Incidence and prevalence of chronic pulmonary aspergillosis in patients with post-tuberculosis lung abnormality: Results from a community survey in North India.

BACKGROUND: Post-tuberculosis lung abnormality (PTLA) is the most common risk factor for developing chronic pulmonary aspergillosis (CPA). However, the prevalence and incidence of CPA in PTLA patients in India remain unknown. OBJECTIVES: We aimed to ascertain the incidence and prevalence of CPA in subjects with PTLA. METHODS: We identified a cohort of pulmonary tuberculosis who completed anti-tuberculosis therapy (ATT) before November 2019 from the records of the 12 tuberculosis treatment centers attached to the national program. We recorded the clinical and demographic details. We performed computed tomography (CT) of the chest and estimated serum A. fumigatus-specific IgG. We categorised subjects as PTLA with or without CPA using a composite of clinical, radiological, and microbiological features. We resurveyed the subjects at 6 months (or earlier) for the presence of new symptoms. We calculated the prevalence and the incidence rate (per 100-person years) of CPA. RESULTS: We included 117 subjects with PTLA, with a median of 3 years after ATT completion. Eleven subjects had CPA in the initial survey, and one additional case developed CPA during the second survey. The prevalence of CPA in PTLA subjects was 10.3% (12/117). The total observation period was 286.7 person-years. The median (interquartile range) time to develop CPA after ATT completion was 12.5 (5-36.7) months. We found the CPA incidence rate (95% confidence interval) of 4.2 (1.8-6.5) per 100-person years. CONCLUSION: Chronic pulmonary aspergillosis complicates 10% of PTLA subjects after successful outcomes with ATT. Four new CPA cases may develop per 100-persons years of observation after ATT completion. We suggest screening patients with PTLA who develop new symptoms for CPA.

Risk factors for clinically significant diffuse parenchymal lung abnormalities persisting after severe COVID-19 pneumonia.

Background & objectives: The risk factors for clinically significant diffuse parenchymal lung abnormalities (CS-DPLA) persisting after severe coronavirus disease 2019 (COVID-19) pneumonia remain unclear. The present study was conducted to assess whether COVID-19 severity and other parameters are associated with CS-DPLA. Methods: The study participants included patients who recovered after acute severe COVID-19 and presented with CS-DPLA at two or six month follow up and control group (without CS-DPLA). Adults volunteers without any acute illness, chronic respiratory illness and without a history of severe COVID-19 were included as healthy controls for the biomarker study. The CS-DPLA was identified as a multidimensional entity involving clinical, radiological and physiological pulmonary abnormalities. The primary exposure was the neutrophil-lymphocyte ratio (NLR). Recorded confounders included age, sex, peak lactate dehydrogenase (LDH), advanced respiratory support (ARS), length of hospital stay (LOS) and others; associations were analyzed using logistic regression. The baseline serum levels of surfactant protein D, cancer antigen 15-3 and transforming growth factor-ß (TGF-ß) were also compared among cases, controls and healthy volunteers. Results: We identified 91/160 (56.9%) and 42/144 (29.2%) participants with CS-DPLA at two and six months, respectively. Univariate analyses revealed associations of NLR, peak LDH, ARS and LOS with CS-DPLA at two months and of NLR and LOS at six months. The NLR was not independently associated with CS-DPLA at either visit. Only LOS independently predicted CS-DPLA at two months [adjusted odds ratios (aOR) (95% confidence interval [CI]), 1.16 (1.07-1.25); P<0.001] and six months [aOR (95% CI) and 1.07 (1.01-1.12); P=0.01]. Participants with CS-DPLA at six months had higher baseline serum TGF-ß levels than healthy volunteers. Interpretation and conclusions: Longer hospital stay was observed to be the only independent predictor of CS-DPLA six months after severe COVID-19. Serum TGF-ß should be evaluated further as a biomarker.

Isolated tracheobronchial mucormycosis: Report of a case and systematic review of literature.

BACKGROUND: Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature. CASE DESCRIPTION AND SYSTEMATIC REVIEW: A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky haemoptysis, and hoarseness of voice 2 weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycaemic control, posaconazole, and inhaled amphotericin B (8 weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in two lung transplant recipients), post-viral illness (post-COVID-19 [n = 3], and influenza [n = 1]), and post-intubation mucormycosis (n = 1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26; 19.2%) or bronchoscopic instillation (1/26; 3.8%) of amphotericin B and surgery (6/26; 23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive haemoptysis. CONCLUSION: Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible.

Role of pre-transplant chest high-resolution computed tomography and serum galactomannan index in predicting post-transplant invasive pulmonary aspergillosis in allogeneic hematopoietic cell transplant recipients.

INTRODUCTION: The role of pre-HCT chest high-resolution computed tomography (HRCT) and serum galactomannan index (GMI) in predicting the post-allogeneic hematopoietic cell transplant (HCT) invasive pulmonary aspergillosis (IPA) is debatable. METHODS: This was a single-center, prospective study from 2014 to 2019. The primary objective was to study if pre-HCT chest HRCT and serum GMI predicted IPA post-HCT. The secondary objective was day +100 mortality. All consecutive, consenting patients of ≥12 years of age undergoing allo-HCT were included and had pre-HCT chest HRCT and serum GMI. All patients received mold active antifungal prophylaxis. The EORTC/MSG criteria were used for the diagnosis of IPA. RESULTS: A total of 82 patients with median age 27 years (12-59 years) were included. The underlying diagnoses included hematological malignancies (79%) and aplastic anemia (21%). Fifteen percent of patients was treated for prior history of probable IPA (>6 weeks before HCT). Pre-HCT chest HRCT satisfied EORTC clinical criteria in 24% patients. Serum GMI ≥0.5 was seen in 27% of patients. Post-HCT probable IPA was seen in 24% of patients. There were more patients with pre-HCT chest HRCT findings satisfying EORTC clinical criteria (45% vs. 18%, P = .014) and GMI ≥0.5 (45% vs. 21%, P = .03) in the group with post-HCT IPA compared to those without IPA. There was higher day+100 mortality in patients with post-HCT IPA (55% vs. 18%, P = .001). CONCLUSIONS: The presence of EORTC clinical criteria on pre-HCT chest HRCT, serum GMI ≥0.5, and prior history of IPA predicted post-HCT IPA.

Computed tomography chest in COVID-19: When & why?

Computed tomography (CT) of the chest plays an important role in the diagnosis and management of coronavirus disease 2019 (COVID-19), but it should not be used indiscriminately. This review provides indications of CT chest in COVID-19 suspect, positive and recovered patients based on the current scientific evidence and our personal experience. CT chest is not indicated as a routine screening modality due to its poor sensitivity and specificity. However, it is useful in a small subset of COVID-19 suspects who test negative on reverse transcription-polymerase chain reaction (RT-PCR) with normal/indeterminate chest X-ray (CXR) but have moderate-to-severe respiratory symptoms and high index of clinical suspicion. CT chest is not indicated in every RT-PCR-positive patient and should be done only in specific clinical scenarios, where it is expected to significantly contribute in the clinical management such as COVID-19 patients showing unexplained clinical deterioration and/or where other concurrent lung pathology or pulmonary thromboembolism needs exclusion. Serial CXR and point-of-care ultrasound are usually sufficient to evaluate the progression of COVID-19 pneumonia. CT chest is also indicated in COVID-19-positive patients with associated co-morbidities (age >65 yr, diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease, immune-compromise, etc.) who, despite having mild symptoms and normal/indeterminate CXR, record oxygen saturation of <93 per cent at rest while breathing room air or de-saturate on six-minute walk test. Finally, CT chest plays a crucial role to rule out lung fibrosis in patients recovered from COVID-19 infection who present with hypoxia/impaired lung function on follow up. In conclusion, though CT chest is an indispensable diagnostic tool in COVID-19, it should be used judiciously and only when specifically indicated.

Unraveling the mystery of Covid-19 cytokine storm: From skin to organ systems.

COVID-19 is a global pandemic that emerged from Wuhan, China. Besides pneumonia and acute respiratory distress syndrome, the disease leads to multisystem involvement in the form of myocarditis, arrhythmias, cardiac arrest, gastrointestinal symptoms, hypoxemic brain injury, acute liver, and renal function impairment. There are also reports of cutaneous lesions in form of urticarial and maculopapular rashes, chilblain like fingers and toes (covid feet), livedoid vasculopathy, and chicken-pox like or varicelliform vesicles. Clinically, many of these skin lesions are likely secondary to occlusion of small to medium blood vessels due to microthrombi formation or due to viral laden antigen-antibody immune complexes; and same explanation may hold true for possible hypoxemic injury simultaneously occurring in other vital organs like lungs, heart, brain, and kidneys. The histopathology, immunoflorescence and RT-PCR analysis of skin biopsies can provide useful insights for ascertaining the pathogenesis of this complex viral syndrome. Apparently, it is interplay of disarmed cellular immunity and over-activated humoral immunity that culminates in end-organ changes. The morbidity and mortality can be significantly reduced by upgrading the cellular immunity and downgrading the humoral response; along with prevention of hypoxemic and reperfusion injuries by using antivirals, immunomodulators, antioxidants, anti-platelets, and anticoagulants in judicious and phased manner.

Diagnostic accuracy of magnetic resonance imaging in the evaluation of pulmonary infections in immunocompromised patients.

PURPOSE: To evaluate the accuracy of magnetic resonance imaging (MRI) for diagnosing pulmonary infections in immunocompromised adults. MATERIAL AND METHODS: Computed tomography (CT) and MRI chest were performed in 35 immuno-compromised patients suspected of pulmonary infection. The MRI sequences that were performed included axial and coronal T2 half-Fourier acquisition single-shot turbo spin-echo (HASTE), spectrally attenuated inversion recovery (SPAIR), true fast imaging with steady-state free precession (TRUFI), and three-dimensional fast low angle shot (3D FLASH) using breath-hold and respiratory triggered BLADE (proprietary name for periodically rotated overlapping parallel lines with enhanced reconstruction). The presence of nodules, consolidations, and ground-glass opacities was evaluated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for MRI using CT scan as a reference standard. RESULTS: The sensitivity of MRI in nodule detection was 50% overall and 75% for nodules measuring more than 5 mm. Consolidation was detected with 100% sensitivity. Sensitivity and PPV for the detection of ground-glass opacities (GGOs) were 77.7% and 53.8%, respectively. T2 HASTE axial had the fewest image artefacts. Respiratory triggered MR pulse sequence did not add any significant diagnostic information as compared to the non-respiratory triggered MR pulse sequences. CONCLUSIONS: Sensitivity for detecting small nodules and GGOs on MR is poor; CT scan remains the imaging modality of choice for the evaluation of pulmonary infections in immunocompromised patients. However, MRI can be used in the follow-up imaging of these patients.

Non-bronchial causes of haemoptysis: imaging and interventions.

PURPOSE: To describe non-bronchial causes of haemoptysis on imaging and the role of interventional radiology in their management from cases of haemoptysis archived from our database at a tertiary care, federally funded institution. MATERIAL AND METHODS: Retrospective analysis of cases that presented with haemoptysis in our institution from 2008 to 2013 was done, and details of cases in which the bleeding was from a non-bronchial source were archived and details of imaging and treatment were recorded. RESULTS: Retrospective analysis of patients presenting with haemoptysis yielded 24 (n = 24) patients having haemoptysis from non-bronchial sources. Causes of haemoptysis were: Rasmussen aneurysms (n = 12/24), costocervical trunk pseudoaneurysm (n = 1/24), left internal mammillary artery pseudoaneurysm (n = 1/24), left ventricular aneurysms (n = 3/24), pulmonary arteriovenous malformations (AVMs) (n = 5/24), and proximal interruption of pulmonary artery (n = 2/24). Imaging and interventional radiology management are described in detail. CONCLUSIONS: Haemoptysis can be from non-bronchial sources, which may be either from systemic or pulmonary arteries or cardio-pulmonary fistulas. Bronchial computed tomography angiography (CTBA), if feasible, must always be considered before bronchial artery embolisation because it precisely identifies the source of haemorrhage and vascular anatomy that helps the interventional radiologist in pre-procedural planning. This circumvents chances of re-bleed if standard bronchial artery embolisation is done without CTBA.

Role of perfusion CT in the evaluation of adnexal masses.

The objective of this study was to evaluate the role of perfusion computed tomography (PCT) in differentiating benign from malignant adnexal masses. Twenty patients, each of pathologically proven malignant and benign adnexal masses who had undergone PCT on 64-slice CT scanner, were included in the study. The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) of the adnexal masses were calculated. Statistical analysis to study the association between PCT parameters and histopathological diagnosis was done. In the malignant group, the mean PS, BV and BF values were elevated. The mean Tmax of the benign lesions was higher compared to that of the malignant lesions. There was a significant statistical difference in the PCT parameters between the malignant and benign groups (p value = .001). PCT can be a useful tool for differentiating benign and malignant adnexal masses. Impact statement What is already known on this subject? It is not always possible to distinguish benign from malignant adnexal lesions despite the application of various imaging techniques. Perfusion CT (PCT) is an imaging technique with which we can obtain both the morphological and functional information of tumours. Perfusion-based imaging enables us to objectively evaluate the neovascularity in a lesion. This helps in differentiating the benign lesions from aggressive malignant lesions. What do the results of this study add? The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) were calculated from adnexal masses on a 64-multi-slice CT scanner and correlated with their histopathological diagnoses. The values of the mean PS, BV and BF values were significantly higher in the malignant adnexal masses. The mean Tmax in the benign masses was more compared to that of the malignant lesions. Significant statistical difference was seen in PCT parameters between malignant and benign groups. What are the implications of these findings for clinical practice and/or further research? PCT can be a useful tool for differentiating benign from malignant adnexal masses. However, more collaborative research and robust validation are imperative to further evaluate this innovative evolving technique.

Spectrum of imaging findings in pulmonary infections. Part 1: Bacterial and viral.

Chest radiography is generally the first imaging modality used for the evaluation of pneumonia. It can establish the presence of pneumonia, determine its extent and location, and assess the response to treatment. Computed tomography is not used for the initial evaluation of pneumonia, but it may be used when the response to treatment is unusually slow. It helps to identify complications, detect any underlying chronic pulmonary disease, and also to characterise complex pneumonias. Although not diagnostic, certain imaging findings may suggest a particular microbial cause over others. Knowledge of whether pneumonia is community-acquired or nosocomial, as well as the age and immune status of the patient, can help us in narrowing the differential diagnoses. The purpose of this article is to briefly review the various pulmonary imaging manifestations of pathogenic organisms. This knowledge along with clinical history and laboratory investigations of the patient may help in guiding the treatment of pneumonia.

Spectrum of imaging findings in pulmonary infections. Part 2: Fungal, mycobacterial, and parasitic.

Chest radiography is generally the first imaging modality used for the evaluation of pneumonia. It can establish the presence of pneumonia, determine its extent and location, and assess the response to treatment. Computed tomography is not used for the initial evaluation of pneumonia, but it may be used when the response to treatment is unusually slow. It helps to identify complications, detect any underlying chronic pulmonary disease, and characterise complex pneumonias. Although not diagnostic, certain imaging findings may suggest a particular microbial cause over others. Knowledge of whether pneumonia is community-acquired or nosocomial, as well as the age and immune status of the patient, can help to narrow the differential diagnoses. The purpose of this article is to briefly review the various pulmonary imaging manifestations of pathogenic organisms. This knowledge, along with the clinical history and laboratory investigations of the patient, may help to guide the treatment of pneumonia.

Spectrum of magnetic resonance imaging findings in ovarian torsion.

PURPOSE: Ovarian torsion is the twisting of the ovary on its vascular pedicle resulting in vascular compromise. Diagnosis of ovarian torsion is challenging in patients who have atypical clinical or ultrasound (US) findings. The objective of our study was to demonstrate the magnetic resonance imaging (MRI) features of ovarian torsion to help radiologists make a conclusive diagnosis when the clinical and US findings are unclear. MATERIAL AND METHODS: We retrospectively reviewed the clinical and MRI features in 10 females with surgically proven ovarian torsion, who had inconclusive clinical, US, or computed tomography findings. RESULTS: All patients showed a significantly enlarged ovary with size ranging from 5 to 18 cm. 'Twisted ovarian pedicle' sign was seen in seven patients. Eight cases showed areas of haemorrhage within the ovarian stroma. Non-enhancement of ovarian stroma was observed in six patients. Seven patients showed an ipsilateral deviation of the uterus. CONCLUSIONS: MRI features of ovarian torsion include ovarian enlargement, twisted ovarian pedicle, ovarian haemorrhage, abnormal ovarian enhancement, and ipsilateral deviation of the uterus. Awareness of these imaging features will enable the radiologist to recognise ovarian torsion and differentiate it reliably from other benign or malignant ovarian lesions.