Delayed inflammatory pulmonary syndrome: A distinct clinical entity in the spectrum of inflammatory syndromes in COVID-19 infection?

BACKGROUND

During the second wave of the coronavirus disease 2019 (COVID-19) pandemic, a subset of critically ill patients developed delayed respiratory deterioration in the absence of new infection, fluid overload or extra-pulmonary organ dysfunction.

AIM

To describe the clinical and laboratory characteristics, outcomes, and management of these patients, and to contrast this entity with other post COVID-19 immune dysregulation related inflammatory disorders.

METHODS

This was a retrospective observational study of adult patients admitted to the medical intensive care unit of a 2200-bed university affiliated teaching hospital, between May and August 2021, who fulfilled clearly defined inclusion and exclusion criteria. Outcome was assessed by a change in PaO2/FiO2 ratio and levels of inflammatory markers before and after immunomodulation, duration of mechanical ventilation after starting treatment, and survival to discharge.

RESULTS

Five patients developed delayed respiratory deterioration in the absence of new infection, fluid overload or extra-pulmonary organ dysfunction at a median interquartile range (IQR) duration of 32 (23-35) d after the onset of symptoms. These patients had elevated inflammatory markers, required mechanical ventilation for 13 (IQR 10-23) d, and responded to glucocorticoids and/or intravenous immunoglobulin. One patient died (20%).

CONCLUSION

This delayed respiratory worsening with elevated inflammatory markers and clinical response to immunomodulation appears to contrast the well described Multisystem Inflammatory Syndrome - Adults by the paucity of extrapulmonary organ involvement. The diagnosis can be considered in patients presenting with delayed respiratory worsening, that is not attributable to cardiac dysfunction, fluid overload or ongoing infections, and associated with an increase in systemic inflammatory markers like C-reactive protein, inteleukin-6 and ferritin. A good response to immunomodulation can be expected. This delayed inflammatory pulmonary syndrome may represent a distinct clinical entity in the spectrum of inflammatory syndromes in COVID-19 infection.

Society of Chest Imaging and Interventions Consensus Guidelines for the Interventional Radiology Management of Hemoptysis

The recommendations from the Society of Chest Imaging and Interventions expert group comprehensively cover all the aspects of management of hemoptysis, highlighting the role of diagnostic and interventional radiology. The diversity existing in etiopathology, imaging findings, and management of hemoptysis has been addressed. The management algorithm recommends the options for effective treatment while minimizing the chances of recurrence, based on the best evidence available and opinion from the experts.

Imaging Recommendations for Diagnosis, Staging, and Management of Lung Cancer

Globally and in India, lung cancer is one of the leading malignancies in terms of incidence and mortality. Smoking and environmental pollution are the common risk factors for developing lung cancer. Traditionally, lung cancer is divided into small cell and nonsmall cell types, with nonsmall cell carcinomas including squamous cell carcinoma, adenocarcinoma, and large cell carcinoma.

In this review article, we describe the imaging recommendations and findings in the diagnosis, staging, and management of lung cancer, including the imaging of treatment-related complications.

Diagnostic Value of Connective Tissue Disease Related CT Signs in Usual Interstitial Pneumonia Pattern of Interstitial Lung Disease

Purpose  Usual interstitial pneumonia (UIP) pattern of interstitial lung disease (ILD) can have varied etiology, with connective tissue disease (CTD) being a common known cause. The anterior upper lobe (AUL) sign, exuberant honeycombing (EHC), and straight edge (SE) sign are recently described computed tomography (CT) signs in CTD-related UIP. We test the diagnostic value of these CT signs for CTD in patients with UIP and compare the incidence of these signs between CTD-related UIP and non-CTD-related UIP. We also evaluated the interobserver agreement in detection of these CT signs. Methods  Retrospective study of all patients who had UIP pattern of ILD on CT thorax done from January 1, 2016 to January 31, 2019, was grouped into two: non-CTD-related UIP or CTD-related UIP. CT thorax was reviewed for the presence of these signs-AUL, SE, and EHC. The diagnostic values of these signs in diagnosing CTD-related UIP was assessed. For assessment of interobserver agreement, another radiologist reviewed a subset of 30 randomly selected cases and looked for the presence of these signs. Results  Of the 156 patients included, 76 had CTD. The incidence of CT signs were significantly higher in CTD-related UIP. The specificities of AUL, EHC, and SE were 82.5, 75, and 85%, respectively. The EHC sign had highest sensitivity of 48.7%. Inclusion of more than one sign increased the specificity of diagnosis of CTD-related UIP; however, the sensitivity decreases. There was excellent interobserver agreement (0.81-0.87) for each of these signs. Conclusion  The presence of SE, AUL, and EHC signs in cases with UIP pattern are specific imaging markers to diagnose underlying CTD; however, due to its low sensitivity, the absence of these signs cannot exclude the same. Because of its excellent interobserver agreement, these signs are reliable in the evaluation of CTD-related ILD.

Thoracic air leak syndrome as the sole manifestation of chronic lung graft-versus-host disease: a case report

Background

Thoracic air leak syndrome (TALS) is a rare complication associated with chronic lung graft-versus-host disease (GVHD) and bronchiolitis obliterans syndrome (BOS). In the present case, TALS was the sole pulmonary manifestation of GVHD.

Case presentation

A 30-year-old woman presented with dyspnea on exertion and swelling of the neck and face after allogeneic stem cell transplantation for acute myeloid leukemia. She was found to have subcutaneous emphysema, and chest imaging suggested pneumomediastinum, with normal lung parenchyma. Her clinical and radiological findings indicated TALS. There were no other features suggestive of lung GVHD. Her condition improved with conservative management and increased immunosuppression. However, she subsequently had two relapses, developed severe infection and pneumothorax, and died.

Conclusions

The present case report illustrates a unique presentation of TALS, a rare complication of GVHD, in a post-stem cell transplant patient. It highlights the challenges in the diagnosis and management of this condition.

ABPA sans asthma: an entity to remember

A male patient in his 20s presented with a cough and a small volume of haemoptysis that lasted a year. He had no other constitutional symptoms and a respiratory examination was suggestive of a consolidation. A chronic infection, such as tuberculosis, was suspected. The routine evaluation showed peripheral eosinophilia with raised serum total IgE. Sputum examination for tuberculosis was negative; hence, a high-resolution CT of the thorax was performed, which revealed bilateral bronchiectasis with high-attenuation mucus plugging. The imaging and blood profiles were in favour of allergic bronchopulmonary aspergillosis, but there was no history suggestive of asthma, and the pulmonary function test was normal. The patient underwent a skin prick test and an allergen-specific IgE test forAspergillus fumigatus, and both were positive. His bronchoalveolar lavage cultures also grewA. fumigatus, and he responded well to antifungal therapy. This case illustrates the presentation of a rare entity—allergic bronchopulmonary aspergillosis sans asthma.

Pneumococcal serotypes causing non-invasive pneumonia in adults from a South Indian tertiary care hospital and the impact of the newer conjugate vaccines

Background

Streptococcus pneumoniae is the leading cause of community-acquired pneumonia (CAP) in adults. Ageing, chronic conditions and comorbidities are important risk factors for pneumococcal pneumonia.

Purpose

There is lack of data on the pneumococcal serotypes causing non-invasive pneumonia in India. This study aims to determine the prevalent pneumococcal serotypes causing non-invasive pneumonia, the associated comorbidities, and the coverage of both the available pneumococcal vaccines in India and conjugate vaccines that are currently undergoing clinical trials.

Methods

A total of 280 subjects (aged >16 years) who had clinical symptoms correlating with radiological findings for non-invasive bacteremic pneumonia and microbiological evidence of S. pneumoniae between 2018 and 2020 were included. The clinical, demographic, radiological and microbiological findings were retrieved from the Hospital Information System (HIS).

Result

The common serotypes in order of prevalence were 19F, 9V, 23F, 6B, 11A, 13, 34, 10A, 19A and 6A. The predominant non-vaccine serotypes were 13, 34, 35B, 31 and 16F. The associated radiological findings were pneumonic consolidation and multi-lobar involvement. Other coinfected bacterial pathogens included H. influenzae, S. aureus, K. pneumoniae and P. aeruginosa.

Conclusion

The pneumococcal vaccines: PCV10/GSK, PCV10/SII, PCV13, PCV15, PCV20 and PPSV23 provide an overall serotype coverage of 36, 41, 47, 48, 61 and 69 %, respectively of S. pneumoniae causing non-invasive pneumonia in South India. Increasing catch-up vaccination using PCV10(SII) in pre-school children could have a more significant impact on reducing pneumococcal pneumonia in adults (>50 years) in terms of increased herd immunity at an affordable cost.

Giant cystic pulmonary hamartoma-images

Hamartoma is the commonest benign tumor of the lung. They usually present as an asymptomatic solitary solid nodule of varying size, located peripherally in the lung parenchyma and picked up incidentally in a chest X-ray. Rarely, they may be intra-bronchial in location. A giant cystic variant of hamartoma is very rare, with only a few cases reported in literature so far. It may be misdiagnosed as any other cystic disease of the lung and thus get mismanaged. We herewith present the images of a patient with a giant cystic pulmonary hamartoma who presented with respiratory distress.

Magnetic resonance imaging as an adjunct to computed tomography in the diagnosis of pulmonary Hydatid cysts

Introduction:

Although pulmonary hydatid cysts can be diagnosed on computed tomography (CT), sometimes findings can be atypical. Other hypodense infective or neoplastic lesions may mimic hydatid cysts. We proposed that magnetic resonance imaging (MRI) may act as a problem-solving tool, aiding the definite diagnosis of hydatid cysts and differentiating it from its mimics. The aim of this study is to assess the findings of pulmonary hydatid cysts on CT and MRI and the additional contribution of MRI in doubtful cases.

Materials and Methods:

This is a retrospective study of 90 patients with suspected hydatid cysts. CT and MRI findings were noted and role of MRI in diagnosing hydatid cysts and its mimics was studied. Descriptive statistics for CT findings and sensitivity and specificity of MRI were calculated using surgery or histopathology as gold standard.

Results:

Of the 90 patients with suspected pulmonary hydatid cysts, there were 52 true-positive and 7 false-positive cases on CT. Commonest CT finding was unilocular thick-walled cyst. In the 26 patients who had additional MRI, based on T2-weighted hypointense rim or folded membranes, accurate preoperative differentiation of 14 patients with hydatid cysts from 10 patients with alternate diagnosis was possible. There was one false-positive and one false-negative case on MRI.

Conclusion:

Although hydatid cyst can be diagnosed on CT on most occasions, sometimes there are challenges with certain mimics and atypical appearances. T2-weighted MRI can act as a problem solving tool to conclusively diagnose hydatid cyst or suggest an alternate diagnosis.

rospective Clinical Trial Comparing IV Esmolol to IV Metoprolol in CT Coronary Angiography: Effect on Hemodynamic, Technical Parameters and Cost

BACKGROUND

Intravenous [IV] esmolol, an alternative to IV metoprolol for coronary computed tomography angiography [CCTA], has shorter half-life that decreases the risk of prolonged hypotension. The primary aim was to prospectively compare IV esmolol alone to IV metoprolol alone for effectiveness in achieving heart rate [HR] of 60 beats per minute[bpm] during CCTA. The secondary aim was to compare hemodynamic response, image quality, radiation dose and cost.

MATERIALS AND METHODS

Institutional Review Board approved prospective randomized study of 28 CCTA patients medicated in a 1:1 blinded match with IV esmolol or IV metoprolol to achieve HR of 60 bpm. Serial hemodynamic response was measured at 6 specified times. Two cardiac radiologists independently scored the image quality.

RESULTS

Both IV esmolol and IV metoprolol achieved the target HR. IV esmolol resulted in significantly less profound and shorter duration of reduction in systolic blood pressure [BP] than IV metoprolol with a difference of -10, -14 and -9 mm Hg compared to -20, -26 and -25 mmHg at 2, 15 & 30 min respectively. No significant difference in HR at image acquisition, exposure window, radiation dose and image quality. Although IV esmolol was expensive, the overall cost of care was comparable to IV metoprolol due to shortened post CCTA observation period consequent to faster restoration of hemodynamic status.

CONCLUSION

Comparison of IV esmolol and IV metoprolol demonstrate that both are effective in achieving the target HR but significantly faster recovery of HR and BP in patients who receive IV esmolol was found.

Can the 12-Lead Electrocardiogram Predict Myocardial Viability?

Introduction: In patients with coronary artery disease and left ventricular dysfunction, the assessment of myocardial viability, prior to revascularisation has been shown to be of significant benefit. Most methods to assess myocardial viability such as Positron Emission Tomography (PET) and Cardiac MRI (CMR) are not readily available in resource constrained settings. The present study sought to determine if an easily available and inexpensive tool, such as the 12-lead surface Electrocardiogram (ECG) can be used as a screening tool to assess for myocardial viability. It is hypothesised that the R wave height as a marker of electrical activity would correlate with viability. Aim: To determine if the surface ECG can be used to predict myocardial viability. Materials and Methods: This retrospective study was conducted at the Christian Medical College and Hospital, Vellore, Tamil Nadu, India. Among all patients who had undergone CMR viability assessment as part of their routine care between February 2008 and October 2017, and analysis and preliminary write up was done between November 2017 and Decemeber 2018, 119 patients with previous anterior wall myocardial infarctions were identified. The 12-Lead ECGs of these patients were assessed for the height of R wave in lead V3 and sum of R wave heights in all precordial leads. Myocardial viability was assessed based on the extent of Late Gadolinium Enhancement (LGE) on CMR. Measures of diagnostic accuracy including sensitivity, specificity, predictive values and likelihood ratios were calculated. Results: It was found that a R wave height of less than 3 mm in lead V3 was 90.3% sensitive for the detection of non viable myocardium. Similarly, when the sum of the R wave heights in all precordial leads was less than 28.5 mm, it was 93.2% sensitive for the detection of non viable myocardium. Conclusion: In patients with previous anterior wall myocardial infarctions when the R wave height was less than 3 mm in lead V3, it was 90.3 % sensitive to identify those with non viable Left Anterior Descending artery (LAD) territory. The 12-Lead ECG is therefore a sensitive, inexpensive and easily available screening test to assess for LAD territory non viability.

Pulmonary embolism from cardiac hydatids

Metastatic hydatid disease of the lung may happen when a hydatid cyst (HC) anywhere in the body ruptures into a systemic vein, a right heart chamber or a pulmonary artery (PA), resulting in the embolisation of the cyst's contents into the lungs. We submit herewith, the images of embolised hydatids within the PA, in a patient who had surgery for HC involving the right ventricular (RV) wall in 2014. Despite adequate surgical and medical management, investigations in 2017 revealed multiple embolised cysts within PA branches. Further continued medical therapy resulted only in partial resolution of the disease, indicating probably the inadequacy of the currently available treatment strategies.

An arcade in the heart: Multimodality imaging

Congenital mitral stenosis (MS) is a spectrum of anomalies that result in functional and anatomic obstruction of inflow into the left ventricle. Mitral arcade is one of the varieties of congenital MS where there is an abnormal development of chordae tendineae, resulting in stenosis, regurgitation, or both. Here, we describe the case of a mitral arcade in a child, which was diagnosed on echocardiography and confirmed with other imaging modalities.

Organising pneumonia in Rhupus syndrome

Interstitial lung disease (ILD) is seen in 17% of patients with Rhupus syndrome. Organising pneumonia (OP), a subtype of connective tissue disease-associated ILD, is rare but associated with good outcomes. Here, we present a patient with Rhupus who developed OP.

Characteristics of Cardiovascular Magnetic Resonance Imaging and Outcomes in Adults With Repaired Truncus Arteriosus

The cardiovascular magnetic resonance imaging (CMR) features of adults with repaired truncus arteriosus (rTA) are largely undefined. We sought to explore CMR characteristics in rTA and to identify associations between imaging findings and cardiovascular outcomes. Adults with rTA and CMR were identified and anatomic subtypes (1-4) were assigned (Collett and Edwards classification). CMR characteristics, clinical data at last follow-up and adverse cardiovascular outcome were recorded. Twenty-seven adults (19% male) were studied (median age at cardiovascular magnetic resonance 26 years [interquartile range 18 to 40]) over 5.2-year duration [interquartile range 2.5 to 7.5]. With the exception of mildly increased RV mass (30 ± 12 g/m²), cardiac chamber measurements were within the normal range. In CMR measurements, only pulmonary artery peak velocity differed in subtypes (highest in subtype 3, 318 ± 26 cm/s, p = 0.029). Number of cardiovascular interventions in adulthood was moderately correlated with left ventricular end-diastolic volume (r = 0.463, p = 0.015), left ventricular ejection fraction (r = 0.425, p = 0.027) and neoaortic root size (r = 0.398, p = 0.039). Cardiovascular events (nonmutually exclusive) in 5 of 27 patients (19%) included death (n = 1), heart failure (n = 1), ventricular tachycardia (n = 1), and atrial tachycardia (n = 3). Increased cardiovascular risk was associated with decreased right ventricular ejection fraction (odds ratio 1.153, confidence interval 1.003 to 1.326, p = 0.046) and smaller ascending aorta diameter (odds ratio 1.758, confidence interval 1.037 to 2.976, p = 0.036). In conclusion, decreased right ventricular ejection fraction and smaller ascending aorta on cardiovascular magnetic resonance were associated with adverse events in rTA.

A Retrospective Case-Control Study to Evaluate the Diagnostic Accuracy of Honeycomb Sign in Melioid Liver Abscess

Among pyogenic liver abscesses, melioid etiology is considered in endemic regions in the presence of known health or occupational risk factors. "Honeycomb sign," used to describe an abscess with multiple internal septations dividing the abscess cavity into multiple loculations of comparable sizes on imaging, is a sensitive sign for melioid liver abscess. This is a retrospective case-control study investigating incidence, sensitivity, and specificity of "honeycomb sign" in melioid liver abscess, in a cohort of patients with culture-proven melioidosis infection. Abscesses ≥ 2 cm were analyzed for the honeycomb sign. P value < 0.05 was taken as statistically significant. Interobserver agreement was calculated between two radiologists for the presence of the sign, sensitivity, and specificity. A total of 40 abscesses were analyzed. Thirty-four abscesses (85%) manifested the honeycomb sign with interobserver agreement (kappa = 0.70 and 0.92). Sensitivity of the sign is 85% (95% confidence interval [CI]: 70-94%), specificity is 75% (95% CI: 59-87%), positive predictive value is 77% (95% CI: 62-88%), and negative predictive value is 83% (95% CI: 67-94%). If abscess size is ≥ 3 cm, the sensitivity is 91% (95% CI: 77-98%), specificity is 75% (95% CI: 59-87%), positive predictive value is 76% (95% CI: 61-88%), and negative predictive value is 91% (95% CI: 76-98%). Honeycomb sign is a novel imaging marker for melioid liver abscess. Increased awareness and recognition of this imaging feature has the potential to affect patient management.

Can the imaging manifestations of melioidosis prognosticate the clinical outcome? A 6-year retrospective study

OBJECTIVE

Melioidosis being an important cause of community-acquired sepsis, caused by Burkholderia pseudomallei in the tropical and subtropical countries, is often underreported or misinterpreted on imaging investigations. We aim to describe the spectrum of imaging manifestations of melioidosis and to evaluate its role in prognosticating clinical outcome, and look for association of specific organ involvement with risk factors.

METHODS

From January 2011 to October 2017, retrospective analysis of imaging investigations of 189 consecutive patients with culture-proven melioidosis was performed. Clinical and demographic records were collected from the hospital medical records.

RESULTS

Out of 67% with a localised disease musculoskeletal involvement was most common, whereas the common organs involved in disseminated infections were the lungs, spleen, liver and genitourinary tract in descending order. Twenty percent suffered unfavourable outcome with a mortality rate of 8.5%. The lung involvement was associated with unfavourable outcome (OR 3.2 [95%CI 1.54-6.63] p = 0.002). The lymph node involvement (OR 0.22 [95% CI 0.05-0.95] p = 0.04) predicted a favourable outcome. Those with diabetes were at a higher risk of splenic (OR 3.05 [95% CI 1.62-5.77]; p = 0.001) and musculoskeletal involvement (OR 2.14 [95% CI 1.09-4.17] p = 0.03) of melioidosis.

CONCLUSIONS

In this study, we have described the spectrum of imaging manifestation of melioidosis and evaluated its association with clinical outcome. Respiratory system involvement in melioidosis showed significant association with unfavourable outcome. Diabetes mellitus, a common risk factor for melioidosis, is more prone for infection of the spleen and musculoskeletal system. Thus awareness of imaging manifestations of melioidosis can complement microbiological diagnostic tests for accurate early diagnosis and management.

Undifferentiated thymic carcinoma with intracranial metastasis in a two-year-old

Thymic carcinoma with central nervous system involvement is very rare in children. A 27-month-old girl presented with a unilateral squint, vomiting, and behavioral changes. Imaging studies showed a silent anterior mediastinal mass and a large metastatic mass at the base of the skull. Biopsy of the anterior mediastinal mass confirmed an undifferentiated tumor consistent with thymic carcinoma. The child died within 3 months of the onset of symptoms, due to progression of the disease. These lethal tumors of unknown histogeneses and etiology are aggressive in nature, resistant to therapy, and have a rapidly fatal course.

Non-Invasive and Minimally Invasive Imaging Evaluation of CSF Rhinorrhoea - a Retrospective Study with Review of Literature

Background

Localization of a cerebrospinal fluid [CSF] fistula is a diagnostic challenge. The choice of an optimal imaging technique is necessary to locate the site of CSF leak which is required for surgical/endoscopic repair of the CSF fistula.

Material/Methods

Retrospective analysis of imaging was performed in 33 patients who presented with symptoms suggestive of CSF rhinorrhoea over a period of two years. Either a bone defect on high resolution CT [HRCT] or CSF column extending extracranially from the subarachnoid space with or without brain/ meningeal herniation on magnetic resonance [MR] cisternography was considered positive for CSF leak. The MR imaging technique included 1-mm heavily T2-weighted [TR 2000 ms; TE-200 ms] fast spin echo study in coronal and sagittal planes. HRCT sections involved 0.625 to 0.8-mm sections in the coronal plane, with or without axial planes, through the paranasal sinuses, reconstructed in a sharp algorithm and acquired with the patient in prone position. Imaging findings were compared with endoscopic findings, being the gold standard for the assessment of CSF rhinorrhea.

Results

A total of 25 patients had a combination of HRCT and MR cisternography. The sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] of both MR cisternography and HRCT together were 93%, 100%, 100% and 50% respectively. Two patients underwent only MR cisternography, 5 patients underwent only HRCT and one patient underwent HRCT, MR cisternography and CT cisternography. Though PPV was 100% in the groups with HRCT alone, MR cisternography alone and combined CT cisternography, HRCT and MR cisternography, the results were not statistically significant as the number of patients in those groups was lower.

Conclusions

Combination of MR cisternography and HRCT appears to be complementary, accurate and non-invasive and should be considered as optimal imaging modality for pre-op imaging in the evaluation of CSF rhinorrhoea.

Unilateral Obstructive Emphysema in Infancy due to Mediastinal Bronchogenic Cyst-Diagnostic Challenge and Management

Bronchogenic cysts are the most common cystic mediastinal lesion in children. Bronchogenic cyst causing unilateral obstructive emphysema is a rare presentation. We report the case of a one and half month old infant who presented with respiratory distress which was initially suspected as left pneumothorax on frontal chest radiograph but was later found to be due to hyperinflated left lung and hence the possibility of congenital lobar emphysema was considered. CT thorax and limited MRI sections revealed a cystic lesion in mediastinum causing obstructive emphysema and mediastinal displacement. He underwent an emergency thoracotomy and excision of the cyst via an extrapleural approach. Post operatively, rapid improvement of the infant was noticed both clinically as well as radiologically. Cross sectional imaging like CT or MR is required for reaching the correct and early diagnosis in paediatric patients with respiratory distress, when there is diagnostic dilemma based on chest radiograph.