Temporal changes of haematological and radiological findings of the COVID-19 infection-a review of literature.

BACKGROUND: COVID-19 is a systemic viral infection which mainly targets the human respiratory system with many secondary clinical manifestations especially affecting the hematopoietic system and haemostasis. Few studies have highlighted the prognostic value of blood findings such as lymphopenia, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, LDH, CRP, cardiac troponin, low-density lipoproteins and chest radiographic abnormality. A study of progressions of blood and radiological results may help to identify patients at high risk of severe outcomes. This systematic review aimed to assess the temporal progression of blood and radiology findings of patients with COVID-19. METHODS: Comprehensive systematic literature search was conducted on Medline, Embase and Cochrane databases to identify articles published for peripheral blood investigation and radiological results of COVID-19 patients. RESULTS: A total of 27 studies were included in this review. The common laboratory features reported include lymphopenia, elevated levels of C-reactive proteins and lactate dehydrogenase. For radiological signs, ground-glass opacifications, consolidations, and crazy paving patterns were frequently reported. There is a correlation between lymphocyte count, neutrophil count and biomarkers such as C-reactive proteins and lactate dehydrogenase; at a later phase of the disease (more than 7 days since onset of symptoms), lymphopenia worsens while neutrophil count, C-reactive protein levels and lactate dehydrogenase levels increase. Frequencies of ground-glass opacifications and ground-glass opacifications with consolidations decrease at a later phase of the disease while that of consolidation and crazy paving pattern rises as the disease progresses. More extensive lung involvement was also seen more frequently in the later phases. CONCLUSION: The correlation between temporal progression and the reported blood and radiological results may be helpful to monitor and evaluate disease progression and severity.

Pulmonary metastasectomy of colorectal cancer origin: Evaluating process and outcomes.

BACKGROUND: This study was undertaken to evaluate the effect of change in policy of computed tomography (CT) scan of the thorax in staging and follow-up of colorectal cancer (CRC). Another objective was to review the outcomes following pulmonary metastasectomies (Pmets) and to determine the prognostic factors affecting outcomes. METHODS: This is a retrospective analysis from a prospective cohort database of patients, who underwent Pmet for CRC origin from August 2004 to February 2016. The outcome measures were number of Pmets per year, overall survival (OS), disease-free survival (DFS), and prognostic factors affecting survival. RESULTS: Of 71 patients, 38% (n = 27) underwent Pmet before 2013 and 62% ( n = 44) had surgery after 2013. The 2-year DFS after Pmet was 49.3% and estimated 5-year OS was 51.4% at a median follow-up of 28 months. There was a significant increase in number of Pmets/year ( P = 0.0015), increased detection of synchronous pulmonary metastasis (PM) ( P = 0.005), increased diagnosis of extra-pulmonary metastases (EPM) ( P = 0.005), and improved OS ( P = 0.026) after introduction of CT scan as staging tool. Site of primary tumor (colon) ( P = 0.045), primary nodal stage ( P = 0.009), and the presence of EPM ( P = 0.01) were independent important prognostic factors affecting survival. CONCLUSION: The CT scan of thorax as a baseline tool for staging and follow-up in CRC increases referral for pulmonary metastasectomy. Surgery achieves excellent prognosis and long-term survival outcomes in CRC with isolated PM and carefully selected patients with solitary liver metastasis.

Clinical, Radiological, and Lung Function Characteristics of Post-tuberculosis Bronchiectasis: An Experience From a Tertiary Care Center in India.

Introduction Among chronic respiratory diseases, bronchiectasis is one of the important causes of mortality and morbidity in developing countries. Objective This study aimed to assess the clinical, radiological, microbiological, and pulmonary function profiles of adult patients with post-tubercular bronchiectasis. Methods We enrolled 138 patients with bronchiectasis confirmed by high-resolution CT scans from July 2017 to August 2018. Results A total of 138 patients with bronchiectasis were enrolled. The data from 132 patients were analyzed; six patients were excluded from the study. The mean age of post-TB bronchiectasis (post-tuberculosis bronchiectasis) patients was 36.08±13.08, which was lower than the non-tuberculosis bronchiectasis group. The proportion of the male population was more in the post-TB bronchiectasis group (54.55% vs. 37.88%, p=0.48). Smoking prevalence was high in post-TB bronchiectasis (27.27% vs. 12.12%, p=0.04). The predominant symptom was cough in the post-tubercular bronchiectasis group (48.5% vs. 41.7%, p=0.019). The history of the recurrent common cold was seen most frequently in non-post-tubercular bronchiectasis (40.9% vs. 12.9%, p=0.001). The most common radiological variant of bronchiectasis found in all patients was a cystic type (75%). The most common site of involvement was the left lower lobe, followed by the lingula in all patients and post-tuberculosis bronchiectasis patients. Pulmonary function on spirometry revealed obstructive, restrictive, and mixed patterns in 55%, 25%, and 15%, respectively. Patients with post-tuberculosis bronchiectasis had lower lung function post-FEV1/FVC (forced expiratory volume in one second/forced vital capacity) ratio (70.31±15.56 vs. 76.85±11.82, p=0.015). Binary multivariate logistic regression analysis showed that only recurrent cough cold was a significant independent risk factor for post-TB bronchiectasis. Conclusion Post-tuberculosis, and bronchiectasis followed by post-infectious causes, were the most common causes of bronchiectasis and poor lung function.

To CT or not to CT: Questioning the Cost-Effectiveness of CT Thorax in Head and Neck Cancers.

Computed tomography (CT) scan has been an integral part of the diagnostic workup for patients with head and neck squamous cell carcinoma. Our study was designed to find out the incidence of distant metastasis and second primary tumor and to correlate the cost-effectiveness of CT thorax in detecting the same. This study was conducted among 326 cancer patients who visited our center with curative intent in the year 2021, with lesions in various head and neck subsites. Data were collected based on their pathological TNM staging and the presence of distant metastasis as evident on their CT thorax imaging with various variables related to the disease. Incremental cost-effectiveness ratio (ICER) was calculated for detecting a single metastatic deposit and second primary tumor in terms of Indian currency and was correlated to each subsite and stage of disease at presentation. Out of these 326 patients, 281 patients were included in our study after considering the inclusion criteria, and among these 281 patients, 235 of them underwent CT thorax for metastatic workup. No patient was found to have a second primary. Metastases were found in 12 patients. The site of primary lesion and clinical tumor (cT) staging were found to be significantly influencing the incidence of metastasis on CT thorax. ICER was least for larynx, pharynx, and paranasal sinuses and was highest for oral cavity primaries and early-stage disease. As per our observations and results of ICER, CT thorax is indeed a valuable modality but should be used judiciously when it comes to initial diagnostic workup.

Comparison of clinical characteristics and outcome in RT-PCR positive and false-negative RT-PCR for COVID-19: A Retrospective analysis.

Cases with SARS-CoV-2 RT-PCR negative pneumonia are an understudied group with uncertainty remaining regarding their treatment approach. We aimed to compare the clinical and radiological characteristics of RT-PCR positive and clinically diagnosed RT-PCR negative COVID-19. This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age ≥18 years) with suspicion of COVID-19 with SARI (severe acute respiratory infections) who were subjected to RT-PCR testing (nasal/oropharyngeal swab) were included. Based on RTPCR results, patients were categorized and compared for demographic, clinical, and biochemical characteristics and outcomes. Out of 500 patients, 339 (67.8%) found RT-PCR positive. Except for the radiological findings, both groups differ in clinical presentation, disease severity (inflammatory markers), and outcome. RT-PCR-positive patients had raised ferritin, NLR (Neutrophil-Lymphocyte ratio), LDH, and high mortality compared to the swab-negative group. In-hospital mortality was also significantly high in RT-PCR positive group (HR=1.9, 95% CI=1.4-2.5, p=0.001). On multivariate analysis, NLR, ferritin, and d-dimer were the independent predictors of mortality in RT-PCR-positive (p=0.038, 0.054, and 0.023). At the same time, raised TLC (total leukocyte count) and procalcitonin were the risk factors for poor outcomes in RT-PCR-negative patients (p=0.041 and 0.038). We found significantly raised ferritin, NLR, and LDH levels and increased mortality in RT-PCR positive patients compared to RT-PCR negative. Incorporating clinical features, radiological, and biochemical parameters could be prudent while managing the RT-PCR-negative patients.

Imaging Approach to Pulmonary Infections in the Immunocompromised Patient.

Pulmonary infections are the major cause of morbidity and mortality in immunocompromised patients and almost one-third of intensive care unit patients with pulmonary infections belong to the immunocompromised category. Multiple organisms may simultaneously infect an immunocompromised patient and the overwhelming burden of mixed infections further predisposes critically ill patients to acute hypoxemic respiratory failure. Notwithstanding that lung ultrasound is coming into vogue, the primary imaging investigation is a chest radiograph, followed by thoracic CT scan. This review based on our experience at tertiary care teaching hospitals provides insights into the spectrum of imaging features of various pulmonary infections occurring in immunocompromised patients. This review is unique as, firstly, the imaging spectrum described by us is categorized on basis of the etiological infective agent, comprehensively and emphatically correlated with the clinical setting of the patient. Secondly, a characteristic imaging pattern is emphasized in the clinical setting-imaging-pattern conglomerate, to highlight the most likely diagnosis possible in such a combination. Thirdly, the simulating conditions for a relevant differential diagnosis are discussed in each section. Fourthly, not only are the specific diagnostic and tissue sampling techniques for confirmation of the suspected etiological agent described, but the recommended pharmaco-therapeutic agents are also enumerated, so as to provide a more robust insight to the radiologist. Last but not the least, we summarize and conclude with a diagnostic algorithm, derived by us from the characteristic illustrative cases. The proposed algorithm, illustrated as a flowchart, emphasizes a diagnostic imaging approach comprising: correlation of the imaging pattern with clinical setting and with associated abnormalities in the thorax and in other organs/systems, which is comprehensively analyzed in arriving at the most likely diagnosis. Since a rapid evaluation and emergent management of such patients is of pressing concern not only to the radiologist, but also for the general physicians, pulmonologists, critical care specialists, oncologists and transplant surgery teams, we believe our review is very informative to a wide spectrum reader audience.

Chest CT Findings and SARS-CoV-2 Infection in Trauma Patients-Is There a Prediction towards Higher Complication Rates?

Background: Polytrauma patients with SARS-CoV-2 infections may be associated with an increased complication rate. The main goal of this study was to analyze the clinical course of trauma patients with COVID infection and a positive CT finding. Methods: This was a retrospective in-hospital study. Polytrauma patients diagnosed with SARS-CoV-2 infections were included in our analysis. The outcome parameters were pulmonary complication during admission, pulmonary embolism, pleural effusion, pneumonia, mortality, length of stay and readmission < 30 days. Results: 48 patients were included in the study. Trauma patients in the age-adjusted matched-pair analysis with typical changes in SARS-CoV-2 infection in CT findings showed significantly more pulmonary complications in general and significantly more cases of pneumonia (complications: 56% vs. 11%, p = 0.046; pneumonia 44% vs. 0%, p = 0.023). In addition, the clinical course of polytrauma patients with SARS-CoV-2 infection showed a high rate of pulmonary complications in the inpatient course (53%). Conclusion: The results of our study show that the changes in the CT findings of trauma patients with SARS-CoV-2 infection are a good indicator of further inpatient outcomes. Similarly, polytrauma patients with a SARS-CoV-2 infection and positive CT findings are shown to have increased risk for pulmonary complications.

Cavitary Lung Metastases in Prostate Cancer.

Teaching Point: Adenocarcinomas very rarely cause cavitary lung metastases.

Isolated Posterior Mediastinal Thyroid Nodule Simulating Esophageal Pathology: A Multi-Modality Diagnosis.

Posterior mediastinal goiter is not a common cause of dysphagia, and symptoms can simulate esophageal malignancy. This case report highlights two critical clinical aspects. First, the patient's symptoms of gradually worsening dysphagia to solids and liquids, odynophagia, and hoarseness of voice secondary to retrosternal thyroid nodule extension can simulate esophageal malignancy. Second, a barium swallow study can effectively rule out esophageal pathology even though more advanced studies, like High-resolution computed tomography (HRCT), are inconclusive. We present a unique case of isolated posterior mediastinal exophytic thyroid nodule simulating the symptoms of esophageal pathology.

Clinical, Biochemical, and Radiological Presentation of RT-PCR-Positive vs RT-PCR-Negative SARS-CoV-2 Pneumonia Requiring ICU Care: An Observational, Cross-Sectional, Single-Center Study in Kalaburagi, Kalyana Karnataka.

Introduction Studies have reported similar clinical, biochemical, and radiological features between real-time polymerase chain reaction (RT-PCR)-positive and RT-PCR-negative patients. Therefore, the present study aims to assess differences in RT-PCR-positive versus RT-PCR-negative patients' characteristics. Methods We prospectively included 70 consecutive patients with typical coronavirus disease 2019 (COVID-19)-like clinical features who were either RT-PCR-positive or negative, requiring admission to the intensive care unit. The patients were classified into positive and negative RT-PCR groups and evaluated for clinical features, comorbidities, laboratory findings, and radiologic features. Results Fifty-seven point one percent (57.1%; 40/70) were RT-PCR positive, and 42.9% (30/70) were RT-PCR negative patients. The respiratory rate was higher among negative patients (P = 0.02), whereas the mean duration of fever was longer (3.34 vs 2.5; P = 0.022) among positive patients. At presentation, RT-PCR-negative patients had lower saturation of peripheral oxygen (SpO2) (near significant P = 0.058). Evaluation of co-morbidities revealed no differences. The neutrophil/lymphocyte ratio (NLR) (4.57 vs 6.52; P = 0.048), C-reactive protein (CRP) (9.97 vs 22.7; P = 0.007), and serum ferritin (158 vs 248.52; P = 0.010) were higher in patients who tested negative for RT-PCR. Thrombocytopenia (2.42 vs 1.76; P = 0.009), D-dimer levels (408.91 vs 123.06; P = 0.03), and interleukin (IL-6) levels (219.3 vs 80.81; P = 0.04) were significantly elevated among RT-PCR positive patients. The percentage of lung involvement in negative cases was 42.29+/-22.78 vs 36.21+/-21.8 in positive cases (P=0.23). The CT severity score was similar in both cohorts. Conclusion Both RT-PCR-positive and negative patients have similar clinical, biochemical, and radiological features. Considering that we are amidst a pandemic, it is advisable to have a similar approach irrespective of the RT-PCR report and triage and isolate accordingly. We recommend an RT-PCR-negative intensive care unit (ICU) ward and that the treating physician take a call on the management with a holistic approach driven clinically by the laboratory findings and helped by radiological findings. Stressing only on the RT-PCR report for management can be counterproductive.

Bronchoscopy in the investigation of outpatients with hemoptysis at a lung cancer clinic.

BACKGROUND: In the investigation of lung cancer, current practice in many healthcare systems would support bronchoscopy regardless of CT findings in patients with hemoptysis. We sought to identify the cause, the diagnostic yield of CT and bronchoscopy and the requirement for bronchoscopy in at risk patients with hemoptysis with a normal CT scan through our rapid access lung cancer clinic (RALC). METHODS: Initially, a chart review was performed on all patients with hemoptysis (2011-2012) and thereafter a prospective analysis was performed (2013-2016). RESULTS: Our analysis represents the largest study to date in outpatients with hemoptysis. In our retrospective study, 155 patients reported hemoptysis. Causes were lower respiratory tract infections (RTIs) (47%) and lung cancer (16%). Our prospective study included 182 patients. The causes of hemoptysis were RTIs (50%) and lung cancer (18%). There were no false negative CT-scans for lung cancer. 47/57 present with lung cancer underwent bronchoscopy and 43/47 were positive for lung cancer (92%). Patients with hemoptysis and lung cancer have a higher stage of malignancy with a predominance of squamous cell lung carcinoma. Smoking status, the duration of hemoptysis or description of hemoptysis were not predictive of lung cancer however lung cancer was not identified in patients age <50. CONCLUSIONS: One sixth of patients presenting with hemoptysis to our lung cancer clinic had lung cancer. No patient identified with cancer related haemoptysis had a CT negative for lung cancer and a combination of bronchoscopy plus endobronchial ultrasound trans-bronchial needle aspiration (EBUS-TBNA) in those patients with a CT suspicious of lung cancer is 92% sensitive for lung cancer causing hemoptysis.

Late perforation of Durata ICD lead--a case report.

Late ICD lead perforation is an uncommon but clinically significant complication. The pathophysiology, predictors, clinical presentations and management although have been described earlier but still remain inconclusive. Our case highlights the challenges involved in clinical recognition, the value of CT scan in its diagnosis and need for careful management of this potentially life threatening condition. It is the first report on Durata lead perforation to the best of our knowledge.

A case of missed blunt traumatic aortic injury (BTAI)

We are reporting a case of missed blunt traumatic aortic injury (BTAI). A 28 year male presented with chest pain following a motor vehicle accident. He was discharged following normal clinical signs and chest radiograph. The following day he complained of lower limb weakness. Traumatic aortic dissection was revealed via computer tomography (CT) of the thorax. BTAI cannot be ruled out with normal clinical signs and chest radiograph alone. CT thorax is mandatory to rule out BTAI in high impact chest injury.

Occult primary spontaneous pneumothorax

We report a case of occult primary spontaneous pneumothorax in a 30 years-old woman. She developed symptoms and signs that were suggestive of pneumothorax. However, chest radiograph failed to reveal pneumothorax. Therefore, we proceeded with computed tomography (CT) thorax which revealed significantly moderate right pneumothorax. The diagnostic approach and the management of this case are discussed.

Computed tomography of the thorax with 3D reconstruction in penetrating chest injury

Penetrating chest wounds is less common but more deadly then blunt trauma. Majority of penetrating chest trauma can be managed conservatively with observation and simple thoracotomy. This case report highlights a bizarre occupational hazard causing a penetrating chest injury and the option of non-invasive management with the aid of computed tomography with 3D reconstruction.