CTPA imaging findings, beyond pulmonary embolism, in patients with Severe Acute Respiratory Syndrome Corona Virus-2 infection and their relation to clinical outcome - a single center experience

OBJECTIVE

The aim of our study was to investigate a potential association between the severity of COVID-19 disease and related 28-day mortality, with the presence of mediastinal lymphadenopathy, the extension of lung parenchymal infiltrates, the presence of pulmonary embolism, the density and distribution of mediastinal and subcutaneous fat, the inflammatory markers and the direct and indirect radiological signs of right heart overload and strain.

PATIENTS AND METHODS

We retrospectively included patients diagnosed with SARS-CoV-2 infection, who were admitted to the Departments of Internal and Respiratory Medicine of Patras University Hospital during the second pandemic wave (February 2021 up to July 2021) and underwent CTPA for routine diagnostic workup. Demographic characteristics, routine laboratory, radiological parameters and 28-day mortality were also recorded.

RESULTS

Fifty-three consecutive patients were included. The mean age was 64.47±17.1 years and 64,1% (n=34) were males. Pulmonary embolism (PE) (p=0.019), Right Ventricle-to-Left Ventricle Diameter (RV/LV)  Ratio>1 (p<0.01), Reverse Flow in Hepatic Veins (RFHV) (p=0.019), higher density in subcutaneous fat (-99 HU vs. -104HU, p=0.016), increased Lactic Dehydrogenase (LDH), Polymorphonuclear cells (PMN), ferritin, and d-dimer levels (534 vs. 367 U/L, p=0.001, 9220 vs. 5660 Κ/μL, p=001, 956 vs. 360 ng/ml, p=0.005 and 2300 vs. 1040 μg/ml, p=0.003, respectively) were statistically significant related with worse 28-day mortality. Binomial multivariate regression analysis revealed that only RV/LV diameter>1, higher subcutaneous fat density and higher LDH values were independently associated with increased 28-day mortality (OR: 82.9, 95%CI: 1.334-5158, p=0.036, OR: 1.2, 95%CI: 1.016-1.426, p=0.032 and OR:1.016, 95% CI:1.004-1.029, p=0.011, respectively). Subgroup analysis revealed that mediastinal lymph node enlargement (EML) and PE were associated to increased Pulmonary Disease Severity Index (PDSI) score (p=0.042 and p=0.007, respectively), but not to mortality.

CONCLUSIONS

Our study showed that right heart strain as depicted by a RV/LV diameter>1, higher subcutaneous fat density and higher LDH values are independently associated with an increased 28-day mortality in our SARS-COV2 patient group.

Procalcitonin and sepsis in the Emergency Department: an update

OBJECTIVE

Due to significant mortality and morbidity which may be reduced by prompts treatment, there is great interest in determining an ideal biomarker for the diagnosis of sepsis upon presentation to the Emergency Department. The most specific test is a positive blood culture, but its sensitivity is very low, and the results are usually available 2 days after sampling. For this reason, research is conducted into serum biomarkers with greater sensitivity for which results can be available within hours of presentation. High initial procalcitonin levels are a sensitive marker of bacterial infection, and the degree of procalcitonin elevation may determine which patients are at greater risk for adverse outcomes (mortality or ICU admission). The purpose of this narrative review is to evaluate the utility of procalcitonin as a diagnostic marker of sepsis in the emergency department and the use of procalcitonin-guided management algorithms.

MATERIALS AND METHODS

A PubMed search was conducted in June 2020 for procalcitonin, resulting in the retrieval of 371 articles which were screened for relevance. 48 articles were included in the review.

CONCLUSIONS

Procalcitonin elevation may be used as an indication for initiation of antibiotic treatment, and antibiotics may be discontinued once procalcitonin normalizes. This approach leads to reduced antibiotic consumption, but it is not yet clear whether it ensures better outcomes for patients. Procalcitonin in centers where it is available could be a useful diagnostic and prognostic biomarker for patients presenting to the Emergency Department with symptoms suggestive of sepsis. Further research is however required to determine whether the use of procalcitonin measurements in management algorithms leads to improved patient outcomes.

Differential diagnosis and treatment of acute cauda equina syndrome in the human immunodeficiency virus positive patient: a case report and review of the literature

BACKGROUND

Acute cauda equina syndrome is an uncommon but significant neurologic presentation due to a variety of underlying diseases. Anatomical compression of nerve roots, usually by a lumbar disk hernia is a common cause in the general population, while inflammatory, neoplastic, and ischemic causes have also been recognized. Among human immunodeficiency virus (HIV) infected patients with acquired immunodeficiency syndrome, infectious causes are encountered more frequently, the most prevalent of which are: cytomegalovirus, herpes simplex virus 1/2, varicella zoster virus, and Mycobacterium tuberculosis infections. Studies of cauda equina syndrome in well-controlled HIV infection are lacking. We describe such a case of cauda equina syndrome in a well-controlled HIV-infected patient, along with a brief review of the literature regarding the syndrome's diagnosis and treatment in individuals with HIV infection.

CASE PRESENTATION

A 36-year-old Greek male, HIV-positive patient presented with perineal and left hemiscrotal numbness, lumbar pain, left-sided sciatica, and urinary incontinence. Magnetic resonance imaging of the patient's lumbar spine revealed intrathecal migration of a fragment from an intervertebral lumbar disk exerting pressure on the cauda equina. A cerebrospinal fluid examination, brain computed tomography scan, spine magnetic resonance imaging, and serological test results were negative for central nervous system infections. Our patient underwent emergency neurosurgical spinal decompression, which resolved most symptoms, except for mild urinary incontinence.

CONCLUSIONS

Noninfectious etiologies may also cause cauda equina syndrome in HIV-infected individuals, especially in well-controlled disease under antiretroviral therapy. Prompt recognition and treatment of the underlying cause is important to minimize residual symptoms. Targeted antimicrobial chemotherapy is used to treat infectious causes, while prompt surgical decompression is favored for anatomical causes of cauda equina syndrome in the HIV-infected patient.

-572 G/C single nucleotide polymorphism of interleukin-6 and sepsis predisposition in chronic renal disease

Single nucleotide polymorphisms (SNPs) of interleukin (IL)-6 are associated with the development of chronic renal disease (CRD). Their impact for sepsis in the field of CRD was investigated. One control cohort of 115 patients with CRD without infection and another case cohort of 198 patients with CRD and sepsis were enrolled. Genotyping at the −174 (rs1800795) and −572 positions of IL-6 (rs1800796) was done by restriction fragment length polymorphism. Circulating IL-6 was measured by an enzyme immunoassay. The GG genotype of rs1800796 was more frequent among cases (78.3 %) than controls (62.6 %). No difference in the genotype frequencies of rs1800795 between cases and controls were found. Odds ratio for sepsis was 2.07 (95%CI 1.24–3.44, p = 0.005) with the GG genotype of rs1800796, which was confirmed by logistic regression analysis taking into consideration the presence of chronic comorbidities. All-cause mortality until day 28 was similar between patients with the GG genotype and the GC/CC genotypes of rs1800796, but death caused from cardiovascular events not-related with infection was more frequent with the GG genotype (14.6 % vs 2.4 %, p = 0.031). Circulating IL-6 was greater among patients of the GC/CC genotypes of rs1800796 and multiple organ dysfunction (p = 0.013). The GG genotype of rs1800796 predisposes to sepsis in CRD and to 28-day mortality by sepsis-unrelated cardiovascular phenomena.

Pancreatic mediastinal pseudocyst presenting as a posterior mediastinal mass with recurrent pleural effusions: a case report and review of the literature

Introduction

A rare complication of chronic pancreatitis is the formation of single or multiple mediastinal pseudocysts, which are fueled from the pancreas through anatomical openings of the diaphragm. We present a rare case with a difficult diagnosis, treatment and potentially catastrophic complications.

Case presentation

A 53-year-old Caucasian man was referred to our hospital for further investigation and treatment of a large heterogeneous mass situated in the posterior mediastinum, and bilateral pleural effusions which had developed after recent multiple episodes of pancreatitis. He had a history of chronic alcoholism. Laboratory and imaging modalities established the diagnosis of a pancreatic mediastinal pseudocyst.

Conclusions

Despite successful initial conservative treatment, our patient had a relapse and underwent emergency surgical intervention due to internal hemorrhage. We present his diagnostic and imaging workup, along with the multidisciplinary intervention, and a literature review referring to the diagnosis and treatment of mediastinal pancreatic pseudocysts.

Thyroid storm presenting as intra-abdominal sepsis with multi-organ failure requiring intensive care

Thyroid storm is a rare but life-threatening condition manifesting with several clinical presentations. Atypical thyroid storm should be part of the differential diagnosis in patients with multiple organ dysfunction of unknown aetiology. In this case report, delayed recognition of thyroid storm in a young female who presented with acute abdomen increased the risk of poor outcome. Prompt initiation of anti-thyroid therapy once the diagnosis of thyroid storm was established, combined with adequate vital organ support using a goal-directed therapy protocol in the intensive care unit resulted in a good outcome.

Chronotypology and melatonin alterations in minimal hepatic encephalopathy

Background

"Minimal (subclinical) hepatic encephalopathy" is a term that describes impairment of every day life activities in cirrhosis patients without clinical neurologic abnormalities. Melatonin diurnal pattern disruption and metabolic changes due to liver insufficiency can affect the human biologic clock. Our study was conducted to measure plasma melatonin levels in an attempt to correlate plasma melatonin abnormalities with liver insufficiency severity, and describe chronotypology in cirrhosis patients with minimal encephalopathy.

Methods

Twenty-six cirrhotic patients enrolled in the study and thirteen patients without liver or central nervous system disease served as controls. All patients had full clinical and biochemical evaluation, chronotypology analysis, neurological evaluation, melatonin profile and quality of life assessment.

Results

Cirrhotic patients with minimal encephalopathy exhibit melatonin secretion abnormalities. Cirrhosis patients with more severe hepatic insufficiency (Child-Pugh score > 5) had significantly (p < 0.04) lower evening melatonin levels compared to patients with less severe insufficiency (Child-Pugh score = 5).

Chronotypology analysis revealed Morning Type pattern in 88% of cirrhosis patients.

Discussion

The presence of abnormal plasma melatonin levels before the onset of clinical hepatic encephalopathy, and the finding that patients with more severe cirrhosis have lower evening melatonin levels are the most important findings of this study. Despite these melatonin abnormalities, chronotypology revealed Morning Type pattern in 23 of 26 cirrhosis patients. We believe these findings are important and deserve further study.

Conclusion

Melatonin abnormalities occur in cirrhosis patients without clinical encephalopathy, are related to liver insufficiency severity, may influence chronotypology patterns, and certainly deserve further investigation.