A Rare Presentation of COVID-19 with Pulmonary Embolism. / Uma Apresentação Rara de COVID-19 com Embolia Pulmonar.

Coronavirus disease 2019 (COVID-19) has been reported in almost every country in the world since December 2019. Infection with SARS-CoV-2 is often asymptomatic or with mild symptoms, but it may also lead to hypoxia, a hyperinflammatory state, and coagulopathy. The abnormal coagulation parameters are associated with thrombotic complications, including pulmonary embolism in COVID-19, but little is known about the mechanisms. The similarity of initial symptoms of both diseases can also be confusing, therefore the physicians should be aware of the potential for concurrent conditions. Herein, we present a case who did not have ground-glass opacities in the lungs, yet presented with pulmonary embolism and pleural effusions in association with COVID-19 infection.

A doença de coronavírus 2019 (COVID-19) foi relatada em quase todos os países do mundo desde dezembro de 2019. A infecção por SARS-CoV-2 é frequentemente assintomática ou com sintomas leves, mas também pode levar à hipóxia, um estado hiperinflamatório e coagulopatia. Os parâmetros de coagulação anormais estão associados a complicações trombóticas, incluindo embolia pulmonar na COVID-19, mas pouco se sabe sobre os mecanismos. A semelhança dos sintomas iniciais de ambas as doenças também pode ser confusa, portanto, os médicos devem estar cientes do potencial para condições concomitantes. Apresentamos aqui um caso que não apresentava opacidades em vidro fosco nos pulmões, mas apresentava embolia pulmonar e derrame pleural em associação com infecção por COVID-19.

The relationship between migraine headache and asthma features.

Migraine and asthma are comorbid chronic disorders with episodic attacks thought to involve inflammatory and neurological mechanisms. The objective of the present study is to investigate the relationship of asthma features between the asthma patients with migraine and those without migraine headache. A cross-sectional study was conducted from October 2015 to June 2016. Physician-diagnosed asthma patients aged 18 years and above were included. Demographic data, pulmonary function test and treatment of asthma were recorded. Asthma control was assessed using the asthma control test (ACT) and asthma control questionnaire (ACQ). The diagnosis of migraine was made by the neurologist with face-to face examinations based on the International Classification of Headache Disorders, third edition beta (ICHD-III-beta) criteria. Data about the age at onset, frequency of headache attacks, duration of headache attack, the presence of aura, and severity of headache were recorded. The severity of headache was evaluated using visual analogue scale (VAS). Overall 121 asthma patients were included in this study. Migraine was found to be present in 32 (26.4%) of patients. No statistically significant difference was found between asthma group and asthma with migraine groups in terms of pulmonary function test parameters. The mean ACT score in asthma with migraine patients group was significantly lower than the asthma groups. Morever, in the group asthma with migraine, a negative significant correlations were found between ACT scores with VAS scores. This study demonstrates that migraine headache may be associated with poor asthma control. On the other hand, it should not be forgotten that ACT is a subjective test and can be affected from by many clinical parameters.

The diagnostic significance of signal peptide-complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein-1 levels in pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is a common and potentially life-threatening disorder. Patients with PE often have nonspecific symptoms, and the diagnosis is often delayed. AIM: The aim of our study was to investigate the role of signal peptide-complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 (SCUBE1) used in the diagnosis of PE. METHODS: The study was designed prospectively. A total of 57 patients who were admitted to emergency service with clinically suspected PE were included in the study. The patients diagnosed with PE were defined as PE group (n = 32), and the patients with undetectable embolism on computerized tomographic pulmonary angiography were defined as non-PE group (n = 25). Twenty-five age- and sex-matched healthy cases were chosen for the study. Routine biochemical analysis, complete blood count, D-dimer, SCUBE1, and arterial blood gas analysis were performed early after admission. RESULTS: Mean SCUBE1 levels were higher in the PE group (0.90 ng/mL) than in the non-PE (0.38 ng/mL) and control groups (0.47 ng/mL) (P < 0.01). A cutoff point of 0.49 ng/mL for SCUBE1 indicated 100% sensitivity and 64% specificity in patients with PE. Mean D-dimer levels were not different between PE and non-PE groups (P = 0.591). A multivariable logistic regression analysis (with dichotomous PE groups as the response variable; age, gender, chest pain, syncope, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, D-dimer, neutrophil-lymphocytes ratio, and SCUBE1 variables as predictors) showed that the significant and independent predictors of PE diagnosis were SCUBE1 and chest pain. CONCLUSION: This study suggests that serum SCUBE1 measurement might be used as a diagnostic biomarker in PE.

The clinical significance of hematologic parameters in patients with sarcoidosis.

BACKGROUND: Sarcoidosis is a multisystemic inflammatory granulomatous disease of unknown etiology. No suitable biomarkers are available to evaluate the prognosis of this disease, which still has an unpredictable clinical course. The aim of this study was to evaluate the potential clinical usefulness of hematologic markers. MATERIALS AND METHODS: We investigated 172 subjects: 116 patients with sarcoidosis and 56 healthy individuals at Suleyman Demirel University and Dr. Suat Seren Chest Diseases and Thoracic Surgery Training Hospital. Complete blood count, demographics and pulmonary function test data from sarcoidosis patients between 2008 and 2013 were evaluated and collated retrospectively. The cut-off values were determined by calculating the neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume (MPV) of the patients. RESULTS: The cut-off values were determined as 2 and 8.95 for NLR and MPV, respectively. NLRs were significantly higher in sarcoidosis patients than in healthy controls (P < 0.001) and were directly correlated with erythrocyte sedimentation rate (ESR) levels (R = 0.183, P = 0.017). Receiver operator characteristic (ROC) curve analysis revealed a 0.83 [confidence interval (CI) 68.8%-88.4%] area under the curve, 80% sensitivity and 59% specificity at the cut-off of NLR. Higher NLRs (≥2) were detected in patients with sarcoidosis than in the control group (P < 0.001). Also, high NLRs were more frequent in patients with extrapulmonary involvement (P = 0.031). MPV values were not different between control and patient groups. CONCLUSIONS: NLR may be a biomarker with good sensitivity that is easily detected in serum. It can be proposed in clinical practice to identify a patient's prognosis. However, large prospective studies are required to further demonstrate the prognostic significance of these values.

A New Inflammatory Prognostic Index, Based on C-reactive Protein, the Neutrophil to Lymphocyte Ratio and Serum Albumin is Useful for Predicting Prognosis in Non-Small Cell Lung Cancer Cases

Purpose: We aimed to establish an inflammatory prognostic index (IPI) in early and advanced non-small cell lung cancer (NSCLC) patients based on hematologic and biochemical parameters and to analyze its predictive value for NSCLC survival. Materials and Methods: A retrospective review of 685 patients with early and advanced NSCLC diagnosed between 2009 and 2014 was conducted with collection of clinical, and laboratory data. The IPI was calculated as C-reactive protein × NLR (neutrophil/ lymphocyte ratio)/serum albumin. Univariate and multivariate analyses were performed to assess the prognostic value of relevant factors. Results: The optimal cut-off value of IPI for overall survival (OS) stratification was determined to be 15. Totals of 334 (48.8%) and 351 (51.2%) patients were assigned to high and low IPI groups, respectively. Compared with low IPI, high IPI was associated with older age, greater tumor size, high lymph node involvement, distant metastases, advanced stage and poor performance status. Median OS was worse in the high IPI group (low vs high, 8.0 vs 34.0 months; HR, 3.5; p<0.001). Progression free survival values of the patients who had high vs low IPI were determined 6 months (95% CI:5.3-6.6) and 14 months (95% CI:12.1-15.8), respectively (HR; 2.4, P<0.001). On multivariate analysis, stage, performance status, lactate dehydrogenase and IPI were independent prognostic factors for OS. Subgroup analysis showed IPI was generally a significant prognostic factor in all clinical variables. Conclusion: The described IPI may be an inexpensive, easily accessible and independent prognostic index for NSCLC patients, useful for clinical practice.

Thiol/disulfide homeostasis: A prognostic biomarker for patients with advanced non-small cell lung cancer?

BACKGROUND: The aim of this study was to investigate oxidative stress and thiol/disulfide status with a novel automated homeostasis assay in advanced non-small cell lung cancer (NSCLC). METHODS: Thirty-five patients with advanced NSCLC, who had been newly diagnosed and previously untreated, and 35 healthy subjects were chosen for the study. We measured plasma total thiol (-SH+-S-S-), native thiol (thiol) (-SH), and disulfide (-S-S-) levels in the patients with NSCLC and the healthy subjects. The thiol/disulfide (-SH/-S-S-) ratio was also calculated. RESULTS: Statistically significant differences between the patient group and the control group were detected for the thiol/disulfide parameters. The mean native thiol, total thiol, and disulfide levels were significantly lower in the group with advanced stage NSCLC. The cut-off value was 313 and 13.8 for native thiol and disulfide, respectively. Median overall survival (OS) was significantly shorter in patients with low native thiol and disulfide levels according to the cut-off value (respectively, P = 0.001; P = 0.006). Native thiol, total thiol, and disulfide levels were correlated with Karnofsky performance status (KPS), OS, and age. Additionally, hierarchical regression analyses showed gender, KPS, lung metastases, and plasma native thiol levels were the determinants of OS in the final model. CONCLUSION: These results suggest that in advanced stage NSCLC, the native thiol, total thiol, and disulfide levels decrease, while the native thiol/disulfide ratio does not change. Low levels of thiol/disulfide parameters are related to tumor aggressiveness and may predict a poor outcome for patients with NSCLC.

Elevated serum matrix metalloproteinase-2 and -9 and their correlations with severity of disease in patients with community-acquired pneumonia.

BACKGROUND/AIM: To determine the role of matrix metalloproteinases (MMPs) and their relationship with the clinical course of community-acquired pneumonia (CAP). MATERIALS AND METHODS: Sixty-two consecutively hospitalized patients with CAP were enrolled and their pneumonia severity index (PSI), time to clinical stability (TCS), treatment response, and complications were recorded. The pre- and posttreatment serum concentrations of MMPs and their inhibitors were analyzed by ELISA. The activities of MMPs were evaluated by gelatin zymography. RESULTS: MMP-2 and -9 serum levels and their activities were higher in CAP patients than controls (P < 0.001 and P < 0.001, respectively). Low-risk patients had lower levels of MMP-2 and TIMP-1 than high-risk patients (P = 0.044, P = 0.001, respectively). Pretreatment serum TIMP-1 level was higher in patients with TCS of >3 days (P = 0.004) and was correlated with oxygenation and PSI scores. Posttreatment serum levels of MMP-9 and TIMP-1 were decreased after antibiotics (P = 0.000 1 and P = 0.0 17, respectively). CONCLUSION: Although MMP-2, MMP-9, and TIMP-1 correlate with many poor prognostic factors, more studies are required to prove their possible role in predicting the severity of CAP.

A simple clinical model composed of ECG, shock index, and arterial blood gas analysis for predicting severe pulmonary embolism.

BACKGROUND: Objective diagnosis of severe pulmonary embolism (PE) is obligatory because of its considerable mortality. AIM: To assess the abilities of electrocardiography (ECG) score (sECG) and the newly generated scoring system composed of the scores obtained from arterial blood gas (ABG) analysis and shock index (SI) in addition to sECG in predicting severe PE. MATERIAL AND METHODS: The degree of pulmonary vascular obstruction (sPVO) and the right ventricular dysfunction (RVD) were determined with spiral computed tomography (CT) in 53 consequent patients with PE. Twelve-lead ECG taken within a day of PE event and ABG values were evaluated according to ECG scoring system and original Geneva system, respectively. RESULTS: The mean age of patients was 62.6 ± 13.4 years. Right ventricular dysfunction, sPVO ≥ 50%, hypoxemia, and SI were present in 34 (64.2%), 27 (50.9%), 50 (94.3%), and 22 (41.5%) patients, respectively. The mean sECG, 5.9 ± 5.1, was correlated with sPVO, maximum diameter of right ventricle (RV), and right ventricle to left ventricle (RV/LV) ratio (r = .385, r = .415, and r = .329, respectively). The mean newly generated score was 10.9 ± 5.5 and correlated with sPVO, maximum diameter of RV, and RV/LV ratio (r = .394, r = .483, and r = .393, respectively). Receiver operator characteristic (ROC) curve analyses revealed that sECG ≥ 3.5, s (ECG + SI) ≥ 4.5, and s (ECG + SI + ABG) ≥ 9.5 predict the severe PE patients with 70.6%, 61.8%, 58.8% sensitivities and 52.6%, 63.2%, 73.7% specificities, respectively. CONCLUSION: Adding the scores obtained from SI and ABG to the sECG enhances the specificity of sECG in predicting RVD (+) or severe PE patients, although a lesser degree decreasing in sensitivity may occur.