Pulmonary embolism versus pulmonary vasculitis in Hughes-Stovin syndrome: Characteristic computed tomography pulmonary angiographic findings and diagnostic and therapeutic implications. HSS International Study Group.

BACKGROUND AND AIM: Hughes-Stovin syndrome (HSS) is a rare systemic vasculitis with widespread venous/arterial thrombosis and pulmonary vasculitis. Distinguishing between pulmonary embolism (PE) and in-situ thrombosis in the early stages of HSS is challenging. The aim of the study is to compare clinical, laboratory, and computed tomography pulmonary angiography (CTPA) characteristics in patients diagnosed with PE versus those with HSS. METHODS: This retrospective study included 40 HSS patients with complete CTPA studies available, previously published by the HSS study group, and 50 patients diagnosed with PE from a single center. Demographics, clinical and laboratory findings, vascular thrombotic events, were compared between both groups. The CTPA findings were reviewed, with emphasis on the distribution, adherence to the mural wall, pulmonary infarction, ground glass opacification, and intra-alveolar hemorrhage. Pulmonary artery aneurysms (PAAs) in HSS were assessed and classified. RESULTS: The mean age of HSS patients was 35 ± 12.3 years, in PE 58.4 ± 17 (p < 0.0001). Among PE 39(78 %) had co-morbidities, among HSS none. In contrast to PE, in HSS both major venous and arterial thrombotic events are seen.. Various patterns of PAAs were observed in the HSS group, which were entirely absent in PE. Parenchymal hemorrhage was also more frequent in HSS compared to PE (P < 0.001). CONCLUSION: Major vascular thrombosis with arterial aneurysms formation are characteristic of HSS. PE typically appear loosely-adherent and mobile whereas "in-situ thrombosis" seen in HSS is tightly-adherent to the mural wall. Mural wall enhancement and PAAs are distinctive pulmonary findings in HSS. The latter findings have significant therapeutic ramifications.

Is High-Flow Nasal Oxygenation a Game Changer in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration?: A pilot study.

Objectives: This study aimed to compare the high-flow nasal oxygen (HFNO) and supraglottic airway device (SAD) techniques in oncological patients undergoing endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) to evaluate the efficacy of HFNO in them. Methods: This pilot study was conducted at Sultan Qaboos Comprehensive Cancer Care and Research Centre, Muscat, Oman, from May 2022 to March 2023. Patients undergoing EBUS TBNA under moderate sedation were quasi-randomised into the HFNO and SAD groups. The episodes and duration of hypoxia and the lowest level of oxygen saturation were the primary outcomes measured. Results: A total of 24 patients were included in the study (10 of them were in the HFNO group and 14 were in the SAD group), with an equal number of males and females. The duration of the procedure in both groups was similar (45 ± 20 and 44 ± 17 minutes in the HFNO and SAD groups, respectively). The mean lowest oxygen saturation in the HFNO group was 93.5 ± 4.5%, which was significantly higher than that of the SAD group (90 ± 3%; P <0.001). In both groups, maximum hypoxia occurred during the early phase of the procedure. However, the HFNO and SAD groups were similar in terms of the cumulative duration of hypotension (140 versus 95 seconds, respectively) and bradycardia (25 versus 40 seconds, respectively). Conclusion: HFNO is a good alternative to SAD and could be used safely and efficiently in patients undergoing EBUS TBNA.

Bleomycin and perioperative care: a case report.

 Bleomycin is associated with pulmonary toxicity ranging from pneumonitis, pulmonary fibrosis, to fatal acute respiratory distress syndrome. Oxygen administration can potentiate or precipitate bleomycin pulmonary toxicity, and the most common setting of oxygen exposure is during anesthesia. We report here the successful management and perioperative care of a patient with documented bleomycin pulmonary toxicity who had to undergo an eight hour long retroperitoneal surgery. With proper preoperative assessment, chest physiotherapy, inhaled steroids and bronchodilators, antibiotics, operative restriction of oxygen and fluids and good postoperative care no further pulmonary insult was inflicted.

Persistence of Symptoms Following Hospitalization for COVID-19 in Oman: A Bidirectional Observational Study.

Objectives: This study sought to assess the prevalence of persistent COVID-19-related symptoms in patients with mild, severe, and critical disease. Methods: We conducted a bidirectional cohort observational study that included all adult patients ≥ 18 years, admitted to Armed Forces Hospital, Muscat between July 2020 and June 2022, with COVID-19 infection and discharged alive. Patients were requested to attend outpatient clinic at weeks six and 12 post-discharge, where they filled out a questionnaire and underwent a chest X-ray. Additionally, blood tests were performed if necessary. Healthcare workers with mild infections were also requested to fill out a questionnaire about their initial symptoms, persistent symptoms, and comorbidities. Results: The study included 468 patients, comprising 261 hospitalized patients and 207 healthcare workers. On follow-up, 39.7% of patients presented with residual symptoms, such as cough, breathlessness, and joint pain. These symptoms were more common in patients with medical comorbidities, particularly hypertension, diabetes, and dyslipidemia. Notably, these symptoms were also observed in patients with mild disease. Post-COVID-19 pulmonary fibrosis was observed in 21 patients, mainly among those admitted to the intensive care unit or requiring prolonged hospitalization. Conclusions: This study highlights the persistence of symptoms and the prevalence of post-COVID-19 syndrome at two months post-discharge, especially among patients with severe and critical disease during the acute phase. Various predictors of post-COVID-19 syndrome were identified, including female gender, older age, presence of comorbidities, disease severity, and hypertension. Therefore, patients in these categories require thorough evaluation and long-term follow-up to manage residual symptoms.

Lung cancer screening in the gulf: Rationale and recommendations.

Lung cancer is the leading cause of cancer-related death worldwide among both men and women. Although advances in therapy have been made, the 5-year survival rates for lung cancer remain poor, ranging from 10% to 20%. One of the main reasons is late presentation, as only 25% of patients are amenable to cure at the time of presentation. Therefore, the emphasis on lung cancer screening (LCS) is growing with the current evidence that has shown benefits with low-dose computed tomography scan of the chest in high-risk populations. LCS remains a debated topic in Gulf Cooperation Council (GCC) countries, possibly due to a lack of local experience. In this article, we explore the rationale and give recommendations on the best approach for LCS in GCC.

Respiratory Complications after COVID-19.

COVID-19 pandemic has been associated with high short-term morbidity and mortality. Lungs are the main organs affected by SARS-CoV-2 infection. In the long-term, the pulmonary sequelae related to COVID-19 are expected to rise significantly leading to an extended impact on community health and health care facilities. A wide variety of long-term respiratory complications secondary to COVID-19 have been described ranging from persistent symptoms and radiologically observable changes to impaired respiratory physiology, vascular complications, and pulmonary fibrosis. Even after two-years, respiratory sequalae related to post-acute SARS-CoV-2 infection have not been fully explored and understood. The main treatment for most COVID-19 respiratory complications is still symptomatic and supportive-care oriented. In this review article, we shed light on current knowledge of the post-COVID-19 complications, focusing on pulmonary fibrosis, treatment directions, and recommendations to physicians.

Pulmonary vasculitis in Hughes-Stovin syndrome (HSS): a reference atlas and computed tomography pulmonary angiography guide-a report by the HSS International Study Group.

INTRODUCTION: Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by widespread venous/arterial thrombosis and pulmonary artery aneurysms (PAAs), which is associated with serious morbidity and mortality. All fatalities reported in HSS resulted from unpredictable fatal suffocating hemoptysis. Therefore, it is necessary to recognize pulmonary complications at an early stage of the disease. OBJECTIVES: The aims of this study are to develop a reference atlas of images depicting the characteristic features of HSS by computed tomography pulmonary angiography (CTPA). To make a guide for physicians by developing a classification of PAAs according to the severity and risk of complications associated with each distinct lesion type. METHODS: The Members of the HSS International Study Group (HSSISG) collected 42 cases, with high-quality CTPA images in one radiology station and made reconstructions from the source images. These detailed CTPA studies were reviewed for final image selection and approved by HSSISG board members. We classified these findings according to the clinical course of the patients. RESULTS: This atlas describes the CTPA images that best define the wide spectrum of pulmonary vasculitis observed in HSS. Pulmonary aneurysms were classified into six radiographic patterns: from true stable PAA with adherent in-situ thrombosis to unstable leaking PAA, BAA and/or PAP with loss of aneurysmal wall definition (most prone to rupture), also CTPA images demonstrating right ventricular strain and intracardiac thrombosis. CONCLUSION: The HSSISG reference atlas is a guide for physicians regarding the CTPA radiological findings, essential for early diagnosis and management of HSS-related pulmonary vasculitis. Key Points • The Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by extensive vascular thrombosis and pulmonary artery aneurysms (PAAs) that can lead to significant morbidity and mortality. • All fatalities reported in HSS were related to unpredictable massive hemoptysis; therefore, it is critical to recognize pulmonary complications at an early stage of the disease. • The HSS International Study Group reference atlas  classifies pulmonary vasculitis in HSS at 6 different stages of the disease process and defines the different radiological patterns of pulmonary vasculitis notably pulmonary artery aneurysms, as detected by computed tomography pulmonary angiography (CTPA). • The main aim of the classification is to make a guide for physicians about this rare syndrome. Such a scheme has never been reached before since the first description of the syndrome by Hughes and Stovin since 1959. This classification will form the basis for future recommendations regarding diagnosis and treatment of this syndrome.

A critical analysis of 57 cases of Hughes-Stovin syndrome (HSS). A report by the HSS International Study Group (HSSISG).

BACKGROUND: Hughes-Stovin syndrome (HSS) is a systemic disease characterized by widespread vascular thrombosis and pulmonary vasculitis with serious morbidity and mortality. The HSS International Study Group is a multidisciplinary taskforce aiming to study HSS, in order to generate consensus recommendations regarding diagnosis and treatment. METHODS: We included 57 published cases of HSS (43 males) and collected data regarding: clinical presentation, associated complications, hemoptysis severity, laboratory and computed tomography pulmonary angiography (CTPA) findings, treatment modalities and cause of death. RESULTS: At initial presentation, DVT was observed in 29(33.3 %), thrombophlebitis in 3(5.3%), hemoptysis in 24(42.1%), and diplopia and seizures in 1 patient each. During the course of disease, DVT occurred in 48(84.2%) patients, and superficial thrombophlebitis was observed in 29(50.9%). Hemoptysis occurred in 53(93.0%) patients and was fatal in 12(21.1%). Pulmonary artery (PA) aneurysms (PAAs) were bilateral in 53(93%) patients. PAA were located within the main PA in 11(19.3%), lobar in 50(87.7%), interlobar in 13(22.8%) and segmental in 42(73.7%). Fatal outcomes were more common in patients with inferior vena cava thrombosis (p = 0.039) and ruptured PAAs (p < 0.001). Death was less common in patients treated with corticosteroids (p < 0.001), cyclophosphamide (p < 0.008), azathioprine (p < 0.008), combined immune modulators (p < 0.001). No patients had uveitis; 6(10.5%) had genital ulcers and 11(19.3%) had oral ulcers. CONCLUSIONS: HSS may lead to serious morbidity and mortality if left untreated. PAAs, adherent in-situ thrombosis and aneurysmal wall enhancement are characteristic CTPA signs of HSS pulmonary vasculitis. Combined immune modulators contribute to favorable outcomes.

A 48-Year-Old South African Woman with Rheumatoid Arthritis and Lung Nodules.

CASE PRESENTATION: We present the case of a 48-year-old South African woman with no smoking history, and seropositive rheumatoid arthritis diagnosed in 2001. She was treated with chloroquine (150 mg, 4 times per week) and methotrexate (30 mg weekly) with well-controlled symptoms until 2015, when she developed a disease flare. Her treatment regimen was changed to leflunomide (20 mg daily) monotherapy with subsequent symptom control. Biologic agents were not accessible because of cost constraints.

Neuromyelitis optica with unilateral diaphragmatic paralysis.

In this case report, we describe the course of a female patient who is known to have neuromyelitis optica (NMO) and developed left hemiparesis and unilateral diaphragmatic paralysis. She was initially treated with intravenous methylprednisolone 1 g daily for 5 days without improvement. Subsequently, she received five sessions of a plasmapheresis. Her hemiparesis had improved after few days. however, the phrenic nerve palsy remained.

Recurrent Pulmonary Aneurysms: Hughes-Stovin Syndrome on the Spectrum of Behçet Disease.

In this report, we describe a male patient who presented with recurrent life-threatening hemoptysis due to the sequential formation of multiple pulmonary aneurysms. Both pulmonary artery coil embolization and right lower lobectomy were performed, with limited success. The patient experienced extensive bilateral femoral DVT extending into the inferior vena cava, with massive hemoptysis, fulfilling the diagnosis of Hughes-Stovin syndrome. A final diagnosis of Behçet disease was made following extensive investigation, and the patient responded well to prednisone 20 mg orally and azathioprine 100 mg orally.