis. Radiologists have a pivotal role in identifying COVID-19 pneumonia patterns, reporting possible overlapping with long-lasting lung diseases, and suggesting potential differential diagnoses. An optimal evaluation of HRTC may help in containing the disease, in promoting better treatment for patients, and in providing an efficient allocation of human and economic resources.