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1.
Radiographics ; 40(6): 1574-1599, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33001783

RESUMO

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) results in coronavirus disease 2019 (COVID-19), which was declared an official pandemic by the World Health Organization on March 11, 2020. The infection has been reported in most countries around the world. As of August 2020, there have been over 21 million cases of COVID-19 reported worldwide, with over 800 000 COVID-19-associated deaths. It has become apparent that although COVID-19 predominantly affects the respiratory system, many other organ systems can also be involved. Imaging plays an essential role in the diagnosis of all manifestations of the disease, as well as its related complications, and proper utilization and interpretation of imaging examinations is crucial. With the growing global COVID-19 outbreak, a comprehensive understanding of the diagnostic imaging hallmarks, imaging features, multisystemic involvement, and evolution of imaging findings is essential for effective patient management and treatment. To date, only a few articles have been published that comprehensively describe the multisystemic imaging manifestations of COVID-19. The authors provide an inclusive system-by-system image-based review of this life-threatening and rapidly spreading infection. In part 1 of this article, the authors discuss general aspects of the disease, with an emphasis on virology, the pathophysiology of the virus, and clinical presentation of the disease. The key imaging features of the varied pathologic manifestations of this infection that involve the pulmonary and peripheral and central vascular systems are also described. Part 2 will focus on key imaging features of COVID-19 that involve the cardiac, neurologic, abdominal, dermatologic and ocular, and musculoskeletal systems, as well as pediatric and pregnancy-related manifestations of the virus. Vascular complications pertinent to each system will be also be discussed in part 2. Online supplemental material is available for this article. ©RSNA, 2020.


Assuntos
Betacoronavirus/fisiologia , Infecções por Coronavirus/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Pandemias , Pneumonia Viral/diagnóstico por imagem , Tromboembolia/diagnóstico por imagem , Trombose/diagnóstico por imagem , Angiografia/métodos , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Síndrome da Liberação de Citocina/etiologia , Síndrome da Liberação de Citocina/fisiopatologia , Progressão da Doença , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Inflamação , Peptidil Dipeptidase A/fisiologia , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Artéria Pulmonar/diagnóstico por imagem , Receptores Virais/fisiologia , Síndrome do Desconforto Respiratório do Adulto/diagnóstico por imagem , Síndrome do Desconforto Respiratório do Adulto/etiologia , Avaliação de Sintomas , Tromboembolia/sangue , Tromboembolia/etiologia , Trombose/sangue , Trombose/etiologia , Microangiopatias Trombóticas/diagnóstico por imagem , Microangiopatias Trombóticas/etiologia , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodos
2.
Monaldi Arch Chest Dis ; 90(3)2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32885626

RESUMO

'Tree-in-bud' (TIB) appearance in computed tomography (CT) chest is most commonly a manifestation of infection. We here describe an unusual cause of TIB during the COVID-19 pandemic. A young male patient who had a history of fever, cough, and respiratory distress presented in the emergency department. As these symptoms matched with coronavirus infection, the COVID-19 test was done, which was found negative. He was then moved to the intensive care unit where he developed severe acute respiratory distress syndrome and was put on mechanical ventilation. Further workup did not reveal any source of infection, as all his cultures were negative, but his CT chest showed a tree-in-bud appearance. After obtaining a detailed history from his friends, the patient was found a chronic abuser of inhaled cocaine and treated with intravenous steroids. Subsequently, he was weaned from the ventilator and discharged from the intensive care unit after becoming asymptomatic.


Assuntos
Fumar Cocaína/efeitos adversos , Transtornos Relacionados ao Uso de Cocaína/diagnóstico , Infecções por Coronavirus/diagnóstico , Lesão Pulmonar/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Pneumonia Viral/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/diagnóstico por imagem , Adulto , Betacoronavirus , Transtornos Relacionados ao Uso de Cocaína/complicações , Diagnóstico Diferencial , Glucocorticoides/uso terapêutico , Humanos , Lesão Pulmonar/etiologia , Lesão Pulmonar/terapia , Masculino , Metilprednisolona/uso terapêutico , Pandemias , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Tomografia Computadorizada por Raios X
3.
Heart Surg Forum ; 23(5): E574-E578, 2020 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-32990580

RESUMO

OBJECTIVE: To explore the effect of atrial septal defect (ASD) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the treatment of ARDS combined with left ventricular dysfunction (LVD) to find a new effective method for treating severe COVID-19 patients. MATERIALS AND METHODS: Five large animal ARDS models of sheep were established by intravenous injection of Lipopolysaccharide. ASD was made under general anesthesia and VA-ECMO was simulated by extracorporeal circulation machine. The oxygenation of peripheral blood, systemic circulation, and cardiac function were observed under conditions of closed and opened ASD, and the significance of ASD shunt in improving cardiopulmonary function was evaluated. RESULTS: With ASD closed, the atrial shunts disappeared, the peripheral artery pressure of oxygen(PaO2): 141.2±21.4mmHg, the oxygenation index (PaO2/FiO2): 353.0±53.5, the mean blood pressure (MAP): 49.3±13.5 mmHg, the heart was full; with ASD opened, the left-to-right shunt was observed, PaO2: 169.3±18.9mmHg, PaO2/FiO2: 423.3±47.3, MAP: 68.2±16.1 mmHg, the range of cardiac motion significantly increased, heart beat was powerful, and systemic circulation significantly improved. Statistical analysis showed that there were significant differences between opened and closed ASD (P < .01). CONCLUSION: ASD plus VA-ECMO is an effective method for the treatment of ARDS combined with LVD, which is the main cause of death in severe COVID-19 patients. However, further clinical validation is needed.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Oxigenação por Membrana Extracorpórea , Comunicação Interatrial/complicações , Pneumonia Viral/complicações , Síndrome do Desconforto Respiratório do Adulto/terapia , Disfunção Ventricular Esquerda/complicações , Animais , Diagnóstico Diferencial , Modelos Animais de Doenças , Pandemias , Síndrome do Desconforto Respiratório do Adulto/etiologia , Ovinos
4.
Blood Adv ; 4(18): 4358-4361, 2020 09 22.
Artigo em Inglês | MEDLINE | ID: mdl-32926122
5.
Undersea Hyperb Med ; 47(3): 405-413, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32931666

RESUMO

Objective: Given the high mortality and prolonged duration of mechanical ventilation of COVID-19 patients, we evaluated the safety and efficacy of hyperbaric oxygen for COVID-19 patients with respiratory distress. Methods: This is a single-center clinical trial of COVID-19 patients at NYU Winthrop Hospital from March 31 to April 28, 2020. Patients in this trial received hyperbaric oxygen therapy at 2.0 atmospheres of pressure in monoplace hyperbaric chambers for 90 minutes daily for a maximum of five total treatments. Controls were identified using propensity score matching among COVID-19 patients admitted during the same time period. Using competing-risks survival regression, we analyzed our primary outcome of inpatient mortality and secondary outcome of mechanical ventilation. Results: We treated 20 COVID-19 patients with hyperbaric oxygen. Ages ranged from 30 to 79 years with an oxygen requirement ranging from 2 to 15 liters on hospital days 0 to 14. Of these 20 patients, two (10%) were intubated and died, and none remain hospitalized. Among 60 propensity-matched controls based on age, sex, body mass index, coronary artery disease, troponin, D-dimer, hospital day, and oxygen requirement, 18 (30%) were intubated, 13 (22%) have died, and three (5%) remain hospitalized (with one still requiring mechanical ventilation). Assuming no further deaths among controls, we estimate that the adjusted subdistribution hazard ratios were 0.37 for inpatient mortality (p=0.14) and 0.26 for mechanical ventilation (p=0.046). Conclusion: Though limited by its study design, our results demonstrate the safety of hyperbaric oxygen among COVID-19 patients and strongly suggests the need for a well-designed, multicenter randomized control trial.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Oxigenação Hiperbárica/métodos , Pneumonia Viral/terapia , Pontuação de Propensão , Síndrome do Desconforto Respiratório do Adulto/terapia , Adulto , Idoso , Pressão Atmosférica , Estudos de Casos e Controles , Infecções por Coronavirus/complicações , Infecções por Coronavirus/mortalidade , Feminino , Humanos , Oxigenação Hiperbárica/efeitos adversos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/mortalidade , Respiração Artificial/mortalidade , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Fatores de Risco , Segurança , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
6.
BMC Infect Dis ; 20(1): 658, 2020 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-32912165

RESUMO

BACKGROUND: Stenotrophomonas maltophilia-induced pulmonary haemorrhage is considered a fatal infection among haematological patients. The outcome can be explained by the patients' immunity status and late diagnosis and treatment. CASE PRESENTATION: We present the rare case of successful outcome in a 61-year-old female who developed alveolar haemorrhage and acute respiratory distress syndrome 8 days after a chemotherapy session for her acute lymphoblastic leukaemia, in the context of secondary bone marrow aplasia. Stenotrophomonas maltophilia was isolated in sputum culture. The patient benefitted from early empirical treatment with colistin followed by trimethoprim/sulfamethoxazole, according to the antibiogram. Despite a severe initial clinical presentation in need of mechanical ventilation, neuromuscular blocking agents infusion, and ventilation in prone position, the patient had a favourable outcome and was discharged from intensive care after 26 days. CONCLUSIONS: Stenotrophomonas maltophilia severe pneumonia complicated with pulmonary haemorrhage is not always fatal in haematological patients. Empirical treatment of multidrug-resistant Stenotrophomonas maltophilia in an immunocompromised haematological patient presenting with hemoptysis should be taken into consideration.


Assuntos
Antibacterianos/uso terapêutico , Colistina/uso terapêutico , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Hemorragia/tratamento farmacológico , Pneumonia Bacteriana/tratamento farmacológico , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Stenotrophomonas maltophilia/isolamento & purificação , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/complicações , Feminino , Infecções por Bactérias Gram-Negativas/etiologia , Hemorragia/etiologia , Humanos , Hospedeiro Imunocomprometido , Pessoa de Meia-Idade , Pneumonia Bacteriana/etiologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Alvéolos Pulmonares/patologia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/microbiologia , Escarro/microbiologia , Resultado do Tratamento
7.
PLoS Pathog ; 16(9): e1008874, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32946517

RESUMO

Coronavirus Disease 2019 (COVID-19) pandemic remains a major public health threat in most countries. The causative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus can lead to acute respiratory distress syndrome and result in mortality in COVID-19 patients. Vitamin D is an immunomodulator hormone with established effectiveness against various upper respiratory infections. Vitamin D can stall hyper-inflammatory responses and expedite healing process of the affected areas, primarily in the lung tissue. Thus, there are ecological and mechanistic reasons to promote exploration of vitamin D action in COVID-19 patients. As no curative drugs are available currently for COVID-19, we feel that the potential of vitamin D to alter the course of disease severity needs to be investigated. Clinical studies may be undertaken to address the value of vitamin D supplementation in deficient, high-risk COVID-19 patients.


Assuntos
Betacoronavirus , Infecções por Coronavirus , Pandemias , Pneumonia Viral , Deficiência de Vitamina D/epidemiologia , Vitamina D/metabolismo , Suplementos Nutricionais , Humanos , Síndrome do Desconforto Respiratório do Adulto/etiologia
8.
J Transl Med ; 18(1): 359, 2020 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-32958009

RESUMO

More than seven months into the coronavirus disease -19 (COVID-19) pandemic, infection from the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to over 21.2 million cases and resulted in over 760,000 deaths worldwide so far. As a result, COVID-19 has changed all our lives as we battle to curtail the spread of the infection in the absence of specific therapies against coronaviruses and in anticipation of a proven safe and efficacious vaccine. Common with previous outbreaks of coronavirus infections, SARS and Middle East respiratory syndrome, COVID-19 can lead to acute respiratory distress syndrome (ARDS) that arises due to an imbalanced immune response. While several repurposed antiviral and host-response drugs are under examination as potential treatments, other novel therapeutics are also being explored to alleviate the effects on critically ill patients. The use of mesenchymal stromal cells (MSCs) for COVID-19 has become an attractive avenue down which almost 70 different clinical trial teams have ventured. Successfully trialled for the treatment of other conditions such as multiple sclerosis, osteoarthritis and graft versus host disease, MSCs possess both regenerative and immunomodulatory properties, the latter of which can be harnessed to reduce the severity and longevity of ARDS in patients under intensive care due to SARS-CoV-2 infection.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Transplante de Células-Tronco Mesenquimais , Pneumonia Viral/terapia , Animais , Ensaios Clínicos como Assunto , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/imunologia , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/imunologia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/imunologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Pesquisa Médica Translacional
9.
PLoS One ; 15(9): e0238827, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32903258

RESUMO

INTRODUCTION: The role of systemic corticosteroid as a therapeutic agent for patients with COVID-19 pneumonia is controversial. OBJECTIVE: The purpose of this study was to evaluate the effect of corticosteroids in non-intensive care unit (ICU) patients with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure (AHRF). METHODS: This was a single-center retrospective cohort study, from 16th March, 2020 to 30th April, 2020; final follow-up on 10th May, 2020. 265 patients consecutively admitted to the non-ICU wards with laboratory-confirmed COVID-19 pneumonia were screened for inclusion. 205 patients who developed AHRF (SpO2/FiO2 ≤ 440 or PaO2/FiO2 ≤ 300) were only included in the final study. Direct admission to the Intensive care unit (ICU), patients developing composite primary outcome within 24 hours of admission, and patients who never became hypoxic during their stay in the hospital were excluded. Patients were divided into two cohorts based on corticosteroid. The primary outcome was a composite of ICU transfer, intubation, or in-hospital mortality. Secondary outcomes were ICU transfer, intubation, in-hospital mortality, discharge, length of stay, and daily trend of SpO2/FiO2 (SF) ratio from the index date. Cox-proportional hazard regression was implemented to analyze the time to event outcomes. RESULT: Among 205 patients, 60 (29.27%) were treated with corticosteroid. The mean age was ~57 years, and ~75% were men. Thirteen patients (22.41%) developed a primary composite outcome in the corticosteroid cohort vs. 54 (37.5%) patients in the non-corticosteroid cohort (P = 0.039). The adjusted hazard ratio (HR) for the development of the composite primary outcome was 0.15 (95% CI, 0.07-0.33; P <0.001). The adjusted hazard ratio for ICU transfer was 0.16 (95% CI, 0.07 to 0.34; P < 0.001), intubation was 0.31 (95% CI, 0.14 to 0.70; P- 0.005), death was 0.53 (95% CI, 0.22 to 1.31; P- 0.172), composite of death or intubation was 0.31 (95% CI, 0.15 to 0.66; P- 0.002) and discharge was 3.65 (95% CI, 2.20 to 6.06; P<0.001). The corticosteroid cohort had increasing SpO2/FiO2 over time compared to the non-corticosteroid cohort who experience decreasing SpO2/FiO2 over time. CONCLUSION: Among non-ICU patients hospitalized with COVID-19 pneumonia complicated by AHRF, treatment with corticosteroid was associated with a significantly lower risk of the primary composite outcome of ICU transfer, intubation, or in-hospital death, composite of intubation or death and individual components of the primary outcome.


Assuntos
Corticosteroides/uso terapêutico , Infecções por Coronavirus/tratamento farmacológico , Pneumonia Viral/tratamento farmacológico , Adulto , Idoso , Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , New York , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Modelos de Riscos Proporcionais , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/etiologia , Estudos Retrospectivos , Resultado do Tratamento
10.
J Investig Med High Impact Case Rep ; 8: 2324709620957778, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32911986

RESUMO

Coronavirus disease 2019 (COVID-19) caused by a novel human coronavirus has led to a tsunami of viral illness across the globe, originating from Wuhan, China. Although the value and effectiveness of extracorporeal membrane oxygenation (ECMO) in severe respiratory illness from COVID-19 remains unclear at this time, there is emerging evidence suggesting that it could be utilized as an ultimate treatment in appropriately selected patients not responding to conventional care. We present a case of a 32-year-old COVID-19 positive male with a history of diabetes mellitus who was intubated for severe acute respiratory distress syndrome (ARDS). The patient's hypoxemia failed to improve despite positive pressure ventilation, prone positioning, and use of neuromuscular blockade for ventilator asynchrony. He was evaluated by a multidisciplinary team for considering ECMO for refractory ARDS. He was initiated on venovenous ECMO via dual-site cannulation performed at the bedside. Although his ECMO course was complicated by bleeding, he showed a remarkable improvement in his lung function. ECMO was successfully decannulated after 17 days of initiation. The patient was discharged home after 47 days of hospitalization without any supplemental oxygen and was able to undergo active physical rehabilitation. A multidisciplinary approach is imperative in the initiation and management of ECMO in COVID-19 patients with severe ARDS. While ECMO is labor-intensive, using it in the right phenotype and in specialized centers may lead to positive results. Patients who are young, with fewer comorbidities and single organ dysfunction portray a better prognosis for patients in which ECMO is utilized.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Oxigenação por Membrana Extracorpórea/métodos , Pneumonia Viral/complicações , Síndrome do Desconforto Respiratório do Adulto/terapia , Terapia de Salvação/métodos , Adulto , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Humanos , Masculino , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Respiração com Pressão Positiva/métodos , Radiografia Torácica , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/etiologia , Tomografia Computadorizada por Raios X
11.
Med Sci Monit ; 26: e925974, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32973126

RESUMO

BACKGROUND Coronavirus disease 2019 (COVID-19) is a new infectious disease, and acute respiratory syndrome (ARDS) plays an important role in the process of disease aggravation. The detailed clinical course and risk factors of ARDS have not been well described. MATERIAL AND METHODS We retrospectively investigated the demographic, clinical, and laboratory data of adult confirmed cases of COVID-19 in Beijing Ditan Hospital from Jan 20 to Feb 29, 2020 and compared the differences between ARDS cases and non-ARDS cases. Univariate and multivariate logistic regression methods were employed to explore the risk factors associated with ARDS. RESULTS Of the 130 adult patients enrolled in this study, the median age was 46.5 (34-62) years and 76 (58.5%) were male. ARDS developed in 26 (20.0%) and 1 (0.8%) death occurred. Fever occurred in 114 patients, with a median highest temperature of 38.5 (38-39)°C and median fever duration of 8 (3-11) days. The median time from illness onset to ARDS was 10 (6-13) days, the median time to chest CT improvement was 17 (14-21) days, and median time to negative nucleic acid test result was 27 (17-33) days. Multivariate regression analysis showed increasing odds of ARDS associated with age older than 65 years (OR=4.75, 95% CL1.26-17.89, P=0.021), lymphocyte counts [0.5-1×109/L (OR=8.80, 95% CL 2.22-34.99, P=0.002); <0.5×109/L(OR=36.23, 95% CL 4.63-2083.48, P=0.001)], and temperature peak ≥39.1°C (OR=5.35, 95% CL 1.38-20.76, P=0.015). CONCLUSIONS ARDS tended to occur in the second week of the disease course. Potential risk factors for ARDS were older age (>65 years), lymphopenia (≤1.0×109/L), and temperature peak (≥39.1°C). These findings could help clinicians to predict which patients will have a poor prognosis at an early stage.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Pandemias , Pneumonia Viral/complicações , Síndrome do Desconforto Respiratório do Adulto/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções Bacterianas/etiologia , China , Cidades/epidemiologia , Comorbidade , Infecções por Coronavirus/epidemiologia , Feminino , Febre/etiologia , Humanos , Modelos Logísticos , Linfopenia/etiologia , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/epidemiologia , Estudos Retrospectivos , Fatores de Risco
12.
BMC Cardiovasc Disord ; 20(1): 389, 2020 08 26.
Artigo em Inglês | MEDLINE | ID: mdl-32842957

RESUMO

BACKGROUND: Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). CASE PRESENTATION: A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. CONCLUSION: Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.


Assuntos
Antivirais/uso terapêutico , Cardiotônicos/uso terapêutico , Infecções por Coronavirus/terapia , Síndrome da Liberação de Citocina/terapia , Troca Plasmática , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Choque Cardiogênico/terapia , Cardiomiopatia de Takotsubo/terapia , Adulto , Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Síndrome da Liberação de Citocina/complicações , Síndrome da Liberação de Citocina/diagnóstico , Combinação de Medicamentos , Ecocardiografia , Humanos , Lopinavir/uso terapêutico , Masculino , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/etiologia , Ritonavir/uso terapêutico , Choque Cardiogênico/etiologia , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Cardiomiopatia de Takotsubo/etiologia
13.
Trials ; 21(1): 743, 2020 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-32843098

RESUMO

OBJECTIVES: The aim of this study is to explore the effectiveness and safety of high dose dexamethasone treatment for Acute Respiratory Distress Syndrome secondary to SARS-Cov-2 pneumonia. TRIAL DESIGN: Multicentre, randomized clinical trial, controlled, open label, parallel group, to evaluate the effectiveness and safety of high dose dexamethasone in adult patients with confirmed COVID-19, with Acute Respiratory Distress Syndrome. PARTICIPANTS: We will include patients with SARS-Cov-2 pneumonia who develop acute respiratory distress syndrome, in several intensive care units (ICU) in Buenos Aires, Argentina (CEMIC, Clinica Bazterrica, Sanatorio Sagrado Corazon) Inclusion criteria: Men and women, age ≥ 18 years old. Confirmed diagnosis of SARS-CoV-2 infection, by RT-PCR. Diagnosis of Acute Respiratory Distress Syndrome (hypoxemic respiratory failure not explained by cardiac disease + PaO2/FiO2 ratio < 300 with a Positive End-Expiratory Pressure ≥ 5 cm H2O + bilateral pulmonary infiltrates) Length of mechanical ventilation of at least 72 hours Informed consent (next of kin / legal guardian) Exclusion criteria: Pregnant or breast-feeding women. Terminal disease (advanced cancer; under palliative care; cardiovascular, respiratory, or renal disease with a life expectancy less ≤ 1 year). Therapeutic limitation (advance directives or do not resuscitate order) Severe immunosuppression (HIV infection, long-term use of immunosuppressive agents, active cancer). Patients under chronic treatment with glucocorticoids for other diseases (≥ 8 mg prednisone, or equivalent) Participation in another randomized clinical trial. INTERVENTION AND COMPARATOR: Eligible patients will be randomized to receive standard ICU patient care (group 1) or standard ICU patient care plus high dose dexamethasone (group 2). Group 1: dexamethasone up to 6 mg/24 hours for up to 10 days + ventilatory, hemodynamic, nutritional, and antimicrobial support according to international guidelines. Group 2: dexamethasone 16 mg/24 hours for 5 days followed by dexamethasone 8 mg/24 hours for 5 days + ventilatory, hemodynamic, nutritional, and antimicrobial support according to international guidelines. MAIN OUTCOME: The main result is ventilator-free days at 28 days (Days without ventilator support in the first 28 days following randomization). Secondary outcomes are 28-days and 90-days mortality, frequency of nosocomial infections in the first 28 days after randomization, Sequential Organ Failure Assessment (SOFA) score variation and prone position in the first 10-days, viral shedding 28-days after randomization, and delirium and muscle weakness at ICU discharge. RANDOMISATION: Treatment will be assigned according to site stratified randomization by permuted random blocks sequence 1:1 generated with a table in R language concealed in a randomization tool in REDCap (Research Electronic Data CAPture) platform. BLINDING (MASKING): This is an open trial, so no masking of treatment assignment will be used. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): Assuming a 3 days difference in ventilator-free days between treatment groups, with a mean of 9 days, and a standard deviation of 9 days; the necessary sample size would be 284 subjects (142 per group), with a power of 80% and a two-tailed alpha error of 0.05. TRIAL STATUS: The protocol with code 1264, version 3.0 on date: May 13, 2020 is approved by the local Ethics Committee. The trial is in the recruitment phase. Recruitment began May 22, 2020 and is anticipated to be complete by the end of December 2021. TRIAL REGISTRATION: The trial was registered under the title "Dexamethasone for COVID-19 Related ARDS: a Multicenter, Randomized Clinical Trial" with ClinicalTrials number NCT04395105, https://clinicaltrials.gov/ct2/show/NCT04395105 , registered on 20 May 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Assuntos
Infecções por Coronavirus/tratamento farmacológico , Dexametasona/administração & dosagem , Glucocorticoides/administração & dosagem , Pneumonia Viral/tratamento farmacológico , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Argentina , Betacoronavirus , Infecções por Coronavirus/complicações , Infecção Hospitalar/epidemiologia , Delírio/epidemiologia , Humanos , Mortalidade , Escores de Disfunção Orgânica , Pandemias , Posicionamento do Paciente , Pneumonia Viral/complicações , Decúbito Ventral , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório do Adulto/etiologia , Eliminação de Partículas Virais
14.
Medicine (Baltimore) ; 99(31): e21431, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756151

RESUMO

RATIONALE: The use of autologous hematopoietic stem cell transplantation (AHSCT) for autoimmune diseases has become the first indication for transplant in nonmalignant disease. Mucormycosis is a rare invasive infection with increasing incidence in patients treated with AHSCT. We report the first case of pulmonary mucormycosis following AHSCT for systemic sclerosis (SSc). PATIENT CONCERNS: A 24-year-old woman with rapidly progressive diffuse cutaneous SSc presented with an acute respiratory distress syndrome 6 days after AHSCT. DIAGNOSES: The results of clinical and computed tomography scan were consistent with pulmonary mucormycosis and the diagnosis was confirmed by a positive Mucorales Polymerase Chain Reaction on a peripheral blood sample. INTERVENTIONS AND OUTCOMES: Early antifungal therapy by intravenous amphotericin B provided rapid improvement within 4 days and sustained recovery after 2 years of follow-up. LESSONS: With the progressively increasing use of AHSCT and other stem cell therapy for treatment of severe SSc and other autoimmune diseases, the potential onset of rare post-transplant fungal infections, such as mucormycosis, requires careful patient monitoring and better awareness of early initiation of adequate therapy.


Assuntos
Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Mucormicose/etiologia , Esclerodermia Difusa/etiologia , Escleroderma Sistêmico/terapia , Transplante Autólogo/efeitos adversos , Doença Aguda , Administração Intravenosa , Assistência ao Convalescente , Anfotericina B/administração & dosagem , Anfotericina B/uso terapêutico , Antifúngicos/administração & dosagem , Antifúngicos/uso terapêutico , Feminino , Transplante de Células-Tronco Hematopoéticas/métodos , Humanos , Pneumopatias Fúngicas/diagnóstico por imagem , Pneumopatias Fúngicas/microbiologia , Pneumopatias Fúngicas/patologia , Mucorales/genética , Síndrome do Desconforto Respiratório do Adulto/etiologia , Esclerodermia Difusa/patologia , Transplante Autólogo/métodos , Resultado do Tratamento , Adulto Jovem
16.
BMC Infect Dis ; 20(1): 637, 2020 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-32854630

RESUMO

BACKGROUND: An ongoing outbreak of coronavirus disease 2019 (COVID-19) is spreading globally. Recently, several articles have mentioned that the early acute respiratory distress syndrome (ARDS) caused by COVID-19 significantly differ from those of ARDS due to other causes. Actually, we newly observed that some mechanically ventilated COVID-19 patients recovering from severe ARDS (more than 14 days after invasive ventilation) often experienced evidently gradual increases in CO2 retention and minute ventilation. However, the underlying mechanics remain unclear. CASE PRESENTATION: To explain these pathophysiological features and discuss the ventilatory strategy during the late phase of severe ARDS in COVID-19 patients, we first used a metabolic module on a General Electric R860 ventilator (Engstrom Carestation; GE Healthcare, USA) to monitor parameters related to gas metabolism, lung mechanics and physiological dead space in two COVID-19 patients. We found that remarkably decreased ventilatory efficiency (e.g., the ratio of dead space to tidal volume 70-80%, arterial to end-tidal CO2 difference 18-23 mmHg and ventilatory ratio 3-4) and hypermetabolism (oxygen consumption 300-400 ml/min, CO2 elimination 200-300 ml/min) may explain why these patients experienced more severe respiratory distress and CO2 retention in the late phase of ARDS caused by COVID-19. CONCLUSION: During the recovery period of ARDS among mechanically-ventilated COVID-19 patients, attention should be paid to the monitoring of physiological dead space and metabolism. Tidal volume (8-9 ml/kg) could be increased appropriately under the limited plateau pressure; however, barotrauma should still be kept in mind.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Pneumonia Viral/terapia , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/terapia , Idoso , Infecções por Coronavirus/complicações , Feminino , Humanos , Monitorização Fisiológica , Consumo de Oxigênio , Pandemias , Pneumonia Viral/complicações , Síndrome do Desconforto Respiratório do Adulto/etiologia , Volume de Ventilação Pulmonar , Ventiladores Mecânicos
17.
Biomolecules ; 10(8)2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32796765

RESUMO

Recently, the stabilization of the endothelium has been explicitly identified as a therapeutic goal in coronavirus disease 2019 (COVID-19). Adrecizumab (HAM8101) is a first-in-class humanized monoclonal anti-Adrenomedullin (anti-ADM) antibody, targeting the sepsis- and inflammation-based vascular and capillary leakage. Within a "treatment on a named-patient basis" approach, Adrecizumab was administered to eight extreme-critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS). The patients received a single dose of Adrecizumab, which was administered between 1 and 3 days after the initiation of mechanical ventilation. The SOFA (median 12.5) and SAPS-II (median 39) scores clearly documented the population at highest risk. Moreover, six of the patients suffered from acute renal failure, of whom five needed renal replacement therapy. The length of follow-up ranged between 13 and 27 days. Following the Adrecizumab administration, one patient in the low-dose group died at day 4 due to fulminant pulmonary embolism, while four were in stable condition, and three were discharged from the intensive care unit (ICU). Within 12 days, the SOFA score, as well as the disease severity score (range 0-16, mirroring critical resources in the ICU, with higher scores indicating more severe illness), decreased in five out of the seven surviving patients (in all high-dose patients). The PaO2/FiO2 increased within 12 days, while the inflammatory parameters C-reactive protein, procalcitonin, and interleukin-6 decreased. Importantly, the mortality was lower than expected and calculated by the SOFA score. In conclusion, in this preliminary uncontrolled case series of eight shock patients with life-threatening COVID-19 and ARDS, the administration of Adrecizumab was followed by a favorable outcome. Although the non-controlled design and the small sample size preclude any definitive statement about the potential efficacy of Adrecizumab in critically ill COVID-19 patients, the results of this case series are encouraging.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Infecções por Coronavirus/complicações , Endotélio Vascular/efeitos dos fármacos , Pneumonia Viral/complicações , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Sepse/tratamento farmacológico , Adulto , Idoso , Anticorpos Monoclonais Humanizados/administração & dosagem , Anticorpos Monoclonais Humanizados/farmacologia , Infecções por Coronavirus/patologia , Estado Terminal , Endotélio Vascular/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/patologia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Sepse/etiologia
18.
BMJ Case Rep ; 13(8)2020 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-32788159

RESUMO

A 33-year-old pregnant woman was hospitalised with fever, cough, myalgia and dyspnoea at 23.5 weeks of gestation (WG). Development of acute respiratory distress syndrome (ARDS) mandated invasive mechanical ventilation. A nasopharyngeal swab proved positive for severe acute respiratory syndrome coronavirus 2 by reverse transcription-PCR. The patient developed hypertension and biological disorders suggesting pre-eclampsia and HELLP (haemolysis, elevated liver enzyme levels and low platelet levels) syndrome. Pre-eclampsia was subsequently ruled out by a low ratio of serum soluble fms-like tyrosine kinase-1 to placental growth factor. Given the severity of ARDS, delivery by caesarean section was contemplated. Because the ratio was normal and the patient's respiratory condition stabilised, delivery was postponed. She recovered after 10 days of mechanical ventilation. She spontaneously delivered a healthy boy at 33.4 WG. Clinical and laboratory manifestations of COVID-19 infection can mimic HELLP syndrome. Fetal extraction should not be systematic in the absence of fetal distress or intractable maternal disease. Successful evolution was the result of a multidisciplinary teamwork.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/complicações , Nascimento Vivo , Pneumonia Viral/complicações , Complicações Infecciosas na Gravidez/etiologia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Adulto , Infecções por Coronavirus/diagnóstico , Feminino , Humanos , Pandemias , Pneumonia Viral/diagnóstico , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico por imagem , Complicações Infecciosas na Gravidez/terapia , Radiografia Torácica , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/diagnóstico por imagem , Síndrome do Desconforto Respiratório do Adulto/terapia
19.
Emerg Microbes Infect ; 9(1): 1869-1877, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32795143

RESUMO

Critically ill patients with coronavirus diseases 2019 (COVID-19) are of grave concern. Those patients usually underwent a stage of excessive inflammation before developing acute respiratory distress syndrome. In this study, we test the hypothesis that short-term, low-to-moderate-dose corticosteroids would benefit patients when used in the early phase of excessive inflammation, namely, the therapeutic window. Among a Shanghai cohort and a validation cohort, we enrolled COVID-19 patients showing marked radiographic progression. Short-term, low-to-moderate-dose corticosteroids were considered for them. After identifying the possible markers for the therapeutic window, we then divided the patients, based on whether they were treated with corticosteroids within the therapeutic window, into the early-start group and control group. We identified that the therapeutic window for corticosteroids was characterized by a marked radiographic progression and lactase dehydrogenase (LDH) less than two times the upper limit of normal (ULN). The Shanghai cohort comprised of 68 patients, including 47 in the early-start group and 21 in the control group. The proportion of patients requiring invasive mechanical ventilation was significantly lower in the early-start group than in the control group (10.6% vs. 33.3%, difference, 22.7%, 95% confidence interval 2.6-44.8%). Among the validation cohort of 51 patients, similar difference of the primary outcome was observed (45.0% vs. 74.2%, P = 0.035). Among COVID-19 patients with marked radiologic progression, short-term, low-to-moderate-dose corticosteroids benefits patients with LDH levels of less than two times the ULN, who may be in the early phase of excessive inflammation.


Assuntos
Corticosteroides/uso terapêutico , Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Corticosteroides/administração & dosagem , Biomarcadores , Estudos de Coortes , Infecções por Coronavirus/diagnóstico por imagem , Infecções por Coronavirus/patologia , Infecções por Coronavirus/terapia , Progressão da Doença , Humanos , Inflamação/prevenção & controle , L-Lactato Desidrogenase/sangue , Pneumonia Viral/diagnóstico por imagem , Pneumonia Viral/patologia , Pneumonia Viral/terapia , Radiografia , Reprodutibilidade dos Testes , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/etiologia , Resultado do Tratamento
20.
Ann Am Thorac Soc ; 17(8): 918-921, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32735170

RESUMO

Amid efforts to care for the large number of patients with coronavirus disease (COVID-19), there has been considerable speculation about whether the lung injury seen in these patients is different than acute respiratory distress syndrome from other causes. One idea that has garnered considerable attention, particularly on social media and in free open-access medicine, is the notion that lung injury due to COVID-19 is more similar to high-altitude pulmonary edema (HAPE). Drawing on this concept, it has also been proposed that treatments typically employed in the management of HAPE and other forms of acute altitude illness-pulmonary vasodilators and acetazolamide-should be considered for COVID-19. Despite some similarities in clinical features between the two entities, such as hypoxemia, radiographic opacities, and altered lung compliance, the pathophysiological mechanisms of HAPE and lung injury due to COVID-19 are fundamentally different, and the entities cannot be viewed as equivalent. Although of high utility in the management of HAPE and acute mountain sickness, systemically delivered pulmonary vasodilators and acetazolamide should not be used in the treatment of COVID-19, as they carry the risk of multiple adverse consequences, including worsened ventilation-perfusion matching, impaired carbon dioxide transport, systemic hypotension, and increased work of breathing.


Assuntos
Doença da Altitude , Infecções por Coronavirus , Hipertensão Pulmonar , Pandemias , Pneumonia Viral , Síndrome do Desconforto Respiratório do Adulto , Acetazolamida/farmacologia , Doença da Altitude/fisiopatologia , Doença da Altitude/terapia , Betacoronavirus/isolamento & purificação , Inibidores da Anidrase Carbônica/farmacologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Humanos , Hipertensão Pulmonar/fisiopatologia , Hipertensão Pulmonar/terapia , Lesão Pulmonar/etiologia , Lesão Pulmonar/fisiopatologia , Lesão Pulmonar/terapia , Nifedipino/farmacologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Síndrome do Desconforto Respiratório do Adulto/terapia , Vasodilatadores/farmacologia
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